Master Techniques in Facial Rejuvenation 2

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
41
Figure 3.41  An older patient with good craniofacial support and healthy elastic skin was treated (using hyaluronic acid with a 25 gauge cannula)
in the suborbicularis oris fat of the upper and lower lip (as shown in Fig. 3.38) as well as in the lateral (labiomandibular fat) of the chin as pic­
tured in Fig. 3.39 with a natural appearing result. A small amount of product was also placed in the body of the lip, however no filler was placed
directly in the vermillion border. Placement in the deep fat alone served to evert the lip and accentuate the vermillion border. The patient was also
treated with a very conservative amount of hyaluronic acid in the DLCF (a shadow from loss of volume in that area can be seen on the patient’s
right side) as well as in the anterior chin as discussed below. Photographs courtesy of Rebecca Fitzgerald MD.
Figure 3.42  Images from Geirloff et al of a volume-rendered 3-D spiral CT of the chin demonstrated two distinct fat compartments in the mental
region-the superficial chin fat and the submental fat. The superficial chin fat (left) reaches superiorly almost to the mentolabial sulcus and is delineated
laterally by the labiomandibular fat and inferiorly by the superficial portion of the submentalis fat. The submentalis fat consists of a superficial and
a deep portion. The deep portion is located above the periosteum and is covered by the mentalis muscle . It is located topographically underneath
the mentolabial sulcus. The superficial, inferior portion of this fat compartment is located directly under the skin and accentuates the shape of the
mentum. (Reproduced with permission from Gierloff M, Stöhring C, Buder T, et al. The subcutaneous fat compartments in relation to aesthetically
important facial folds and rhytides. J Plast Reconstr Aesthet Surg 2012;65(10):1292–7.)
SMF
M
Figure 3.43  Submentalis fat (SMF) is found deep to the mentalis muscle
(M). This fat did not cross the midline of the mandible; two separate com­
partments exist. It is postulated that volume loss of this fat contributes to
the prominence of the lip-chin hollow noted with age. (Reproduced with
permission from Rohrich R, Pessa J. The Anatomy and Clinical Implica­
tions of Perioral Submuscular Fat. Plast Reconstr Surg 2009;124:266.)

42
MASTER TECHNIQUES IN FACIAL REJUVENATION
in surgery, although the premaxillary and prezygomatic
spaces are a potential target for fat or filler, especially
in a patient without pronounced skin laxity. Fig. 3.50
illustrates the boundaries of these spaces. It also illus­
trates a space deep to the medial aspect of the DMCF
initially referred to as Ristow’s space [33], and thought
to be fat. This was recently studied by Surek et al in 12
hemifacial cadaver dissections and described as a facial
accounts for many of the characteristic changes that
occur with aging of the face as noted earlier, including
TT deformity, nasojugal fold, malar bags, and jowling.
Accordingly, as the boundaries widen and the ligaments
weaken, the facial spaces dissect easily in older patients,
often with simple blunt finger dissection. In young people,
the spaces are tight and are more potential than real.
The main utility of these spaces are dissection planes
Figure 3.44  Pre and postinjection photographs of a middle-aged male patient with a deep labiomental sulcus, horizontal microgenia, and a
narrow chin shape before and after injection with 2 mL of hyaluronic acid (1 mL centrally deep to the mentalis muscle and 0.5 mL to each lateral
mandibular region in the area of the labiomandibular fat). (Reproduced with permission from Sykes J, Fitzgerald R. Choosing the Best Procedure
to Augment the Chin: Is Anything Better than an Implant? Facial Plast Surg 2016;32:507–512.)
Figure 3.45  Treating the masseters with neuromodulator can refeminize a female face. Hypertrophic masseters can masculinize a female face as
seen in this before image. Neuromodulater can be injected into the masseter muscle to soften this effect as seen here. This patient was also treated
with hyaluronic acid in the temples. No treatment was done in the cheeks (they appear larger in the after photograph because the masseters are
smaller and the temples are fuller). Photographs courtesy of Rebecca Fitzgerald MD.

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
43
Figure 3.46  “Nefertiti lift” of the neck. The platysma muscle originates in the skin over the lower neck and upper lateral chest and inserts into
the skin and over the inferior border of the mandible (and interdigitates with the depressor anguli oris muscle and the mandible ligament). Bands
of muscle form with time. Injection of neuromodulator into these platysmal bands can efface the downward pull on the corners of the mouth and
jawline resulting in a mild neck lift called the “Nefertiti lift”. Photographs courtesy of Rebecca Fitzgerald, MD.
Figure 3.47  Topographical anatomy of layer 4 over the lateral face.
Spaces (blue), ligaments (red), and the areas of important anatomy
(stippled). The largest area of ligamentous attachment, the platysma
auricular fascia, dominates the posterior part of level 4 at the least
mobile part of the face. The lateral face transitions into the anterior
face at the vertical line of retaining ligaments. Immediately above and
below the arch of the zygoma are the triangular-shaped areas that
contain the important anatomy proceeding from the lateral into the
anterior face.
#
1
*
*
2
PG
3
Figure 3.48  Cadaveric dissection showing the anatomy of layer 4
over the lateral face. View into the right premasseter compartments of
a male fresh-frozen specimen. Dissection is performed in layer 4, that
is, between the SMAS (uplifted) and the deep fascia of the face which is
here formed by the parotideomasseteric fascia (down). The cross in the
left-upper corner of the image shows the orientation. The superior (1),
middle (2), and the inferior (3) premasseter compartments are encircled.
Between the inferior and the middle compartment the buccal branch
of the facial nerve is marked with an asterisk. The star points to the
parotid duct, between the middle and the superior premasseter com­
partment. Note that both the buccal nerve and the parotid duct pierce
the masseteric ligaments at the anterior border of the masseter muscle.
The red mark in the image shows the cut edge of the McGregor’s
patch. The hash mark indicates the zygomaticus major muscle which
originates from the zygomatic bone and has in this image been skel­
etonized for a better visualization. The arrows show the location where
the muscle passes through layer 3 to reach the modiolus at the angle
of the mouth immediately under the skin (layer 1). PG, parotid gland.
(Reproduced with permission from Cotofana S, Schenck TL, Trevidic P,
et al. Midface: clinical anatomy and regional approaches with injectable
fillers. Plast Reconstr Surg 2015;136(5S):219S–34S.)
space (the pyriform space) for anatomic continuity [61].
Unlike the well-defined prezygomatic space and premax­
illary spaces, they found no discernible encapsulation of
the deep pyriform space; however, the boundaries of the
space are well defined by the fanning insertion of the
depressor septi nasi and septation of the postorbicularis
oris fat, which provide a robust inferior hammock. This
space is shown in the cadaveric dissection in Fig. 3.51.
The average measured dimensions of the deep pyriform
space in this study were 1.1 × 0.9 cm. Pneumatization
of the space traverses cephalic to the level of the TT
ligament in a plane deep to the premaxillary space. The
study authors found that this midface cavity cradled by
the pyriform aperture and DMCF compartment resides

44
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 3.49  The system of retaining ligaments situated around the
bony cavities stabilizes the soft tissue over the cavities. (Adapted from
Mendelson B, Wong C. Anatomy of the aging face. Section I, Chap 6.
Aesthetic Surgery of the Face. Elsevier; 2013.)
vascular injury. The authors conclude that this may prove
to be a vital target area for restructuring the aging ante­
rior midface, and my experience completely agrees with
this. I have been treating this area deeply on the bone
with good results since its description as Ristow’s space
in 2007 [33]. Injections in this area serve to push the base
of the nose anteriorly, shorten and lift the upper lip, and
lift and project the midcheek fat. Clinical examples will
be shown later in the chapter.
Periosteum and Deep Fascia: Layer 5
The deep fascia, the deepest soft tissue layer of the face,
is formed by the periosteum where it overlies bone. Over
the lateral face, where the muscles of mastication (tem­
poralis and masseter) overlie the bone, the deep fascia
is instead the fascial covering of the muscles, the deep
temporal fascia above the zygomatic arch, and masseteric
fascia below the arch. The parotid fascia is also part of
the deep fascia.
BONE
The idea that significant and consistent changes occur
in the craniofacial skeleton as it ages, and that these
changes contribute significantly to the clinical appear­
ance of the aging face is currently more widely accepted,
although still controversial. Mendelson and Wong note
that improvements in imaging technology (such as CT
scanning), have enabled a more accurate understanding
of facial skeletal aging than has previously been pos­
sible. This advance has provided evidence that aging of
the facial skeleton includes selective remodeling at spe­
cific sites [63]. Multiple studies have demonstrated sig­
nificant craniofacial skeletal changes with age. An often
cited study is Shaw and Kahn’s review of 60 3D CTs
Premaxillary
space
Levator labii
superioris
Orbicularis
oculi
Prezygomatic
space
Zygomaticus
minor
Zygomaticus
major
Angular
artery
Deep medial
cheek fat
Deep
pyriform
space
Figure 3.50  Medical illustration of the deep pyriform space and
important adjacent structures. (Adapted from Surek C, Vargo J, Lamb
J. Deep pyriform space: anatomical clarifications and clinical implica­
tions. Plast Reconstr Surg 138: 59, 2016.)
Angular artery
Deep
pyriform
space
Deep
medial
cheek fat
Poof
Figure 3.51  The deep pyriform space is cradled medially by the pyri­
form aperture and depressor septi nasi. The angular artery courses
between the space and the deep medial cheek fat compartment. Note
that the artery is not directly on the periosteum, but superficial and
lateral within the roof of the space. Postorbicularis oris fat is stained
green. (Reproduced from Surek CK, Vargo J, Lamb J. Deep pyriform
space: Anatomical clarifications and clinical implications. Plast Recon­
str Surg 2016;138(1):59–64.)
in a deeper plane than either the premaxillary space or
the DMCF compartment. Bony recession of the maxilla
with age predisposes this space for use as a potential area
of deep volumization to support overlying cheek fat and
draping lip elevators that reside superficial to this space.
The position of the angular artery in the roof of the space
allows safe injection on the bone without concern for

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
45
lower third of the face. Now look back at the asymmet­
ric face in Fig. 3.5. Many of these changes can already
be found on the less volumized side of her face, which
started with less bone and is aging prematurely compared
with the fuller side.
These changes have been summarized in a comprehen­
sive review by Mendelson and Wong and are illustrated
in the schematic in Fig. 3.53. The size of the arrow in
the schematic correlates with the amount of resorption.
Many of these changes can be appreciated in Fig. 3.54,
of a man in his twenties and again fifty years later. The
schematic in Fig. 3.55 illustrates the impact of adequate
pyriform support on the convexity of the midface relative
from a young, middle-aged, and older group. Statisti­
cally significant findings were a change in contour of the
orbit (with superior medial and inferiolateral remodeling)
and a decrease in the glabellar, pyriform, and maxillary
angles. These changes can be readily seen in the images
of a younger and older CT from this study pictured
in Fig. 3.52. A younger and older patient with severe
lipoatrophy are shown next to the CTs in an attempt to
better visualize the clinical consequences of these skeletal
changes. Compare the size and shape of the orbits (round
in the young man, and “lemon drop” shape in the older
with superior medial and inferior lateral remodeling).
Look at the position of the nose, and the ratio in the
C
D
Nasal area:
669.8 mm2
Nasal area:
610.4 mm2
A
B
Figure 3.52  (A, B) Craniofacial skeletal support and facial shape. A young and aged face with extreme lipoatrophy shown here illustrate both the
shape of the underlying craniofacial skeleton in youth and aging, as well as the different clinical appearance noted when the overlying outer skin
envelope is able, or less able, to accommodate the underlying volume loss. (Reproduced with permission from Fitzgerald R, Vleggaar D. Facial
volume restoration of the aging face with poly-l-lactic acid Dermatol Ther, Vol. 24, 2011, 2–27.) (C, D) This retrospective study of computed
tomography images from 60 patients (half male/half female) from three age groups (young, middle age, old) demonstrated that significant and
consistent changes occur as the craniofacial skeleton ages. The most consistent findings were a change in contour of the orbit (with superior medial
and inferiolateral remodeling) and a decrease in the glabellar, pyriform, and maxillary angles. (Reproduced with permission from Shaw RB Jr, Kahn
DM. Aging of the midface bony elements: a three-dimensional computed tomographic study. Plast Reconstr Surg 2007;119:675–681.)

46
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 3.53  Arrows indicate the areas of the craniofacial skeleton that
are susceptible to resorption with aging. (Reproduced with permission
from Mendelson B, Wong C. Anatomy of the aging face. Section I, Chap
6. Aesthetic Surgery of the Face. Elsevier; 2013.)
Figure 3.54  Note that the areas of the craniofacial skeleton that are susceptible to resorption with aging as pictured in the previous figure can be
appreciated in this photograph of a man in his twenties and again almost sixty years later.
Figure 3.55 The relationship of the lip and nose affect overall facial
balance. The absence of midface projection (congenital or acquired
through age or trauma) can make the face appear concave. This is
most appreciated in the profile view. Pyriform aperature augmentation
increases the projection of the nasal base, opening the nasolabial angle.
This may help serve to prevent a “ducky” look to the lips sometimes
seen with an acute nasolabial angle with or without lip augmentation
as noted in the previous figure. (Reproduced with permission from
Yaremchuk, M. Atlas of Facial Implants. Philadelphia: Saunders Else­
vier; 2007.)
to profile and nasolabial angle. The first figure shows
midface concavity and an acute nasolabial angle. Pyri­
form augmentation creates a convex profile and opens
the nasolabial angle. Note that an acute nasolabial angle
causes the philtrum to fall further back giving the impres­
sion of an overly prominent upper lip. This problem can
be worsened with the addition of filler into the body and
vermillion border of the upper lip as seen in Fig. 3.40.
Fig. 3.56 shows a female who has never had a strong
craniofacial skeleton. Now, at 46 years old, it is aging
her prematurely and she is asking for lip filler. Be aware
that patients with maxillary retrusion, like the Hitchcock
example, can have a ducky-looking lip even without filler.
Placement of filler in the preperiosteal pyriform space
pushes the base of the nose anteriorly, which serves to
evert the lips slightly and increase the prominence of the
cupid’s bow and philtral columns without direct aug­
mentation of the lip. Filler in the submental fat beneath
the labimental sulcus line serves to lift and lengthen her
chin. Combined, it restores the phi ratio to the lower
third of her face.
This is a common presentation in a cosmetic office, as
many women lose bone mass. Please refer to Fig. 3.57,
which shows a woman aged 45 to 55 years [64].

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
47
Figure 3.56  Clinical correlation of placement of product (here using poly-l-lactic acid) in the preperiosteal pyriform space which pushes the base of
the nose anteriorly, serving to evert the upper lip and increase the prominence of the cupid’s bow and philtral columns without direct augmentation
of the lip. Product was also placed in the chin in the area of labiomandibular fat, and deep submentalis fat, which serves to evert the lower lip. It
is not uncommon to see the width of the lip shorten slightly with these injections. No product was used in the lips.
soft tissue envelope [65]. They are also in agreement
with the early description of a “clockwise rotation” of
the maxilla and mandible with aging, as hypothesized by
Pessa and Lambros (also over a decade ago) [66]. These
concepts are illustrated in Fig. 3.58 and were, in fact,
the impetus for many of the aforementioned studies on
changes seen in the craniofacial skeleton with aging.
The maintenance of bone volume and contour is nec­
essary to preserve soft tissue relationships. This concept,
however, is not limited to aging. Bony trauma, congenital
bony abnormalities, and bone degenerative disease also
result in soft tissue distortion. In patients with congeni­
tally weak skeletal structure, the skeleton may be the
primary cause for the manifestations of premature aging.
The facial skeleton has a profound effect on an indi­
vidual’s appearance and a defining characteristic of youth
is good skeletal structural support [62]. The value of this
work lies in its implications for treatment—that is, that
the underlying bony structure may be augmented by solid
implants, as has been done historically, or by injectable
shaping agents, as seen in Figs. 3.59 and 3.60, resulting
in the restoration of soft tissue support and therefore a
reversal, to some degree, of the concertina effect. The
first patient (Fig. 3.59) was treated along the zygomatic
arch and pyriform aperture (over the anterior and lateral
surface of the entire maxilla), temple, lateral superior
orbital rim, and the labiomental sulcus. No neuromodu­
lator was used. The next patient (Fig. 3.60) also had
congenital skeletal hypoplasia, and was treated first with
hyaluronic acid and then eventually calcium hydroxyl­
apatite over her cheeks and chin. The last picture is 7
years later with annual touch ups. The results in these
two patients is simply the recognition, and targeted cor­
rection, of specific anatomic deficiencies - in this case a
concertina effect secondary to congenital skeletal insuf­
ficiency leading to the appearance of premature aging.
CASE HISTORIES
In order to facilitate the practical use of some of the con­
cepts discussed here in injectable treatment of the face,
a number of case reports of patients of different ages,
These findings are in agreement with observations pub­
lished by Pessa et al. over a decade ago, noting that an
infant’s small craniofacial skeleton as well as age-related
bony remodeling caused a decrease in the space available
for the soft tissue in the midface, resulting in a “folding
in” of the soft tissue in a configuration that resembles an
accordion, referred as the “concertina effect,”. However,
a youthful face seemed to represent a point in time when
a particular set of skeletal proportions are ideal for their
Figure 3.57  Menopause. Although rates of bone loss across the meno­
pause transition and factors associated with variation in menopausal
bone loss are still not fully understood, it is widely accepted that bone
loss accelerates substantially in the late perimenopause and early post­
menopausal years. Perhaps this contributes to the changes seen here in
a woman first photogaphed at age 45 and again at age 55.

48
MASTER TECHNIQUES IN FACIAL REJUVENATION
OM
MC
a
a
a
NLC
S
MC
MC
NLC
NLC
S
S
MM
OM
OM
MM
MM
Figure 3.58  (Top) On a frontal view, the ratio of medial canthus (MC) to nasolabial crease (NLC) and the NLC to the lips (S, stomion) in the
infant is approximately 1:1. This ratio is attributable to lack of development in the maxilla from the pyriform to the orbital rim. (Middle) From
infancy to youth, the maxilla grows at a disproportionately fast rate (differential growth), which results in the ratio becoming closer to 1.5:1 at the
time of youth. (Lower) After this point, upward remodeling of pyriform, coupled with continued growth of the lower maxilla, again causes this
ratio to revert back toward 1:1 in an older individual. The ratio of the mid-maxillary (Mm) height to the mid-orbital (Om) diameter is shown for
all. Note that the proportions in the older man are closer to that of the infant. It is of interest that, if the soft tissue contours of the 82-year-old man
(C) were restored to those a youthful person, the proportions would still be those of an older (or infant) face. The appearance of youth depends on
contours and proportions as well as soft tissue signs of aging. (Reproduced from Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial
aging: nonlinear aspects of youthfulness and skeletal remodelling, and why, perhaps, infants have jowls. Plast Reconstruct Surg 1999;103(2):635–44.)
gender, and ethnic backgrounds are presented here in a
“composite” format. As noted previously, this smaller
format makes it easier to quickly recognize facial shape
and proportions, and to determine what is present or
missing that may be moving the face away from the ideal
pictured in Fig. 3.6. In this figure with ideal proportions
of “five eyes across” in the upper face, and three relatively
equal horizontal thirds, we see an inverted egg shape with
an oval facial frame, a convex anterior surface, and a phi
proportion in the lower third of the face. In faces already
close to this ideal, treating areas such as TTs, NLFs, and
marionette lines as isolated entities will suffice, as there
is already a smooth transition from one area to another.
However, faces that deviate from this ideal, either by
congenital lack of structures, or from advanced aging
changes in these structures, may look unnatural with this
approach unless the smooth transitions resulting in these
proportions are addressed. This may involve treating
one or more structural tissue layers. For example, we
know that the presence and maintenance of bone volume
and contour are necessary to provide and preserve ideal
soft tissue relationships. The result of addressing this
one structural tissue is seen in the young patients with
congenital skeletal hypoplasia in Figs. 3.59 and 3.60. As
this was the biggest deficit in these patients, addressing
that “one tissue issue” served to bring these faces closer
to their ideal shape and proportions. In the older patient
pictured in Figs. 3.16 and 3.17, bony changes as well
as specific areas of fat loss were addressed in order to
achieve the same goal.
The approaches outlined in this chapter were applied
to each of the faces in the composite pictures in Figs.
3.61 through 3.63, in order to bring them closer to their
ideal proportions. The patient photographs are lined up
vertically to enable easy comparison of the morphology
of these faces both before and after treatment. Note in all

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
49
Figure 3.59  This 30-year-old “baby-faced” woman presented with poor craniofacial support, resulting in a “concertina effect” as described above.
Product was placed supraperiosteally along her superior lateral orbital rim, zygoma, canine fossa, and mandible in roughly the same areas that
would be treated with a solid implant. Deep injections along the lateral zygoma and the temple were carried into the hairline. Deep soft tissue
injections were done in the mid-cheek and chin, and a small amount of product was placed supraperiosteally 1 cm below the infraorbital rim. This
patient was injected with two vials of poly-l-lactic acid/session over two sessions spaced 2 months apart. Almost an entire vial was split between
her temples in each treatment. No other treatments were carried out in this patient (no botulinum toxin). Note the brow elevation as well as the
change in her facial shape and perioral ratio with these treatments. (Reproduced with permission from Fitzgerald R, Vleggaar D. Poly-l-lactic acid.
In: Jones DH, ed. Injectable fillers: principles andpractice. London: Wiley Blackwell, 2010: 54–74.)
fat, especially in the temple and the lateral cheek, leaving
proportions in the upper face less than the ideal “five eyes
across,” as seen in Fig. 3.61B, D, E, and G as well as
Fig. 3.62A, C, G, and D. Looking at the three horizontal
thirds, the woman pictured in Figs. 3.61H and 3.63A, as
well as the man in Fig. 3.61A, have an upper third of the
face that is somewhat smaller and flatter than the lower
two thirds of the face, which looks more proportional
after treatment of the temples, forehead, and periorbital
areas. The convexity of their midface was achieved by
the before pictures how changes in facial topography seen
with aging sharpen the once smooth transition between
anatomic units, and that this change in topography is
greatly magnified by light reflection and/or shadow. Note
how the face dramatically flattens with age and restoration
of previous arcs and convexities restore youthful light and
shadow patterns. In all of these photos the after pictures
are more ovalized and convex, and have smoother tran­
sitions between anatomic units than the before pictures.
The global oval facial frame can be affected by the loss of
Figure 3.60  Another “baby-faced” patient with suboptimal craniofacial support treated with calcium hydroxylapatite in the zygomatic arch and
the chin in roughly the same areas that would be treated with a solid implant. The patient is shown before (left), and immediately after (middle)
her first treatment, and again 6 years later maintained with annual treatments. A small chin implant was placed following her first treatment but
did not give the volume the patient desired. Since that time hyaluronic acid is used after sterile scrub using care to avoid contact with the capsule
of the implant. Note the change in her facial shape and perioral ratio with this treatment. Photographs courtesy of Rebecca Fitzgerald MD.

50
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
C
D
E
F
G
H
Figure 3.61  Older faces. The practical use of these concepts in injectable treatment of the face can be illustrated using a number of case reports
of patients of different ages, gender, and ethnic backgrounds. In order to look at a number of cases, as well as to compare and contrast different
faces, these cases are presented in a “composite” format. This smaller format makes it easier to recognize facial shape and proportions, harmony
or disharmony of the three thirds of the face, as well as to determine what is present or missing that may be moving the face away from the ideal
shape and proportions. Case details are discussed in the text.

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
51
A
B
C
D
E
F
G
H
Figure 3.62  Younger faces. The practical use of these concepts in injectable treatment of the face can be illustrated using a number of case reports
of patients of different ages, gender, and ethnic backgrounds. In order to look at a number of cases, as well as to compare and contrast different
faces, these cases are presented in a “composite” format. This smaller format makes it easier to recognize facial shape and proportions, harmony
or disharmony of the three thirds of the face, as well as to determine what is present or missing that may be moving the face away from the ideal
shape and proportions. Case details are discussed in the text.

52
MASTER TECHNIQUES IN FACIAL REJUVENATION
On closer observation, this patient would benefit from
filler in her mandibular angle. The woman pictured in
Fig 3.63G has a similar issue, albeit on a much smaller
scale. Her face appears more 3D after filler placement in
her cheeks and chin.
The woman pictured in Figs. 3.63F and 3.62C has
adequate upper face bone and a lateral zygomatic arch
(seen in three-quarter view), but a retrusive anterior
maxilla, and a congenitally suboptimal chin and man­
dible. She has also lost fat in the temporal lateral cheek
compartment (which often leaves the tragus of the ears
visible in the anteroposterior view), affecting her global
facial frame. This is exacerbated by her suboptimal chin,
which truncates off the lower third of her face in anterior
view, giving the impression of early jowling. Treatment
to mimic bony support in the pyriform space as well
as the chin and mandible, as well as treatment of the
injection into the pyriform space. The young woman in
Fig. 3.63B has adequate bony support in the upper and
lower third of her face, but has a congenital lack of bony
support in her midface, exacerbated by loss of fat from
endurance exercise. This was corrected by injections over
the zygomatic arch and in the pyriform space, as well as
into the deep fat pads of the midface (medial and lateral
SOOF, DMCF, and DLCF). The woman to her right in
Fig. 3.63C has ample volume in the upper third of her
face, but a congenital lack of bony support in her mid
and lower face. Her midface was treated with injection
of filler over the zygomatic arch to mimic craniofacial
support. The lack of bony support in her perioral area is
causing her lips to elongate slightly as they drape over this
area. This is easily corrected with injection of filler into
the pyriform space and anterior mandible/chin, as well as
in the labiomandibular and submental fat compartment.
A
B
C
D
E
F
G
H
I
J
K
L
Figure 3.63  Three quarter views. The practical use of these concepts in injectable treatment of the face can be illustrated using a number of case
reports of patients of different ages, gender, and ethnic backgrounds. In order to look at a number of cases, as well as to compare and contrast
different faces, these cases are presented in a “composite” format. This smaller format makes it easier to recognize facial shape and proportions,
harmony or disharmony of the three thirds of the face, as well as to determine what is present or missing that may be moving the face away from
the ideal shape and proportions. Case details are discussed in the text.

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
53
served to feminize her face (masseteric hypertrophy can
be masculinizing in a female face). Masseters were also
treated with neuromodulator in the patient in Fig. 3.62E.
This “baby-faced” patient with congenital skeletal hypo­
plasia was also treated with filler above the superior
lateral orbital rim, the zygomatic arch, medial maxilla/
pyriform, and chin to address her “concertina effect”
similar to the patients pictured in Figs. 3.59, 3.60, and
3.63K. Similar treatment was done in the patient pictured
in Fig. 3.61C. These patients were all a mostly “one tissue
issue” needing craniofacial augmentation. The woman
in Fig. 3.62A was treated for mild bony remodeling in
the pyriform space and anterior mandible/chin to mimic
bone, but was mostly a “one tissue issue” needing aug­
mentation in both the superficial and deep fat pads of
the face. The patient in Fig. 3.63J shows ample bony
support and soft tissue, and was therefore treated with
only a skin-tightening device (Ultherapy, Merz, Germany)
with good results. Finally, the improvement in the global
facial frame of the woman in Fig. 3.61F was achieved
with neuromodulator in the platysma and lip depressors,
and is also seen in Fig. 3.46. No fillers were used in this
patient.
The patient pictured in Fig. 3.63D and Fig. 3.61B,
as well as those in 3.61D and E, are all “multiple tissue
issue” patients needing work in all tissue structural
layers. Patients like these would likely best benefit from
a surgical lift and fat augmentation. Nonsurgical methods
including fillers can be done successfully, but it requires
a lot of product and multiple appointments. Addressing
this with the patient ahead of time will reduce frustration
for both the patient and the practitioner.
COMPLICATIONS
Comments for this chapter are restricted to the most
common placement errors. Safety concerns, although out
of the scope of this present chapter, are of paramount
superficial temporal lateral cheek fat, and deep fat pads
of the midface, have given her a nice result, and have
addressed her facial frame and ideal proportions, includ­
ing the phi proportion in the lower third of her face
(improving the perioral facial frame). This impression of
early jowling is often seen in young patients with a sub­
optimal chin or cheekbones, as pictured in the woman in
Figs. 3.60 and 3.63K. This is, of course, normal jowl fat
with inadequate bony support, but it can also exacerbate
what is seen in older patients as they lose bone in this
area as seen in the patient pictured in 3.63L.
Restoration of midface convexity has been addressed
by application of filler over the entire maxilla and the
pyriform fossa in Fig. 3.62B and H. Both of these women
were also treated with filler in the brow and upper lid to
address their periorbital frame. The global facial frame
was addressed by neuromodulator treatment of their
masseteric hypertrophy. Fig. 3.62B was treated with filler
in the four deep fat pads of the midface, while Fig. 3.62H
was treated in the lateral SOOF and DLCF. The most
obvious issue in the patient pictured in Fig. 3.63H is the
loss in the temporal lateral cheek fat pad, leaving a harsh
bony shadow around her zygomatic arch. She was treated
with filler in that fat compartment as well as with a small
amount to the deep fat pads of the midface. She was also
treated along her superior lateral orbital rim, pyriform
fossa, and anterior mandible restoring convexity to her
anterior midface. More support for her lips was provided
with filler in the deep fat pads of the lower lip. Note that
her lips look more proportional to the face after treat­
ment, although nothing was done to her lips (no filler
dissolved). The patient in Fig. 3.63E was treated in all
the same areas except that no filler was used around the
lips. The increased eversion of the lips secondary to the
perioral support in the pyriform and chin make them
appear larger.
Masseter neuromodulator as well as filler in the
temples was used in the patient in Fig. 3.62G, which
Figure 3.64  Common mistakes in commonly injected areas—lips and undereyes (periorbital and perioral). Also treated in temples and chin, which
serve to ovalize the face.

54
MASTER TECHNIQUES IN FACIAL REJUVENATION
importance, and are addressed well in several articles
referenced here [67–69].
Look at the women in their 50’s in Fig. 3.64, and in
Fig. 3.61G. Both represent common novice placement
errors. The undereye filler is too high, too superficial, and
there is too much. In addition to the Tyndall effect, the
irregular topography created by this placement gives the
face an odd look. Also, the temples and chin are volume
deficient, affecting the facial frame. Volume loss in the
temples and chin is often underrecognized. The empty
temples are skeletonizing in Fig. 3.61G and lead to lid lag
in Fig. 3.64. In the lower face, there is a U-shaped hollow
around the mouth in both patients, separating the lips
from the remainder of the perioral area. A recessed canine
fossa due to maxillary retrusion with aging is seen in both
patients, adding to the depth of the NLF and making
the midface a bit concave. Both were treated in a similar
fashion, first dissolving the misplaced filler infraorbitally
(as well as in the body of the lip and the central cutane­
ous upper lip in Fig. 3.64), followed by treatment in the
temple, lateral face, canine fossa/deep pyriform space,
and chin/lower perioral area. Here, the treatment was in
the labiomandibular fat and the submentalis fat under
the labiomental sulcus. The fat deep to the orbicularis
oris in the cutaneous aspect of the upper and lower lip
was treated in Fig. 3.64, and the lower lip and the lateral
commissures were treated in Fig. 3.61E. These changes
considered the face as a whole rather than a collection
of isolated entities, and led to a softer transition between
anatomic units, as well as addressing the facial frames,
topography, and proportions of the face.
SUMMARY
Those very new to injectables are understandably the
most concerned with learning about particular products
and techniques. However, with a little experience most
of us realize that this is the faster learning curve. The
bigger challenge in achieving optimal results is figuring
out what you want to treat, and why, and how predict­
able that treatment will be. The answer to that challenge,
as in surgery, is anatomy. The current understanding that
volume loss contributes to the appearance of the face as
we age in combination with the advent of newer products
and techniques has dramatically increased the ability to
address these changes outside of the operating room.
Volume replacement, although not a substitute for con­
ventional surgery, may delay or enhance cosmetic surgical
procedures. In addition, as our understanding of the loca­
tion of volume loss increases, our awareness of optimal
targets for replacement improves, as do our results.
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3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
54.e1
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induced premature skin aging and retinoid antagonism. Nature
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23. Fisher GJ, Varani V, Voorhees JJ. Looking older: fibroblast collapse
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24. Fisher GJ, Datta SC, Talwar HS, et al. Molecular basis of sun-
induced premature skin aging and retinoid antagonism. Nature
1996;379:335–9.
25. Wang F, Garza LA, Kang S, et al. In vivo stimulation of de novo
collagen production caused by cross-linked hyaluronic acid dermal
filler injections in photodamaged human skin. Arch Dermatol
2007;143:155–63.
26. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg
2007;119(7):2219–27.
27. Gierloff M, Stöhring C, Buder T, et al. Aging changes of the midfa­
cial fat compartments: a computed tomographic study. Plast Recon­
str Surg 2012;129(1):263–73.
28. Gierloff M, Stöhring C, Buder T, et al. The subcutaneous fat com­
partments in relation to aesthetically important facial folds and
rhytides. J Plast Reconstr Aesthet Surg 2012;65(10):1292–7.
29. Buchanan D, Wulc A. Contemporary thoughts on lower eyelid/
midface aging. Clin Plast Surg 2015;42:1–15.
30. Rohrich RJ, Arbique GM, Wong C, et al. The anatomy of suborbic­
ularis fat: implications for periorbital rejuvenation. Plast Reconstr
Surg 2009;124(3):946–51.
31. Rohrich RJ, Pessa JE. The anatomy and clinical implications of
perioral submuscular fat. Plast Reconstr Surg 2009;124(1):266–71.
32. Rohrich RJ, Pessa JE. The retaining system of the face: histologic
evaluation of the septal boundaries of the subcutaneous fat com­
partments. Plast Reconstr Surg 2008;121(5):1804–9.
33. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep
medial fat compartment. Plast Reconstr Surg 2008;121(6):2107–12.
34. Pessa JE, Rohrich RJ. Facial topography. Clinical anatomy of the
face. St Louis: Quality Medical Publishing; 2012.
35. Rohrich R, Pessa J. Discussion: aging changes of the midfacial fat
compartments: a computed tomographic study. Plast Reconstr Surg
2012;129(1):274–5.
36. Donofrio LM. Fat distribution: a morphologic study of the aging
face. Dermatol Surg 2000;26:1107–12.
37. Wan D, Amirlak B, Rohrich R. The clinical importance of the fat
compartments in midfacial aging. Plast Reconstr Surg Glob Open
2014;1:e92.
38. Wan D, Amirlak B, Giessler P, et al. The differing adipocyte mor­
phologies of deep versus superficial midfacial fat compartments: a
cadaveric study. Plast Reconstr Surg 2014;133:615e–22e.
39. Surek C, Beut J, Stephans R, et al. Pertinent anatomy and anal­
ysis for midface volumizing procedures. Plast Reconstr Surg
2015;135:818e.
40. Surek C, Beut J, Stephans R, et al. Volumizing viaducts of the midface:
defining the Beut techniques. Aesthet Surg J 2015;35(2):121–34.
41. Stern C, Schreiber B, Surek C, et al. Changes in response to com­
partmental volumization of the medial cheek: defining a malar
augmentation zone. Plast Reconstr Surg 2016;137:1401.
42. Cotofana S, Schenck TL, Trevidic P, et al. Midface: clinical anatomy
and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136(5S):219S–34S.
43. Fitzgerald R. Contemporary concepts in brow and eyelid aging.
Clin Plastic Surg 2013;40:21–42.
44. Mitz V, Peyronie M. The superficial musculo-aponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg
1976;58(1):80–8.
45. Gosain AK, Klein MH, Sudhakar PV, et al. A volumetric analysis
of soft-tissue changes in the aging midface using high-resolution
MRI: implications for facial rejuvenation. Plast Reconstr Surg
2005;115(4):1143–52.
46. Le Louarn CL, Buthiau D, Buis J. Structural aging: the facial
recurve concept. Aesthetic Plast Surg 2007;31:213–18.
47. Pessa JE. An algorithm of facial aging: verification of Lambros’s
theory by three-dimensional stereolithography, with reference to the
pathogenesis of midfacial aging, scleral show, and the lateral subor­
bital trough deformity. Plast Reconstr Surg 2000;106(2):479–88.
48. Levy PM. The ‘Nefertiti lift’: a new technique for specific re-
contouring of the jawline. J Cosmet Laser Ther 2007;9:249–52.
49. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr
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50. Furnas DW. Festoons, mounds, and bags of the eyelids and cheek.
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51. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the liga­
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52. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of
the ligamentous attachments of the lower lid and lateral canthus.
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53. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek:
facial layers, spaces, and the midcheek segments. Clin Plast Surg
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system: principles of release, vectors, and fixation. Plast Reconstr
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of the orbitomalar ligament. Ophthal Plast Reconstr Surg 1996;12:
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58. Mendelson B, Wong C. Facial soft-tissue spaces and retaining
ligaments of the midcheek: defining the premaxillary space. Plast
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59. Mendelson BC, Freeman ME, Wu W, et al. Surgical anatomy of the
lower face: the premasseter space, the jowl, and the labiomandibu­
lar fold. Aesthetic Plast Surg 2008;32(2):185–95.
60. Wong C, Mendelson B. Newer understanding of specific anatomic
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55
This chapter was created using the content from Neligan
& Rubin, Plastic Surgery 4th edition, Volume 2, Aesthetic,
Chapter 5.3, Injectables and resurfacing techniques: Bot­
ulinum toxin (BoNT-A), Michael A. C. Kane.
INTRODUCTION
There are many components to the process of facial aging.
Thinning of the dermis, elastosis, loss of facial volume,
genetic factors, gravity, skeletal changes, sun damage,
and smoking all play a part in this process. So does facial
animation. Certain rhytids are primarily caused by facial
movement. Others are caused by other factors as well
as a component of animation. Therefore, as long as a
wrinkle or unattractive shape is as least partially caused
by muscular action, it can be treated with botulinum
toxin A (BoNT-A); however, how well a specific unaes­
thetic area responds to treatment with BoNT-A depends
on how much of the unattractive area is caused by factors
other than animation. For example, a glabellar rhytid
that is almost completely caused by the actions of the
corrugators and procerus muscles in a relatively young
patient can be totally eradicated with BoNT-A. In con­
trast, vertical lip rhytids in an elderly woman with thin
skin, sun damage, a history of smoking, and loss of lip
volume may only be partially improved by careful injec­
tion of the orbicularis oris muscle, which contributes to
the accordion-like scrunching of the overlying lip skin.
BoNT-A treatment is currently the most frequently
performed cosmetic procedure in the US, and its impor­
tance in aesthetic plastic surgery simply cannot be over­
stated. In 2008, nearly 3.6 million BoNT-A procedures
were performed in the US. That is more than all lipo­
suction, breast augmentation, rhinoplasty, facelift, and
blepharoplasty procedures combined.1
Although the subject of this chapter is focused on
the manipulation of facial animation, the ability of the
overlying skin to resist these underlying forces that would
deform it is also of paramount importance when discuss­
ing rhytids.
BASIC SCIENCE
Pharmacology and Pharmacokinetics
Clostridium botulinum is a Gram-positive, anaerobic
bacterium that is known to produce seven serologically
distinct types of toxin, designated A through G, of which
type A is the most potent. Botulinum toxin types A and B
are used medically and are available in the US. The type
A toxin is a fully sequenced, 1296 amino acid polypeptide
protein consisting of a 100-kDa heavy chain joined by a
disulfide bond to a 50-kDa light chain.2
In the normally functioning neuromuscular junction,
the propagation of an action potential at the presyn­
aptic neuron terminal opens voltage-dependent calcium
channels. The influx of extracellular calcium ions causes
vesicles containing acetylcholine to dock and fuse to the
presynaptic neuron’s cell membrane through the action
of a 25-kDa soluble N-ethylmaleimide-sensitive factor
attachment protein (SNAP-25). The released acetyl­
choline crosses the synaptic cleft, where it binds with
nicotinic receptors at the motor endplate, opens sodium–
potassium ion channels, depolarizes the motor endplate,
and initiates the sequence of events that leads to contrac­
tion of the muscle fiber.3
Following the administration of botulinum toxin, the
heavy chain binds to the axon terminal, which enables
C H A P T E R 4 
Injectables and Resurfacing Techniques:
Botulinum toxin (BoNT-A)
Michael A. C. Kane
Key Points
• The most important elements for facial rejuvenation
with BoNT-A are functional anatomy, functional
anatomy, and functional anatomy!
• To minimize the risk of a frozen, unnatural appearance,
use the minimally effective dose of BoNT-A.
• Brow elevation depends on the relative weakness of the
brow elevators versus brow depressors.
• The dose of BoNT-A used should be based on the esti­
mated mass of the muscle being injected, not the depth
of the rhytid.
• Avoiding the use of aspirin and non-steroidal anti-
inflammatory medications will decrease the occurrence
and severity of ecchymosis.
• The lower frontalis muscle has the greatest effect on
brow elevation.
• Threading the injection through the lips gives a more
natural result than the near universal point technique.
• Cooling the skin before injection minimizes discomfort.
• As a general rule, injecting depressors more strongly
than elevators will tend to give a more gentle lift to the
area involved.
• Over-injecting the mentalis can result in a “witch’s
chin” deformity and oral incompetence.

56
MASTER TECHNIQUES IN FACIAL REJUVENATION
the toxin to enter the neuron via endocytosis. In the
cytoplasm, the proteolytic light chain degrades SNAP-25,
thereby preventing fusion of the acetylcholine-containing
vesicle with the cell membrane, preventing release of
acetylcholine. Within a few days, the affected nerve is
incapable of releasing acetylcholine, resulting in flaccid
paralysis of the muscle fiber it innervates. Type-B bot­
ulinum toxin also causes flaccid paralysis but does so
by inhibiting synaptobrevin, a vesicle-associated mem­
brane protein similar to SNAP-25.3 Unless specified,
the remainder of this chapter concerns botulinum toxin
type A.
Recovery begins to occur after several weeks, although
the mechanism for this is not completely understood.
Initially, small neuritic processes grow out of the affected
neurons and establish new functional synapses, which are
capable of acetylcholine release; however, these neuritic
networks shrink and disappear as the original neurons
regain function. The initial clinical response to botuli­
num toxin is usually readily apparent for 3–4 months,
although 6–7 months are often required for the effects
to completely disappear. BoNT-A begins to display an
increased duration of action in most patients when they
undergo treatment on a regular basis. When used cosmet­
ically, the duration of action of BoNT-B is significantly
less than that of type A, with an effective initial response
of 2–3 months.
Commercial Sources of BoNT-A
Several botulinum toxin products are currently available
in the US:
• Botox (onabotulinumtoxinA) for injection (Allergan
Inc., Irvine, CA) is supplied in vials containing 100 U
of vacuum-dried Clostridium botulinum type A neu­
rotoxin complex, 0.5 mg of albumin human, and
0.9 mg of sodium chloride without a preservative.4
• Botox Cosmetic (onabotulinumtoxinA) for injec­
tion (Allergan Inc., Irvine, CA) is provided in vials
containing 50 U of vacuum-dried Clostridium bot­
ulinum type A neurotoxin complex, 0.25 mg of
albumin human, and 0.45 mg of sodium chloride
without a preservative; or 100 U of vacuum-dried
Clostridium botulinum type A neurotoxin complex,
0.5 mg of albumin human, and 0.9 mg of sodium
chloride without a preservative.5
• Dysport
for
injection
(abobotulinumtoxinA)
(Tercica Inc., Brisbane, CA; and Medicis Aesthetics
Inc., Scottsdale, AZ) is supplied in vials containing
500 or 300 U of lyophilized abobotulinumtoxinA,
125 µg human serum albumin and 2.5 mg lactose.6
• Xeomin for injection (incobotulinumtoxinA) (Merz
North America, Raleigh, NC) in 50- and 100-unit
vials.
Commercial Source of BoNT-B
• Myobloc (rimabotulinumtoxinB) injection (Solstice
Neurosciences Inc., South San Francisco, CA) is pro­
vided in 3.5-mL vials containing 5000 U of botuli­
num toxin type B per mL in 0.05% human serum
albumin, 0.01 M sodium succinate, and 0.1 M
sodium chloride.7
The BoNT-A in Dysport and Botox are produced by
fermentation of the bacterium Clostridium botulinum
type A (Hall Strain), while BoNT-B in Myobloc is pro­
duced by fermentation of the bacterium Clostridium bot­
ulinum type B (Bean strain).8 It is important to note that
the potency of each product is specific to the preparation
and assay method utilized, and is not interchangeable
with other preparations of botulinum toxin products.9,10
While this list is comprehensive at the time of writing,
there are other toxins in clinical trials, which we will have
in our armamentarium. Whether these are injectable or
topically applied (RT001, Revance Therapeutics, Newark,
CA), the strategy for these products remains the same; to
identify the offending muscular segments and relax them
to a certain extent. Dosing regimens with these products
will always be in a state of flux. Good judgment, a criti­
cal eye, and an understanding of functional anatomy will
never go out of style. Thus, this chapter is adaptable for
neurotoxins not yet in use. New BoNT-A formulations
will have different complexing proteins, different excipi­
ents, different complex sizes, different pharmacokinet­
ics, and definitely different dosing regimens. The key to
evaluating these products will be dissociation. The basic
function of the lone 1296 amino acid chain is the same.
Cosmetic Indications
Botox Cosmetic is indicated for the temporary improve­
ment in the appearance of moderate to severe glabellar
lines associated with corrugator and/or procerus muscle
activity in adult patients. It is also indicated for the tem­
porary improvement in the appearance of moderate to
severe lateral canthal lines associated with orbicularis
oculi activity in adult patients.5
Dysport is indicated for the temporary improvement
in the appearance of moderate to severe glabellar lines
associated with procerus and corrugator muscle activity
in adult patients <65 years of age.6
Xeomin is indicated for the temporary improvement
in the appearance of moderate to severe glabellar lines
associated with corrugator and/or procerus muscle activ­
ity in adult patients.11
Although the approved use of BoNT-A formulations
for cosmetic use is limited to glabellar rhytids and lateral
canthal lines, it is extensively used off label, and the
author has used it to treat every muscle in the face since
1991.
BoNT-B plays a relatively minor role for cosmetic
applications. It has a faster onset of action than BoNT-A,
which can be beneficial, but its cosmetic usefulness is
limited by greater pain on injection due to its low pH and
a shorter duration of action. In isolated instances, it may
be considered if a patient fails to respond to BoNT-A.
It may also be useful for full-face laser resurfacing and
lower-face scar revision, as the shorter duration of action
will keep the treated area relatively motionless during the
early healing phase while avoiding prolonged, unattract­
ive facial weakness.
The use of BoNT-A and BoNT-B for neurological pur­
poses has become extensive. Its approved use for the
treatment of cervical dystonia12 has grown to include
limb spasticity and dystonias, hypersecretory syndromes

4  INJECTABLES AND RESURFACING TECHNIQUES: BOTULINUM TOXIN (BoNT-A)
57
the use of aspirin and non-steroidal anti-inflammatory
medications for 2 weeks prior to treatment.
Patients have uncommonly developed neutralizing
antibodies for BoNT-A following cosmetic use. These
events are more often associated with the use of high
doses for neurologic purposes,16,17 although this has been
reported following cosmetic use resulting in treatment
failure.18
Dosing
The manufacturer of each BoNT-A product provides rec­
ommended dosing for their product, which is limited to
the indicated uses. However, the facial musculature of
patients is highly variable and precludes the use of stan­
dardized dosing for different aesthetic procedures. Gender
also presents an obvious difference, as men typically (but
not always) have larger muscles requiring higher BoNT-A
doses compared to women.
Using Botox for the treatment of glabellar lines as an
example, the manufacturer recommends injecting 8 U in
each corrugator muscle and 4 U in the procerus muscle
for a total dose of 20 U; however, many practitioners
inject an average of 25 U per glabella, while some advo­
cate doses as high as 80 U and upper face doses of nearly
100 U. A median dose of 15 U is used by the author with
a dose range of 5–22.5 U. Consequently, each clinician
must gain familiarity with these products through expe­
rience and establish their own optimum BoNT-A dosing
techniques.
These principles were demonstrated during a recent
clinical study. Patients were stratified by demographics
and randomized to receive a single treatment with dif­
ferent doses of BoNT-A (Dysport) or placebo.19 Based
on procerus/corrugator muscle mass, women received
doses of 50, 60, or 70 U, while men were treated with
60, 70, or 80 U. Using this variable dosing technique,
85% of BoNT-A-treated patients were rated as treatment
responders by a blinded evaluator after 30 days com­
pared with 3% of placebo-treated patients (p < 0.001).
Compared with patients in other studies who received
50 U to the glabella (the approved, on-label dose), vari­
ably dosed patients tended to have improved efficacy and
quicker onset without increased adverse events.
BoNT-A products are not bioequivalent and cannot
be used interchangeably because of differences in unit
potency and fundamental differences in how these units
are measured. A randomized, double-blind study com­
paring onabotulinumtoxinA and incobotulinumtoxinA
was performed at a dose of 24 units per glabella and
revealed incobotulinumtoxinA to be non-inferior to ona­
botulinumtoxinA.20 I believe it is fair to say that ona­
botulinumtoxinA and incobotulinumtoxinA have similar
dosing regimens while the units of abobotulinumtoxinA
are quite different.
The indicated dilution volume for the 100-unit vial
of Botox Cosmetic is 2.5 mL and for the 300-unit vial
of Dysport is either 2.5 mL or 1.5 mL, both with non-
preserved normal saline. In actual practice, a wide range
of volumes are used from 1.0 mL to 6.0 mL. Most prac­
titioners use preserved saline (off label) for its weak
anesthetic effect (benzyl alcohol is the preservative) and
such as sialorrhea, headache, low back pain,13 and writ­
er’s cramp.14
Warnings and Contraindications
The use of products containing botulinum toxin is con­
traindicated in the presence of infection at the proposed
injection site and in individuals with known hypersensi­
tivity to any botulinum toxin preparation or to any of
the components in the formulation. The use of BoNT-A
is contraindicated in patients with disorders of neuro­
muscular transmission, such as myasthenia gravis or
Lambert–Eaton myasthenic syndrome. Dysport con­
tains a small amount of lactose and may contain trace
amounts of cow’s milk protein. Dysport should not
be use in patients with a known allergy to cow’s milk
protein.6
BoNT-A products should be used with caution in
patients currently taking drugs known to affect neuro­
muscular transmission such as neuromuscular blockers,
lincosamides, aminoglycosides, polymyxins, quinidine,
magnesium sulfate, anticholinesterases, or succinyl­
choline chloride as they may potentiate the effects of
BoNT-A. The safety of administering botulinum toxin to
pregnant women has not been established, and its use in
this population should be avoided.
Adverse Effects
In the United States, due to reports received by the Food
and Drug Administration regarding serious systemic
adverse reactions including respiratory compromise and
death following the use of botulinum toxins types A and
B for both approved and unapproved uses,15 the labeling
of all botulinum toxin-containing products are required
to containing the following boxed warning:
Postmarketing reports indicate that the effects of all
botulinum toxin products may spread from the area of
injection to produce symptoms consistent with botuli­
num toxin effects. These may include asthenia, general­
ized muscle weakness, diplopia, blurred vision, ptosis,
dysphagia, dysphonia, dysarthria, urinary incontinence,
and breathing difficulties. These symptoms have been
reported hours to weeks after injection. Swallowing and
breathing difficulties can be life threatening and there
have been reports of death. The risk of symptoms is
probably greatest in children treated for spasticity but
symptoms can also occur in adults treated for spastic­
ity and other conditions, particularly in those patients
who have underlying conditions that would predispose
them to these symptoms. In unapproved uses, including
spasticity in children and adults, and in approved indi­
cations, cases of spread of effect have occurred at doses
comparable to those used to treat cervical dystonia and
at lower doses.
Adverse events reported by the manufacturers of
BoNT-A and BoNT-B products include nasopharyngitis,
headache, injection site pain, bleeding, bruising, edema,
erythema, infection, inflammation, sinusitis, ecchymosis
and nausea.4–7 Weakness of adjacent muscles may also
occur due to spread of toxin resulting in undesired effects.
These types of adverse events are described in greater
detail below. To minimize bruising, patients should avoid

58
MASTER TECHNIQUES IN FACIAL REJUVENATION
which muscles dominate within the group.21 Even within
a single muscle, different portions of that muscle can
dominate and severely alter animation (Fig. 4.1).
Therefore, it is essential that the face of each patient
be carefully analyzed to determine which portions of
which muscles dominate facial activity and cause wrin­
kles or other unaesthetic shaping of the face. These are
the muscle segments that benefit from treatment with
BoNT-A. The key is to take the necessary time to analyze
the patient’s face and discern these details. This is espe­
cially important in the lower face, and plastic surgeons
should become highly familiar with these muscles and
their possible anatomic variations. Understanding how
the lower face moves is the key to using BoNT-A to
improve nasolabial folds, perioral rhytids, chin dimpling,
marionette lines, and downturned oral commissures. This
is not an area for the novice injector, as a few misplaced
units of BoNT-A is not tolerated nearly as well as they
are in the upper face.22,23
TREATMENT TECHNIQUE
Treatment with BoNT-A does not need to be an all-or-
nothing phenomenon. A certain amount of toxin will
block a certain number of nerve terminals. Thus, fine
control over the amount of denervation desired is pos­
sible. Despite the common use of the word “paralysis”
when discussing the toxin, it is rare that this is actually
as a preservative if the vial is stored for a few days
between uses. A recent poll of a consensus group of
experts revealed that nearly all used each vial on more
than one patient (also not according to the label). Smaller
volumes allow for more concentrated dosing with less
pain (based on volume of injection) per dosage point.
Larger volumes allow for more injection points per dosage
and thus, perhaps, more control. I have used 4.0 mL of
non-preserved saline for both onabotulinumtoxinA and
incobotulinumtoxinA 100-unit vial since 1991 and 2011
and 3.0 mL of non-preserved saline for Dysport since its
introduction.
PATIENT SELECTION
Decision-Making Details of Selecting a Patient
for BoNT-A
The absolute key to becoming a proficient BoNT-A injec­
tor instead of a mere technician is understanding the
functional anatomy of the face. Anatomy textbooks show
the location of different facial muscles and their origins
and insertions. While these texts allow for small and
expected anatomic variations, they cannot prepare the
clinician for the overwhelming differences in functional
anatomy between individuals, or even different sides of
the same face. Even though all individuals have the same
mimetic muscles, their smile patterns vary depending on
Galea aponeurotica
Procerus
Corrugator supercilii
Nasalis
Zygomaticus minor
Zygomaticus major
Levator anguli oris
Buccinator
Masseter
Orbicularis oris
Frontalis
Orbicularis oculi, pretarsal portion
Orbicularis oculi, preseptal portion
Orbicularis oculi, orbital portion
Levator labii superioris alaeque nasi
Levator labii superioris
Auricularis anterior
Risorius
Depressor septi nasi
Platysma
Depressor anguli oris
Depressor labii inferioris
Mentalis
Figure 4.1  Facial muscles.

4  INJECTABLES AND RESURFACING TECHNIQUES: BOTULINUM TOXIN (BoNT-A)
59
not everyone does this. Some people primarily frown in
a vertical pattern, dramatically depressing their brows.
When others frown, they may actually raise their medial
brows while moving them medially, resulting in a quiz­
zical look.
The median dose of BoNT-A used by the author
for treating the corrugators and procerus muscles is
15–17.5 U of Botox and Xeomin for women and men,
respectively, or 50–60 U of Dysport for women and men,
respectively (total dose). After observing the normal ani­
mation of each patient during the consultation process,
the patient is asked to frown and relax, repeatedly, and
then scrunch their nose as if smelling something unpleas­
ant and relax, repeatedly. This allows gauging as to which
sections of which muscles dominate and which specific
areas are to be targeted with BoNT-A (Fig. 4.2).
the desired effect. Rather, a selective weakening of the
musculature is performed to achieve a pleasant cosmetic
effect.
Glabella
The glabella was the first area to be treated cosmetically
with BoNT-A injections. Similar to other areas of the
upper face, this use of BoNT-A was based on longstand­
ing surgical procedures. During a bicoronal browlift, it
was common to debulk the glabellar musculature to ease
glabellar furrowing and reduce downward pull on the
brow.
Even in a seemingly straightforward area of the face as
the glabella, there is a great deal of variation in functional
anatomy. When most people frown, they primarily bring
their brows together as well as depress them; however,
D
C
B
A
Figure 4.2  This patient is in her late 40s. She has been injected with BoNT-A by the author for 16 years. It is 2 years since her last injection.
She has shown an increasing duration of action since 3 years after her injections began. (A) Patient is frowning before injection. Due to long-term
atrophy, she is not able to sharply fold her skin but has mild wrinkling, evidence of muscle bulge, and downward pull on her brows and upper
eyelids. (B) Frowning after injection of 60 Dysport units to her glabellar complex. Her fine rhytids are improved, she can no longer depress her lids
to fully eclipse her lateral eyelids, and her muscle bulge is diminished. Note she has some recruitment of her orbicularis, greater on her right – this
occasionally happens after muscle atrophy. (C) Patient is raising her brows before injection. She is mildly stronger on her left side. (D) Raising brows
after 20 Dysport units were injected into her frontalis with 11 U in her left frontalis and 9 U in her right frontalis. Her forehead is smoother, yet
she is able to exhibit animation and emotion. Her brow asymmetry is partially corrected. Perfect symmetry is not always the goal. As long as asym­
metry is not worsened, most patients are very pleased with the results, as small asymmetries are often not noticed by the patient prior to injection.
Continued

60
MASTER TECHNIQUES IN FACIAL REJUVENATION
F
E
J
I
H
G
(E) Smiling prior to injection. Note the depression of her lateral brow/upper lid mass. She also has a significant pretarsal
orbicularis bulge that she found unsightly. (F) Smiling after 15 Dysport units were injected into her lateral canthal and lower eyelid area (each side
received 15 U). Her crow’s feet are diminished, but very importantly, not removed. No crow’s feet upon smiling is a most unnatural appearance.
Teenagers have crow’s feet when smiling. Her lateral brow is less depressed and her orbicularis roll greatly improved without sacrificing lower lid
position. (G) Showing her lower teeth prior to injection. She exhibits very little depressor anguli oris (DAO) activity. The DAO is the quickest muscle
of the lower face to exhibit signs of atrophy in the author’s experience. Note the asymmetry – the DAO is also the most asymmetric muscle in the
lower face by the author’s experience. (H) Contracting the DAO post-7 Dysport units to the left DAO and 3 units to the right. Her asymmetry is
improved. Her DAO dimple on her left is also improved and her oral commissures are raised. (I) Repose before injection. (J) Repose after above
injections. Her rhytids are improved and she has a slight lift of the brows with decreased upper lid heaviness. The uptick in her oral commissures
is evident. Remember, this patient had less to gain than average patients due to her long-term muscle atrophy.
Figure 4.2, cont’d

4  INJECTABLES AND RESURFACING TECHNIQUES: BOTULINUM TOXIN (BoNT-A)
61
To inject, the author displaces the forehead and brow
cephalad and then with the non-injecting hand fixes it in
position by placing pressure across the superior orbital
rim. The patient is asked to frown, revealing an indenta­
tion in the skin corresponding to the site where the tail
of the corrugator inserts into the dermis of the skin of
the brow in a horizontal frowner. I begin injecting in this
area and progress medially with small injections to the
procerus, which receives little BoNT-A. The same pro­
cedure is repeated across the other brow, moving from
lateral to medial. Most men have significantly longer
corrugators than women with the tail extending lateral
to the mid-pupillary line. Vertical frowners require much
more BoNT-A to be injected into the medial (dominant)
portions of the corrugators and heavy injection of the
procerus. The author often does not inject the lateral tail
of the corrugators in male patients, reducing feminizing
brow spread and permitting more normal animation.
Forehead
Horizontal forehead rhytids may be relieved by inject­
ing and weakening the frontalis muscle. Using Botox
and Xeomin, the dosing range for treating the frontalis
is about 2.5–20 U, although most require 3.75–6.25 U.
The median dose of Dysport in this area is 15 U (all
total doses). The frontalis has highly variable functional
anatomy, and care must be taken to not overly denervate
the frontalis, which can lead to an overly smooth, artifi­
cial appearance, brow ptosis, and eyelid ptosis in patients
who use the frontalis as an accessory eyelid elevator.
Despite its appearance in most anatomy texts, the fronta­
lis is usually continuous across the forehead with muscle
tissue present even at the midline.
After the patient has been observed during normal
animation, they are asked to raise and lower their brows
repeatedly, almost to the point of exhaustion. After observ­
ing this motion, the strongest portions of the muscle, not
the rhytids, are targeted. The author is unaware of any
standard pattern of injection that produces reproducibly
excellent results.
Crow’s Feet and Lower Eyelids
In selected patients, the lateral and inferior orbicularis
oculi can be weakened to diminish the presence of crow’s
feet and lower eyelid rhytids. Patients typically seek treat­
ment for their crow’s feet once they become visible in
repose. Prior to the availability of BoNT-A, the lateral
orbicularis was weakened surgically.24 The convergence
of crow’s feet and lower lid rhytids and the fact that
they are both created by the same muscle lends them to
concomitant treatment with BoNT-A. The classification
of crow’s feet patterns is based on the functional anatomy
of this area.25 In patients with the full-fan pattern, the
lateral orbicularis contracts and wrinkles the overlying
skin from the lateral brow to the lower lid/upper cheek
junction. It is important to recognize different patterns
as well as degrees of asymmetry that may occur in indi­
vidual patients, and treatment is based on the functional
anatomy of the orbicularis oculi.
Overly aggressive treatment in this area can result
in unpleasant results ranging from the “deer in the
headlights” appearance to cheek ptosis. While most
plastic surgeons are aware that the upper lateral orbicu­
laris oculi is a brow depressor, many fail to realize that
the lower lateral portion of the muscle is an important
accessory cheek elevator. If overly denervated in its lower
lateral section, malar flattening as well as an extra “roll”
of skin between the lower lid and cheek can occur.
Excessive chemodenervation of the orbicularis oculi
across the lower lid can produce several unaesthetic
results. In patients with a relatively lax lower eyelid,
frank ectropion or lower lid retraction may result. In
patients with minimal-to-borderline orbital fat prolapse,
weakening the preseptal orbicularis oculi can exaggerate
and hasten the appearance of fat “bags” of the lower
lids. Since this sheet of muscle also functions as a pump,
severe denervation can result in lymphedema.
These potential problems necessitate that these areas
be injected judiciously. Although there are no standard
doses or dosing patterns, the author uses between 3.75
and 5 U of Botox and Xeomin or 12.5 U of Dysport per
side for most patients for both crow’s feet and lower lid
orbicularis. BoNT-A should not be wasted on relatively
adynamic sections of the muscle. To do this, one must
recognize that the functional anatomy of the lateral peri­
orbita varies widely. I inject the most dynamic area of the
muscle first, followed by smaller injections radiating out
from this point. The idea is to create a gentle gradient
of decreased muscle activity and avoid sharp extremes
between total muscle immobility and adjacent areas of
compensatory hypermotility.
Brow Elevation
The use of BoNT-A injections to achieve brow eleva­
tion was once considered controversial. Publications in
the plastic surgical and dermatologic press claimed that
BoNT-A could only depress the brows or at best create
the illusion of a browlift by dropping the medial brow;
however, the author routinely uses BoNT-A to easily and
reliably lift the brows in excess of 6 mm. The concept is
remarkably easy.
To lift the brows, concentrate on injecting muscle seg­
ments that depress the brows actively and at rest, allow­
ing the brows to rise. On the other hand, the concept of
increasing browlift by weakening the only muscle that
lifts them is not well understood. The explanation for
this seeming paradox is that the non-weakened sections
of frontalis react by increasing their pull in compensatory
fashion. This explains why when the lateral orbicularis is
strongly injected, lower lid rhytids will increase.
This is not simply an illusion due to smoothing of
the skin laterally but the result of increasing the resting
tone of the non-injected portion of the muscle across the
lower lid. This also explains why the lateral brows often
peak in an unattractive “Mr. Spock” appearance with
worsening of lateral suprabrow rhytids when only the
central frontalis is injected with a high dose of BoNT-A.
Weakening portions of the frontalis causes other portions
of the frontalis to compensate and lift more strongly. To
maximize browlift, injecting the portions of the frontalis
not responsible for raising brows will induce the frontalis
responsible for brow elevation to pull harder. Usually,

62
MASTER TECHNIQUES IN FACIAL REJUVENATION
Neck
Platysmal bands are another area where BoNT-A injec­
tions can yield excellent results.26 The key to evaluating
the neck as a potential site for cosmetic improvement
involves determining the relative contributions of the skin
and the platysma to banding. The best patients have
minimal skin excess and relatively strong bands (Fig.
4.3). Patients with lax neck skin are poor candidates for
BoNT-A injection because the lax skin will continue to
hang even when the bands are completely paralyzed.
Using Xeomin and Botox, the dosing range is approx­
imately 15–30 U, with most patients requiring about
17.5 U. The typical dose of Dysport is about 50 U. By
asking the patient to show their lower teeth with their
teeth clenched, the platysma band becomes apparent and
may be grasped between the thumb and index finger of
the non-injecting hand. The patient is then asked to relax,
and the muscle is injected starting just below the man­
dibular border and progressing inferiorly to the point at
which the band is visible during normal animation. The
horizontal “necklace” rhytids can also be very minimally
improved by injecting toxin just above and below them.
Good candidates for the treatment of platysmal bands
with BoNT-A include the following: relatively young
(35–45 years) patients with strong bands and minimal
skin laxity are excellent candidates; similarly, patients of
any age who have undergone surgical removal of excess
skin and which have recurrent bands are also good candi­
dates. A smaller but more frequently seen group includes
young patients following an aggressive fat removal via
liposuction in the neck, who subsequently develop visible
platysmal bands.
Nasolabial Folds
The nasolabial fold is an excellent area for BoNT-A
injections in properly selected patients who have been
instructed what to expect.27,28 The levator labii superioris
alaeque nasi is the muscle primarily responsible for the
this means injecting the frontalis more strongly centrally
in the zone above and medial to the brows. The frontalis
lateral to the brows is also injected, causing the frontalis
directly over the brows to lift more strongly.
There are 11 muscle segments that can depress the
medial brow: the procerus, transverse heads of the cor­
rugator, oblique heads of the corrugator, depressor super­
cilii, medial orbicularis oculi, and in some patients, the
nasalis muscles. In most patients, the effect of the nasalis
on brow position is negligible; however, injecting the
other medial brow depressors has occasionally resulted in
disappointing brow elevation. With the other muscle seg­
ments completely non-functional, these patients depress
their brows by wrinkling their nasalis. Subsequent nasalis
injection gave the brows additional elevation.
The lateral brow is depressed by the cephalad portion
of the lateral orbicularis oculi. The dynamic of this action
differs widely among patients, and there is no single point
that can be injected to reliably elevate the lateral brow.
Some patients who do not depress their brows when
smiling will not achieve reliable brow elevation by simply
injecting the upper lateral orbicularis. The key is indi­
vidualized treatment, based on the functional anatomy
of each patient.
There is no standard BoNT-A injection pattern for
brow elevation. For a more medial brow elevation, dener­
vate the medial depressors and weaken the frontalis over
the lateral brow, leaving the medial frontalis strong. For
a more lateral elevation, weaken the lateral depressor
and the medial frontalis. For a peaked and arched brow,
weaken the lateral depressor and leave the frontalis over
the junction of the middle and lateral third of the brow
strong. For men, leave a wider band of frontalis working
to raise the brows uniformly, while keeping them flat,
avoiding feminized, peaked brows. For a unilateral brow­
lift (in addition to the zones not directly over the brows),
weaken the frontalis slightly over the higher brow, induc­
ing the frontalis over the lower brow to pull harder.
B
A
Figure 4.3  This patient is in her mid-30s and requested neck rejuvenation. (A) Straining prior to injection. She has minimal excess skin or fat and
prominent platysmal bands. Her platysma is thick on palpation, she has a greater than normal muscle mass. (B) Straining post-injection of Botox
20 U to her right primary (medial) band and 7.5 U to her right secondary (lateral) band as well as treatment of her left platysma.

4  INJECTABLES AND RESURFACING TECHNIQUES: BOTULINUM TOXIN (BoNT-A)
63
and maxilla. Then ask the patient to smile strongly – the
levator labii superioris alaeque nasi can usually be felt
just lateral to this groove. It is injected once on each
side, just above the periosteum. The dosing range for
this muscle is about 3.75–10 U of Xeomin or Botox with
most patients requiring 5 U in total. The usual total dose
of Dysport is about 15–20 U.
Perioral Lines
BoNT-A is an excellent adjunct for rejuvenating the lower
face; however, excellent control and familiarity with the
drug is essential before injecting these rewarding but tech­
nically demanding areas of the face (Fig. 4.5). Perioral
rhytids, dimpled chin, and downturned oral commissures
are all amenable to improvement by BoNT-A injection.
Once again, fully understanding the functional anatomy
of each patient is the key to achieving reproducibly good
results and avoiding the disastrous consequences of a
few misplaced units of BoNT-A. When first beginning to
inject the lower face, lower doses of BoNT-A and more
frequent touch-ups are better than larger initial doses and
severe complications.22,23
The perioral rhytids are a common area of complaint
for many patients. Radially oriented rhytids are caused by
intrinsic aging of the skin (dermal thinning, sun damage,
smoking), a loss of volume over time, and forced wrin­
kling of the skin caused by its densely adherent under­
lying muscle, the orbicularis oris. The most common
rejuvenative procedure for this area is the injection of
fillers. Injecting hyaluronic acid-containing products into
the vermilion and cutaneous lip improves the rhytids,
restores lost volume, and offers immediate results with
negligible recovery time; however, BoNT-A is an effec­
tive rejuvenative modality for some patients. First, there
are those who are already undergoing BoNT-A treatment
into other areas of the face and wish to also improve
their lip lines. Others want to improve their wrinkles but
are adamant about not increasing the size of their lips
medial nasolabial fold and the final 3–4 mm of central
upper lip elevation.27 Weakening this muscle smooths
the medial nasolabial fold and changes the smile pattern
of the patient. The three major smiling patterns were
described by Rubin.21 The most common or “Mona Lisa”
smile pattern is dominated by the zygomaticus muscle,
which elevates the oral commissures to the highest point
of the smile. The “canine smile” is caused by a dominant
levator labii superioris, and the highest part of the smile
is the central upper lip. This pattern occurs in 35% of the
population, and they are the potential candidates for this
procedure. Since injecting this muscle results in a drop of
the central upper lip when smiling, it converts “canine”
smilers into “Mona Lisa” smilers. Injecting patients with
the Mona Lisa smile results in an exaggerated Mona Lisa
smile that most patients find unattractive.
Patients with “gummy smiles” are basically extreme
canine smile pattern patients (Fig. 4.4). This group ben­
efits the most from BoNT-A injection of the levator labii
superioris aleque nasi. Gummy smilers often smile asym­
metrically, requiring asymmetric injection. They also tend
to have deeper medial nasolabial folds, which are the area
of primary improvement with this technique. The result­
ing drop of the upper lip hides the gingiva and results in
a more pleasing smile.
The technique for this injection is relatively straightfor­
ward once the patient has been determined to be a suit­
able candidate. Before injection, the patient can be given
a preview of the proposed change: the patient smiles into
a mirror held at eye level. Pushing the upper lip down
3–4 mm with a cotton applicator stick gives the patient
a rough approximation of the change to be expected to
the smile as well as the nasolabial fold.
During injection, use the index finger of the non-
injecting hand to firmly press against the inferior portion
of the nasal bone where it meets the maxilla. Thus, half
of the finger is falling into the pyriform aperture while
the other half lies in the groove between the nasal bone
B
A
Figure 4.4  This patient is in her mid-30s and requested improvement of her gummy smile. (A) Prior to injection, smiling. (B) After injection of
750 U of Myobloc (BoNT-B) to her levator labii superioris alaeque nasi muscles and 500 U into her upper orbicularis oris. Note the softening of
her nasolabial folds as well as the lowering of her central greater than her lateral lower lip. This illustrates how all toxins can be used for cosmetic
improvement. The cosmetic use of the currently available BoNT-B is limited, however, by its increased pain on injection (lower pH), potential for
greater spread, and decreased duration of action compared to current BoNT-A preparations.

64
MASTER TECHNIQUES IN FACIAL REJUVENATION
F
E
D
C
B
A
Figure 4.5  This patient complained about the overall appearance of her lower face. The most obvious cause is her mentalis, which is contracted
even in repose (see G). (A) Patient contracting her mentalis prior to injection by pushing her lower lip up. (B) Her mentalis after 5 Botox units
were injected across its surface. The irregularities are greatly improved. (C) Depressing her lower lip reveals her gingival and bilateral rhytids across
her labiomental area (her “DAO dimple”; DAO, depressor anguli oris). (D) Depressing her lower lip after 7.5 Botox units were injected to her
DAO muscles symmetrically. She is unable to show her gingival or even the lower half of her dentition. Her DAO dimples are greatly improved.
(E) Patient puckering her lips prior to injection. (F) Puckering her lips after 2 Botox units were injected into each lip. Her skin puckering is improved
but not gone. Threading toxin injections across the lip can improve this appearance.

4  INJECTABLES AND RESURFACING TECHNIQUES: BOTULINUM TOXIN (BoNT-A)
65
millimeters above the vermillion border and the BoNT-A
is injected as the needle is withdrawn. The upper and
lower lips can be treated in the same session. Complica­
tions can easily result in this area and are usually due
to over-injection. Excessive weakening of the upper lip
leads to problems, first with plosive sounds, followed
by general speech, and finally oral competence. Over-
injection of the lower lip is more likely to result in drool­
ing and competence problems. Beware the elderly patient
with severe rhytids and decreased muscle mass.
Slightly weakening the superficial fibers of the orbicu­
laris oris can help alleviate the overlying rhytids caused
by this sphincter, with or without concomitant filler injec­
tion. In 1998, the author abandoned the more popular
injection point technique and began using the method
of threading the injection a few millimeters above the
vermilion border. This results in a more even appearance
and avoids compensatory areas of hypermotility.
for fear of looking “done”. The third and largest group
of patients receive concomitant BoNT-A and filler injec­
tions. The dermal filler restores volume and fills wrinkles
while the BoNT-A relieves some of the contracting force
applied to the skin by the underlying orbicularis oris.
To judge the relative strength of the sphincter muscle,
the patient is asked to repeatedly purse, then relax, the
lips. The dosing range for Xeomin and Botox is about
2–7 U per lip (5–15 U for Dysport), although most
patients will require only about 3 U per lip (7.5 U for
Dysport). In contrast with other areas of the face where
small, precise doses of BoNT-A are injected, this area is
more broadly injected to achieve a diffuse, general weak­
ening of the sphincter muscle. The philtrum is almost
never injected, as it rarely contains strong rhytids. The
addition of normal saline into the syringe containing the
appropriate BoNT-A dose allows more even placement of
the drug.23 The needle is inserted parallel to and a few
J
I
H
G
(G) Repose prior to injection. (H) Repose after the above injections. Her chin is less wide and more refined from mentalis
injection. Her commissures are raised and her apparent volume deficit below the commissures is gone, due to relaxation of the DAO. Her lips
appear more full and without rhytids from her orbicularis oris injection. The horizontal width of her mouth appears diminished and the overall
shape of the lower face has been improved. (I) Smiling prior to injection. (J) After injection, the patient exhibits a natural smile. Her lower lip is
slightly raised, which helps protect her oral competence and is also more youthful. When injecting many areas of the lower face simultaneously,
the patient can experience a feeling of weakness.
Figure 4.5, cont’d

66
MASTER TECHNIQUES IN FACIAL REJUVENATION
muscles to inject in the lower face. Even if it is slightly
over-injected, it does not lead to oral incompetence but
an actual rising of the lower lip. In fact, patients with oral
competence problems caused by the lower orbicularis oris
or mentalis weakening or a facial nerve injury, may obtain
relief by injecting the depressor anguli oris. Injection of
the lower lip with a viscous hyaluronic acid product at
the same time can also add some static support.
Repair of Surgical Complications
Many complications from aesthetic surgical procedures
can be effectively treated with BoNT-A:
• Browlift: Excessive downward muscle pull on the
brows observed during the early postoperative period
caused by incomplete corrugator or procerus resec­
tion can be treated with BoNT-A, maintaining brow
elevation. Overly elevated brows can be dropped by
aggressively injecting the frontalis muscle.
• Chin augmentation: Surgical misadventures leading
to mentalis disinsertion and dimpling of the chin
can be effectively treated with careful injection of
the superficial mentalis.
• Breast augmentation: Prolonged spasm of the pec­
toralis major can be treated by injecting the lower
pectoralis major.
• Surgery or trauma: Facial nerve injuries can often
be effectively masked by weakening the unaffected
muscle on the other side of the face. For marginal
mandibular nerve injury after facelift, this usually
entails injecting the contralateral depressor anguli
oris muscle and possibly the depressor labii inferi­
oris and mentalis.
Hyperhidrosis
BoNT-A injections have been used for the treatment of
palmar,29 plantar,30 facial,31 and axillary32,33 hyperhidrosis
(excessive sweating). Injections of the soles and palms
may be very painful unless some analgesia is used,34 and
care must be taken not to inject and weaken hand and
foot muscles. Results for this application typically last
somewhat longer, approximately 6 months.
Salivary Glands
Large salivary glands can be decreased in size with
BoNT-A. Controversy exists in plastic surgery over the
surgical resection of submandibular glands during face or
necklift procedures. The author has been decreasing the
apparent size of submandibular and parotid glands for 20
years with BoNT-A. Twenty units of Xeomin or Botox
are used per parotid gland (50 U of Dysport). Large sub­
mandibular glands are started with 15 U of Xeomin or
Botox (40 U of Dysport), which can often be tapered with
repeat injection as the gland shrinks down to 5–7.5 U
(Xeomin or Botox) or 12.5–15 U of Dysport. Patients
are observed in the office for 30 min after submandibular
gland in injection for signs of bleeding into the neck.
POSTOPERATIVE CARE
There is wide disagreement regarding postoperative care
during the first 24 h following treatment with BoNT-A.
Mentalis
Many patients form an unattractive, dimpled pattern on
their chin during active speech or repose with the lips
closed. This appearance results from contraction of the
underlying mentalis muscle, which is connected to the
overlying dermis by dense fibrous septae. These septae
transmit the forces and contours of the superficial men­
talis to the skin. Dimpling and occasional ridging of the
skin in patients with hypertrophy of the mentalis can
result.
Using Botox or Xeomin, the dosing range for the
mentalis is about 2.5–10 U, with most patients requiring
2.5–5 U. Similar results may be achieved using 7–13 U
of Dysport (all doses total). Weakening the mentalis must
be done cautiously, as this muscle raises the chin pad and
lower lip and is critical for oral competence. Care must
be taken to inject only the superficial mentalis, leaving
the deep mentalis fully functional. The injection needle
is threaded cephalad, parallel to the skin surface, aiming
for the plane between the superficial muscle and its over­
lying fascia. It is important to remember that patients
who have an underlying problem with oral competence
can exhibit mentalis hypertrophy from constant use and
present with dimpling. These patients must be injected
with caution and told of the possible risks this treatment
entails. Consequently, injection of the mentalis is often
paired with depressor anguli oris injection to maintain
the height of the lower lip.
Depressor Anguli Oris
The depressor anguli oris is a triangularly shaped muscle
that depresses the oral commissures. This action con­
tributes to the formation of marionette lines and often
creates a distinct diagonal rhytid below the commissure.
Injecting this muscle with BoNT-A raises the oral com­
missures and decreases the show of the lower dentition
when smiling. It also helps to improve marionette lines
and the horizontal crease below the commissure.
Using Xeomin or Botox, the dosing range is about
2.5–10 U, with most patients requiring 5–7.5 U (10–15 U
of Dysport). All doses are total for both sides. The patient
is repeatedly asked to show their lower teeth with their
dentition occluded. This usually creates a diagonal rhytid
below the commissure. Each muscle is injected twice with
the point of the first injection at the level of the horizontal
rhytid. The second injection point is midway between the
first point and the lower border of the mandible, and in
the direction that the muscle pulls the commissure when
contracting. Most patients pull their commissures down
and laterally when contracting; however, some patients
will pull their commissures down and medially. It is along
this axis of motion that the second injection is placed.
Once again, the key to success is to know the func­
tional anatomy of each patient. Also, care must be taken
not to inject the cephalad portion of this muscle. First,
there is very little muscle activity in the cephalad portion
as the muscle tapers and becomes aponeurotic. Second,
the existing muscle (lower orbicularis oris) does not tol­
erate concentrated injections laterally, which can easily
result in oral incompetence and drooling. When properly
injected, the depressor anguli oris is one of the safest

4  INJECTABLES AND RESURFACING TECHNIQUES: BOTULINUM TOXIN (BoNT-A)
67
R E F E R E N C E S
1. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery
National Data Bank: 2014 Statistics. Online. Available at: http://

-aesthetic-plastic-surgery-reports-americans-spent-more-than-12
-billion-in-2014--pro.
2. Sharma S, Zhou Y, Singh B. Cloning, expression, and purification
of C-terminal quarter of the heavy chain of botulinum neurotoxin
type A. Protein Expr Purif 2006;45:288–95.
3. Huang W, Foster J, Rogachefsky A. Pharmacology of botulinum
toxin. J Am Acad Dermatol 2000;43:249–59.
4. Botox® (onabotulinumtoxinA) for injection. Prescribing Informa­
tion. Irvine, CA: Allergan, Inc.; 2009.
5. Botox® Cosmetic (onabotulinumtoxinA) for injection. Prescribing
Information. Irvine, CA: Allergan, Inc.; 2014.
6. Dysport™ for injection (abobotulinumtoxinA). Prescribing Infor­
mation. Brisbane, CA: Tercica, Inc., and Scottsdale, AZ: Medicis
Aesthetics Inc.; 2014.
7. Myobloc® (rimabotulinumtoxinB) injection. Prescribing Informa­
tion. South San Francisco, CA: Solstice Neurosciences Inc.; 2009.
8. Wenzel R, Jones D, Borrego J. Comparing two botulinum toxin
type A formulations using manufacturers’ product summaries.
J Clin Pharm Ther 2007;32:387–402.
9. Wohlfarth K, Sycha T, Ranoux D, et al. Dose equivalence of two
commercial preparations of botulinum neurotoxin type A: Time for
a reassessment? Curr Med Res Opin 2009;25:1573–84.
10. Karsai S, Raulin C. Current evidence on the unit equivalence of dif­
ferent botulinum neurotoxin A formulations and recommendations
for clinical practice in dermatology. Dermatol Surg 2009;35:1–8.
11. Xeomin (incobotulinumtoxinA) for injection. Prescribing Informa­
tion. Greensboro, NC: Merz Pharmaceuticals LLC; 2013.
12. Truong D, Duane D, Jankovic J, et al. The efficacy and safety of
botulinum type A toxin (Dysport) in cervical dystonia: results of the
first US randomized double-blind, placebo-controlled study. Mov
Disord 2005;20:783–91.
13. Ney J, Joseph K. Neurologic uses of botulinum neurotoxin type A.
Neuropsychiatr Dis Treat 2007;3:785–98.
14. Wissel J, Kabus C, Wenzel R, et al. Botulinum toxin in writer’s
cramp: objective response evaluation in 31 patients. J Neurol Neu­
rosurg Psychiatry 1996;61:172–5.
15. Food and Drug Administration. Update of Safety Review of Ona­
botulinumtoxinA (marketed as Botox/Botox Cosmetic), Abobotu­
linumtoxinA (marketed as Dysport) and RimabotulinumtoxinB
(marketed as Myobloc). Department of Health and Human Services;
2009. Online. Available at: <
PostmarketDrugSafetyInformationforPatientsandProviders/Drug
SafetyInformationforHeathcareProfessionals/ucm174959.htm>.
16. Borodic G, Johnson E, Goodnough M, et al. Botulinum toxin
therapy, immunologic resistance, and problems with available
materials. Neurology 1996;46:26–9.
17. Dressler D, Adib Saberi F. New formulation of Botox: complete
antibody-induced treatment failure in cervical dystonia. J Neurol
Neurosurg Psychiatry 2007;78:108–9.
18. Borodic G. Botulinum toxin, immunologic considerations with
long-term repeated use, with emphasis on cosmetic applications.
Facial Plast Surg Clin North Am 2007;15:11–16.
19. Kane M, Brandt F, Rohrich R, et al. Evaluation of variable-dose
treatment with a new U.S. Botulinum Toxin Type A (Dysport) for
correction of moderate to severe glabellar lines: results from a
phase III, randomized, double-blind, placebo-controlled study. Plast
Reconstr Surg 2009;124:1619–29.
20. Sattler G, Callander MJ, Grablowitz D, et al. Noninferiority of
incobotulinumtoxinA, free from complexing proteins, compared
with another botulinum toxin type A in the treatment of glabellar
frown lines. Dermatol Surg 2010;36(Suppl. 4):2146–54.
21. Rubin L. The anatomy of a smile: its importance in the treatment
of facial paralysis. Plast Reconstr Surg 1975;53:384–7.
Recommendations range from no bending for 6 h, to
avoiding airline travel for the first 24 h after treatment,
although evidence for these is lacking. Nevertheless, the
author believes it may be beneficial for patients to avoid
heavy exertion for 90 min following treatment with
BoNT-A. That is approximately the time most believe it
takes for the toxin to bind to the neuron cell membrane.
OUTCOMES, PROGNOSIS, COMPLICATIONS
Potential Adverse Reactions
Adverse events happen with every procedure and BoNT-A
is no exception. Complications, however, tend to be mild,
infrequent, and temporary. Most adverse events related
to treatment arise from proximity spread of the toxin
into adjacent musculature. Difficulty in assessing muscle
mass and consequent dosing also may play a part as there
is no definite method to measure muscle mass prior to
injection.
Ecchymosis and tenderness are common adverse
events that can occur with any percutaneous procedure.
The most frequent adverse events from toxin in the upper
face are brow and lid ptosis. Occasionally, these may be
improved with additional weakening of depressor muscu­
lature, leaving the elevating musculature (frontalis) domi­
nant. Alpha agonist drops may also help to ameliorate lid
ptosis by stimulating Müller’s muscle.
Lower face complications from BoNT-A administra­
tion include asymmetry, dysphagia, and oral competence
issues. For example, adverse events associated with the
treatment of vertical lip rhytids include eating and drink­
ing difficulties or difficulty making certain plosive sounds.
SECONDARY PROCEDURES
Treating Patients Who Had the Procedure but Desire
Improved Results
The most common secondary procedure associated with
BoNT-A injection is concomitant filler injection. The use
of BoNT-A and fillers is highly synergistic. They attack
unaesthetic areas via their different causes, often with
outstanding results. While BoNT-A attacks the underly­
ing mimetic cause, the filler addresses volume and struc­
tural causes of facial and neck aging.
Laser resurfacing is another procedure that benefits
from treatment with BoNT-A. In many ways, the mecha­
nism is similar to the improved results seen with BoNT-A
and scar revision. It appears that the relative decrease in
motion improves wound healing and results in less appar­
ent scar tissue. In addition, it has been apparent that
BoNT-A has several direct dermal effects, which are now
being studied. The author tries to avoid BoNT-A drift
into the dermis because, while it may have a beneficial
effect on acne and pore size, it frequently gives the skin
a shiny, plastic, unnatural appearance.
References available online at expertconsult.com.

4  INJECTABLES AND RESURFACING TECHNIQUES: BOTULINUM TOXIN (BoNT-A)
67.e1
R E F E R E N C E S
1. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery
National Data Bank: 2014 Statistics. Online. Available at: http://

-aesthetic-plastic-surgery-reports-americans-spent-more-than-12
-billion-in-2014--pro.
2. Sharma S, Zhou Y, Singh B. Cloning, expression, and purification
of C-terminal quarter of the heavy chain of botulinum neurotoxin
type A. Protein Expr Purif 2006;45:288–95.
3. Huang W, Foster J, Rogachefsky A. Pharmacology of botulinum
toxin. J Am Acad Dermatol 2000;43:249–59.
4. Botox® (onabotulinumtoxinA) for injection. Prescribing Informa­
tion. Irvine, CA: Allergan, Inc.; 2009.
5. Botox® Cosmetic (onabotulinumtoxinA) for injection. Prescribing
Information. Irvine, CA: Allergan, Inc.; 2014.
6. Dysport™ for injection (abobotulinumtoxinA). Prescribing Infor­
mation. Brisbane, CA: Tercica, Inc., and Scottsdale, AZ: Medicis
Aesthetics Inc.; 2014.
7. Myobloc® (rimabotulinumtoxinB) injection. Prescribing Informa­
tion. South San Francisco, CA: Solstice Neurosciences Inc.; 2009.
8. Wenzel R, Jones D, Borrego J. Comparing two botulinum toxin
type A formulations using manufacturers’ product summaries.
J Clin Pharm Ther 2007;32:387–402.
9. Wohlfarth K, Sycha T, Ranoux D, et al. Dose equivalence of two
commercial preparations of botulinum neurotoxin type A: Time for
a reassessment? Curr Med Res Opin 2009;25:1573–84.
10. Karsai S, Raulin C. Current evidence on the unit equivalence of dif­
ferent botulinum neurotoxin A formulations and recommendations
for clinical practice in dermatology. Dermatol Surg 2009;35:1–8.
11. Xeomin (incobotulinumtoxinA) for injection. Prescribing Informa­
tion. Greensboro, NC: Merz Pharmaceuticals LLC; 2013.
12. Truong D, Duane D, Jankovic J, et al. The efficacy and safety of
botulinum type A toxin (Dysport) in cervical dystonia: results of the
first US randomized double-blind, placebo-controlled study. Mov
Disord 2005;20:783–91.
13. Ney J, Joseph K. Neurologic uses of botulinum neurotoxin type A.
Neuropsychiatr Dis Treat 2007;3:785–98.
14. Wissel J, Kabus C, Wenzel R, et al. Botulinum toxin in writer’s
cramp: objective response evaluation in 31 patients. J Neurol Neu­
rosurg Psychiatry 1996;61:172–5.
15. Food and Drug Administration. Update of Safety Review of Ona­
botulinumtoxinA (marketed as Botox/Botox Cosmetic), Abobotu­
linumtoxinA (marketed as Dysport) and RimabotulinumtoxinB
(marketed as Myobloc). Department of Health and Human Services;
2009. Online. Available at: <
PostmarketDrugSafetyInformationforPatientsandProviders/Drug
SafetyInformationforHeathcareProfessionals/ucm174959.htm>.
16. Borodic G, Johnson E, Goodnough M, et al. Botulinum toxin
therapy, immunologic resistance, and problems with available
materials. Neurology 1996;46:26–9.
17. Dressler D, Adib Saberi F. New formulation of Botox: complete
antibody-induced treatment failure in cervical dystonia. J Neurol
Neurosurg Psychiatry 2007;78:108–9.
18. Borodic G. Botulinum toxin, immunologic considerations with
long-term repeated use, with emphasis on cosmetic applications.
Facial Plast Surg Clin North Am 2007;15:11–16.
19. Kane M, Brandt F, Rohrich R, et al. Evaluation of variable-dose
treatment with a new U.S. Botulinum Toxin Type A (Dysport) for
correction of moderate to severe glabellar lines: results from a
phase III, randomized, double-blind, placebo-controlled study. Plast
Reconstr Surg 2009;124:1619–29.
20. Sattler G, Callander MJ, Grablowitz D, et al. Noninferiority of
incobotulinumtoxinA, free from complexing proteins, compared
with another botulinum toxin type A in the treatment of glabellar
frown lines. Dermatol Surg 2010;36(Suppl. 4):2146–54.
21. Rubin L. The anatomy of a smile: its importance in the treatment
of facial paralysis. Plast Reconstr Surg 1975;53:384–7.
22. Kane M. Botox injections for lower facial rejuvenation. Oral Max­
illofac Surg Clin North Am 2005;17:41–9.
23. Kane M. The functional anatomy of the lower face as it applies
to rejuvenation via chemodenervation. Facial Plast Surg 2005;21:
55–64.
24. Aston S. Orbicularis oculi muscle flaps: a technique to reduce crow’s
feet and lateral canthal skin folds. Clin Plast Surg 1980;8:679–86.
25. Kane M. Classification of crow’s feet patterns among Caucasian
women: the key to individualizing treatment. Plast Reconstr Surg
2003;112(Suppl.):S33–9.
26. Kane M. Nonsurgical treatment of platysmal bands with injection
of botulinum toxin A. Plast Reconstr Surg 1999;103:656–63.
27. Pessa J. Improving the acute nasolabial angle and medial nasolabial
fold by levator alae muscle resection. Ann Plast Surg 1992;29:
23–30.
28. Kane M. The effect of botulinum toxin injections on the nasolabial
fold. Plast Reconstr Surg 2003;112(Suppl.):S66–72.
29. Moreau M, Cauhepe C, Magues J, et al. A double-blind, random­
ized, comparative study of Dysport® vs. Botox® in primary palmar
hyperhidrosis. Br J Dermatol 2003;149:1041–5.
30. Benohanian A. Treatment of recalcitrant plantar hyperhidrosis with
type-A botulinum toxin injections and aluminum chloride in sali­
cylic acid gel. Dermatol Online J 2008;28:5.
31. Glaser D, Hebert A, Pariser D, et al. Facial hyperhidrosis: best
practice recommendations and special considerations. Cutis 2007;
79(5 Suppl.):29–32.
32. Heckmann M, Ceballos-Baumann A, Plewig G. Botulinum toxin
A for axillary hyperhidrosis (excessive sweating). N Engl J Med
2001;344:488–93.
33. Heckmann M, Plewig G. Low-dose efficacy of botulinum toxin A
for axillary hyperhidrosis. Arch Dermatol 2005;141:1255–9.
34. Richards R. Ethyl chloride spray for sensory relief for botulinum
toxin injections of the hands and feet. J Cutan Med Surg 2009;13:
253–6.

68
One of the most important components of any anti­
aging treatment plan is topical skin care. A basic skin
care regimen includes a cleanser, moisturizer, and sun­
screen. Moisturizers that contain beneficial ingredients
are called cosmeceuticals and can be used to improve skin
tone, texture, radiance, hyperpigmentation, pore size, fine
lines, and wrinkles [1]. Treatment outcomes from lasers,
chemical peels and even surgical procedures are signifi­
cantly impacted by the use of skin care products [2]. For
this reason, it is essential to give patients explicit pre­
procedure and postprocedure instructions as to what they
should and should not use on their skin. In this chapter,
we will review the basics of topical skin care and how
cosmeceuticals can be used to rejuvenate aging skin and
enhance treatment outcomes.
CLEANSERS AND TONERS
Cleansers are the most basic component of a skin care
regimen. Cleansers are designed to remove dirt, bacteria,
makeup, and pollution from the skin and to prepare
the skin for product application. Gentle cleansing is
dependent on the composition and pH of the cleanser.
Many cleansing products contain surfactants that disrupt
stratum corneum proteins and lipids, resulting in com­
promised barrier function [3]. In addition, cleansing
products such as true soaps have an alkaline pH, causing
skin irritation. Thus, cleansing products with a neutral
or slightly acidic pH are preferable in the clinical setting.
There are four general categories of cleansing products
including true soaps, synthetic detergent bars (syndets)
and cleansers, combination bars (combars), and lipid-free
cleansers. True soaps are made through saponification,
which is the chemical reaction between a fat and a base
such as lye. These high-pH cleansing bars are excellent
for cleansing the skin but damage stratum corneum lipids
and proteins. Repeated use of true soaps causes dehydra­
tion of the skin and should be avoided. Syndets were
developed to address the problems created by cleansing
with true soaps. Syndets are soap bars and cleansers that
contain less than 10% true soap in combination with
synthetic detergents. With a more favorable pH of 5.5–7,
they can be used daily without causing dry or irritated
skin [4]. Syndets have been tested in patients with sensi­
tive skin and conditions such as rosacea, and are well
tolerated. Lipid-free cleansers are liquid products that
cleanse the skin without the use of fats. They can be used
on dry or wet skin and are massaged to create lather.
Lipid-free cleansers have excellent tolerability and leave
behind a thin moisturizing film on the skin [5]. Patients
who have undergone resurfacing or peeling procedures
may benefit from the gentle cleansing and moisturiza­
tion provided by lipid-free cleansers. Table 5.1 lists mild
cleansing products that are appropriate for postprocedure
patients. Combars are soaps with antibacterial agents
such as triclosan. These are often used to prepare patients
the night before or the morning of a surgical procedure.
Combars are not appropriate for daily use on the face as
they can be drying.
MOISTURIZERS
Chronologically aged skin is characterized by an inherent
reduction in epidermal lipid content, resulting in dehy­
dration and altered skin barrier function [6]. Epidermal
keratinocyte differentiation and desquamation slows with
age, leaving skin dry and flaky. Dry skin is a common
cause of itching in older patients, and in more severe cases
leads to cracks and fissures that impair function. Thus,
the use of properly formulated moisturizers is essential
for patients with aging skin. It is also important to note
that moisturization alone can improve skin wrinkling. A
temporary plumping of the skin occurs after moisturizer
is applied, making lines and wrinkles less noticeable and
giving the skin a dewy appearance. This is why vehicle-
controlled studies are so important for confirming the
long-term benefits of cosmeceutical moisturizers.
Most commercially available moisturizers are oil in
water emulsions. Moisturizers contain approximately
80% water in combination with occlusive, humectant,
and emollient ingredients [7]. Ingredients such as petro­
latum, lanolin, and mineral oil form an occlusive layer on
the surface of the skin increasing stratum corneum hydra­
tion by preventing transepidermal water loss. Glycerin,
hyaluronic acid, sodium lactate, and urea act as humec­
tants that attract water from the dermis upwards into the
epidermis and stratum corneum. Emollients are the ingre­
dients that are responsible for the smooth feel of the skin
that is felt after a moisturizer has been applied. Emollient
ingredients include lanolin, sunflower, and jojoba oil.
Moisturizers include creams and lotions that differ
in their physical properties and chemical composition.
Creams contain more oil, less water, and are thicker and
more occlusive than lotions. Patients with more advanced
skin aging generally prefer creams over lotions. Creams
are also beneficial to treat special areas such as the eyes,
décolletage, and neck. Lotions are easy to spread, making
them good for treating larger surface areas of the body.
C H A P T E R 5 
Topical Skin Care and the
Cosmetic Patient
Patricia K. Farris, MD

5  Topical Skin Care and the Cosmetic Patient
69
Choosing a moisturizer can be daunting, since con­
sumers are faced with so many options. Postprocedure
patients should be advised to use bland moisturizers,
meaning those that do not contain additives such as
alpha hydroxy acids (AHAs), urea, and retinol. These
ingredients can be irritating, causing redness, stinging,
and burning of recently treated skin. In contrast, mois­
turizers with actives such as ceramides, niacinamide, or
hyaluronic acid are preferable, since they provide effec­
tive skin hydration and enhance barrier function without
irritation [8].
It seems counterintuitive, but patients with oily skin
and those who are acne prone also need moisturizers.
Studies have shown that acne patients suffer from defec­
tive barrier function that is exacerbated by the use of
acne medications. Salicylic acid, benzoyl peroxide, and
retinoids all have local adverse effects including irritation
and dry skin. The concomitant use of moisturizers in acne
therapy improves tolerability, and enhances efficacy and
skin comfort [9]. There are many oil-free moisturizers
to choose from that do not contain mineral or vegetable
oils. Oil-free moisturizers use silicone derivatives such as
dimethicone and cyclomethicone to retard moisture loss
without the greasy feel.
SUNSCREEN
Sunscreen is perhaps the most important component of
an antiaging skin care regimen. Sunscreens are the only
topical treatments that have been shown to prevent skin
aging and are essential in patients undergoing cosmetic
procedures [10]. Current photoprotection strategies
include the use of primary and secondary photoprotec­
tors. Primary photoprotection includes sunscreens and
sun-protective clothing that prevent ultraviolet (UV) light
from reaching the skin. Secondary photoprotection refers
to the use of antioxidants and DNA-repair enzymes that
can mitigate damage caused by UV light [11].
Sunscreens are traditionally divided into organic and
inorganic types [12]. Inorganic sunscreens utilize particles
to scatter and reflect UV light. These particles include
zinc oxide and titanium dioxide in micronized forms and
essentially block UV light from entering the skin. Thus,
they are aptly referred to as sunblocks or chemical-free
sunscreens. Inorganic sunscreens are an excellent choice
for postprocedure patients. They are relatively free from
potential allergens and irritating chemicals. Newer for­
mulations with micronized forms of zinc and titanium
dioxide provide a more translucent appearance that is
cosmetically acceptable. Inorganic sunscreens are an
excellent choice for patients with hyperpigmentation or
melasma, as they effectively block both UV A (UVA) and
UV B (UVB) rays. They are also of value for preventing
postinflammatory hyperpigmentation that can occur fol­
lowing resurfacing procedures and peels. Powder-based
mineral sunscreens are popular with consumers and can
be applied several times a day over moisturizer and
makeup. These powders contain organic ingredients and
provide excellent photoprotection.
Organic sunscreen ingredients absorb UV light energy
and transform it into heat. Commonly used UVB-
absorbing ingredients include cinnamates, salicylates,
octocrylene, benzophenones, and menthyl anthranilate.
Effective UVA-absorbing ingredients such as avoben­
zone and ecamsule are now widely available, and offer
expanded broad-spectrum photoprotection. Although
most organic sunscreens are well tolerated, there is a
small risk of contact dermatitis from ingredients like cin­
namates and oxybenzone [13].
COSMECEUTICALS
Aesthetic patients are savvy about skin care and often
seek professional advice when choosing cosmeceuticals.
Cosmeceuticals are moisturizers, serums, and masques
that contain active ingredients that confer added skin
benefits. In the aesthetic practice, the use of cosmeceu­
ticals in combination with cosmetic procedures repre­
sents a new treatment paradigm for skin rejuvenation
[14]. Developing individualized skin care regimens takes
time and requires a basic understanding of cosmeceuti­
cal ingredients. Patients with conditions such as rosacea,
eczema, seborrhea, and acne require specially selected
products that will enhance skin appearance without
exacerbating their underlying conditions. Pre-treatment
with cosmeceuticals can prime the skin for procedures
and post-treatment can mitigate complications. Thus, an
understanding of the benefits of cosmeceutical ingredi­
ents is essential in the clinical setting. Tables 5.2 and 5.3
provide a summary of the benefits of commonly used
cosmeceutical ingredients.
Retinol and Synthetic Retinoids
Vitamin A (retinol) and the synthetic derivatives called
retinoids are among the most well-studied cosmeceutical
ingredients. When applied to the skin, retinol is converted
to retinaldhyde and finally to its active form, all-trans ret­
inoic acid (retinoic acid) [15]. The diverse biologic effects
of retinoic acid are dependent on receptor-mediated
changes in downstream signaling pathways. Retinoic acid
down-regulates UV-induced transcription factor activator
protein 1, turning off the synthesis of the matrix-degrading
enzymes metalloproteinases and increasing collagen pro­
duction. Additionally, retinoic acid downregulates the
UV-induced transcription factor nuclear factor kappa
B (NF-κB), reducing inflammation that contributes to
skin aging. Modulation of these transcription factors is
believed to be responsible for the antiwrinkle effect of
retinoids. Retinoids also lighten hyperpigmentation by
facilitating removal of melanin from the epidermis. Thus,
TABLE 5.1  Gentle Cleansers
Lipid-Free Cleansers
Syndets
Aquanil Cleanser
Aveeno Cleansing Bar Dry Skin
CeraVe Hydrating Cleanser
Cetaphil Gentle Cleansing Bar
Cetaphil Gentle Skin Cleanser
Dove Beauty Cream Bar
Eucerin pH 5

70
MASTER TECHNIQUES IN FACIAL REJUVENATION
Topical application of vitamin C prior to UV exposure
confers photoprotection against sunburn and UV-induced
immunosuppression [18]. In addition, vitamin C acts as
a cofactor for lysyl and prolyl hydroxylase, the enzymes
responsible for the synthesis of collagen. Clinical studies
confirm that consistent use of topical vitamin C improves
skin wrinkling and gives it a more youthful appearance
[19]. Vitamin C inhibits tyrosinase and reduces melanin,
making it an effective skin-lightening agent. Vitamin C
is also an effective anti-inflammatory compound and
has been evaluated in the postprocedure setting. Clinical
studies have demonstrated that topical vitamin C signifi­
cantly reduces postcarbon dioxide (CO2) laser resurfacing
erythema [20].
Products containing vitamin C in combination with
other antioxidants have been shown to provide added
benefits when compared with vitamin C alone. Topical
application of vitamin C plus vitamin E confers greater
photoprotection than either ingredient alone, whereas a
formulation containing vitamin C, E, and the botanical
antioxidant ferulic acid provided eight times the photo­
protection of vitamin C alone [21]. Combination anti­
oxidants have also been looked at in the postprocedure
setting. In a split-face, double-blind, vehicle-controlled
study, patients were treated with vitamin C, E, and
ferulic acid (CEferulic, SkinCeuticals, New York, USA)
or vehicle immediately after fractionated CO2 resurfac­
ing. The antioxidant combination resulted in less edema
and erythema when compared with vehicle control (Fig.
5.1) [22].
Niacinamide
Niacinamide or vitamin B3 is a precursor to the cofac­
tors nicotinamide adenine dinucleotide (NADH) and
nicotinamide adenine dinucleotide phosphate (NADPH),
which are important for a variety of biochemical reac­
tions. Niacinamide readily penetrates human skin and
increased levels of NADH are found in cutaneous tissue
after topical application. There are many clinical benefits
of niacinamide including reducing skin redness, improv­
ing sallowness, and lightening hyperpigmentation [23].
NADPH is a cofactor for synthesis of fatty acids and
lipids such as ceramides, which explains why topical
application of niacinamide enhances skin barrier lipids
and improves barrier function [24]. It also reduces sebum
production and pore size, making it an excellent choice
for patients with oily skin who desire rejuvenation [25].
Niacinamide increases collagen and glycosaminoglycan
production, boosting dermal matrix components that can
smooth wrinkles [23].
Hydroxy Acids
The first-generation hydroxy acids are the alpha hydroxyl
acids (AHAs) including glycolic, citric, and lactic acid.
These compounds were first used for treating hyperker­
atotic skin disorders, and they effectively descale and
smooth skin [26]. Ongoing studies on AHAs demonstrate
that their benefits extend far beyond exfoliation. AHAs
increase glycosaminoglycan and collagen production, and
improve the quality of elastic fibers [27]. Clinical studies
confirm that continued use of AHAs improves fine lines
retinoid-treated skin becomes smoother, less wrinkled,
and has a more even tone.
There are predicable side effects associated with use of
synthetic retinoids that limit their use. Clinically, patients
experience peeling and redness of the skin when first
starting topical retinoids. This reaction, called retinoid
dermatitis, occurs because retinoic acid causes prolifera­
tion of basal keratinocytes, epidermal hyperplasia, and
stratum corneum desquamation. Retinoid dermatitis is
usually self-limited but is the main cause of patients dis­
continuing retinoids. Retinol found in over-the-counter
products is less likely to cause retinoid dermatitis and is
far more tolerable [16]. For this reason, many clinicians
have turned to high-concentration stabilized formulations
of retinol that provide skin benefits without irritation.
Vitamin C
Vitamin C, or L-ascorbic acid, is a water-soluble anti­
oxidant that is a popular cosmeceutical ingredient [17].
TABLE 5.2  Benefits of Cosmeceutical Actives
Cosmeceutical
Ingredient
Skin Benefits
Retinol and
synthetic
retinoids
Improves surface roughness
Reduces matrix metalloproteinases
Increases collagen production
Reduces fine lines and wrinkles
Lightens hyperpigmentation
Vitamin C
Confers photoprotection
Cofactor for collagen synthesis
Reduces fine lines and wrinkles
Lightens hyperpigmentation
Mitigates postlaser erythema
Niacinamide
Improves skin hydration and barrier function
Reduces skin redness and sallowness
Improves fine lines and wrinkles
Lightens hyperpigmentation
Reduces sebum production and pore size
Hydroxy Acids
Exfoliates and smoothens hyperkeratotic skin
Reduce fine lines and wrinkles
Lighten hyperpigmentation
Chelate metals and acts as antioxidant
(polyhydroxy acid, Bionics)
TABLE 5.3  Benefits of Cosmeceutical Actives
Cosmeceutical Ingredients
Skin Benefits
Botanicals
Confers photoprotection
Chemoprevention of skin cancer
Reduces redness
Reduces fine lines and wrinkles
Lightens hyperpigmentation
Inhibits glycation
Peptides
Antimicrobial
Increases collagen and elastin synthesis
Reduces lines and wrinkles
Inhibits muscular contraction
Growth Factors
Boosts collagen production
Softens lines and wrinkles
Enhances postlaser healing

5  Topical Skin Care and the Cosmetic Patient
71
Peptides
Bioactive peptides were first identified through the study
of wound healing. Antimicrobial peptides act as part of
our innate host defense against pathogens and are impor­
tant for wound healing [36]. A second type of peptide
important in wound healing is derived from the break­
down of proteins such as collagen and elastin. These
small peptide fragments are called matrikines and are
produced when skin is injured or inflamed. Matrikines
act to stimulate synthesis of dermal matrix components
such as collagen and glycosaminoglycans [37].
One of the most well-studied matrikines is the penta­
peptide lysine-therine-therine-lysine-serine or KTTKS.
This peptide is derived from the breakdown of pro-
collagen 1 and in vitro studies have confirmed its ability to
stimulate collagen production [38]. KTTKS, or matrixyl,
was one of the first matrikines to be widely available in
cosmeceuticals. A palmitoyl chain was added to KTTKS
to enhance skin penetration, and thus this matrikine is
referred to as Pal-KTTKS. Clinical studies confirm the
benefits of Pal-KTTKS, including improvement in skin
texture and wrinkling [39]. The elastin-derived peptide
valine-glycine-valine-alanine-proline-glycine (VGVAPG)
has also been studied and is chemotactic for fibroblasts
and enhances collagen production [40]. The tripeptide
glycyl-L-histidyl-L-glysine (GHK) has been used as a
carrier to facilitate uptake of copper by cells. The GHK-
copper complex stimulates collagen synthesis by fibro­
blasts and metalloproteinase enzymes, and is important
in dermal remodeling [41].
Peptides that inhibit neurotransmitter release are found
in cosmeceuticals claiming to have Botox-like effects.
Argireline, or acetyl hexapeptide-3, has been shown to
and wrinkles, and thickens skin compared with vehicle
control [28]. AHAs also reduce pigment clumping in the
epidermis, making them effective skin lighteners.
Although AHAs are extremely effective antiaging
ingredients, side effects such as stinging and burning limit
their use in some patients. To address this problem, poly­
hydroxy acids including gluconolactone and bionic acids
such as maltobionic acid and lactobionic acid were devel­
oped. These second- and third-generation hydroxy acids
provide clinical benefits similar to AHAs without irrita­
tion. Gluconolactone has been used to treat patients with
rosacea who are generally sensitive to alpha hydroxys
[29]. As an added benefit, the polyhydroxy and bionic
acids are also antioxidants and chelate metals that con­
tribute to oxidative stress [30].
Botanicals
Botanical extracts are found in many cosmeceutical for­
mulations. Extracts of green tea, grape seed, resveratrol,
pine bark, pomegranate, and Coffea arabica are among
the most popular. Botanical extracts contain a variety of
phenolic and polyphenolic antioxidants that neutralize
free radicals, inhibit metalloproteinase production, and
increase collagen production [31]. Polyphenols inhibit
protein glycation, which contributes to the wrinkling
and sallowness seen in sun-damaged patients [32]. They
also act as anti-inflammatory compounds, inhibiting
NF-κB, cyclooxygenase 2, and other inflammatory path­
ways. Polyphenols confer photoprotection and prevent
skin cancers [33]. Clinical studies confirm the benefits of
topically applied botanical extracts including lightening
pigmentation, improving lines and wrinkles, and reduc­
ing skin redness [34,35].
A
B
Figure 5.1  (A) Day 1 post-laser resurfacing. (B) Day 3 post-laser resurfacing: patient’s left side shows enhanced healing as a result of using a
cosmeceutical containing vitamin C, E and ferulic acid. Right side was treated with a placebo.

72
MASTER TECHNIQUES IN FACIAL REJUVENATION
hyaluronic acid serum (Hyalis; Neocutis, Raleigh, USA)
in combination with a human growth factor and cytokine
cream (Bio-Cream-Bio-restorative Skin Cream with PSP,
Neocutis, Raleigh, USA) used pre- and post-micro-laser-
peel [51]. The use of growth factor cosmeceuticals with
aesthetic procedures remains a mainstay of treatment
today.
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1995;105(4):549–56.
17. Farris PK. Topical vitamin C: a useful agent for treating photoag­
ing and other dermatologic conditions. Dermatol Surg 2005;7(Pt
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21. Lin FH, Lin JY, Gupta RD, et al. Ferulic acid stabilizes a solution
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inhibit soluble N-ethylmaleimide-sensitive fusion protein
attachment protein receptors complex formation, thus
blocking acetylcholine release [42]. Clinical studies have
confirmed that argireline does inhibit muscular contrac­
tion in the forehead, nasal flare, neck, and around the eyes
[43]. In a randomized, placebo-controlled study, topical
argireline was shown to improve periorbital wrinkles, as
evidenced by investigator grading and silicone replicas
[44]. Although this peptide is a promising topical ingre­
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it do not approach the benefits of a neurotoxin that has
been injected intramuscularly [45].
Growth Factors
Growth factors and cytokines regulate a variety of
pathways important in skin aging. The use of growth
factors for skin rejuvenation is supported by the fact
that suppression of transforming growth factor beta by
UV-induced oxidative stress results in overexpression of
metalloproteinases and a reduction in collagen produc­
tion. There are several cosmeceuticals containing human
growth factors and cytokines harvested from fetal fibro­
blasts. Additionally, plants and animal growth factors are
marketed as skin-rejuvenating compounds. The topical
application of growth factors is limited by the fact that
human growth factors are hydrophilic and have a large
molecular weight that prevents them from penetrating
the epidermis [46]. Some have suggested that alternative
routes to the dermis might include hair follicle penetra­
tion. Clinical studies have confirmed that consistent use
of cosmeceuticals containing growth factors and cyto­
kines improves skin wrinkling [47]. Histologic evidence
of collagen production and skin thickening has also been
reported [48,49]. In aesthetic practice, the use of topical
growth factors has gained popularity as an adjunct treat­
ment for patients undergoing laser resurfacing, as they
are known to be important in wound healing [50]. Clini­
cal studies have confirmed the benefits of applying a 1%

5  Topical Skin Care and the Cosmetic Patient 72.e1
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of Dermatology 72nd Annual Meeting, Denver, Colorado. 2014
Poster Presentation; P8601: AB204.

72.e2
MASTER TECHNIQUES IN FACIAL REJUVENATION
skin cream for the treatment of skin rejuvenation. J Cosmet Laser
Ther 2008;10(2):104–9.
50. Moulin V. Growth factors in wound healing. Eur J Cell Biol
1995;68(1):1–7.
51. Gold MH, Cohen J, Katz BE. Human growth factor cream and
hyaluronic acid serum in conjunction with micro laser peel: an
efficient regimen for skin rejuvenation. J Clin Aesthet Dermatol
2007;56(2 Suppl.):AB203.
47. Sundaram H, Mehta RC, Morine JA, et al. Topically applied physi­
ologically balanced growth factors: a new paradigm of skin reju­
venation. J Drugs Dermatol 2009;8(5 Suppl. Skin Rejuvenation):
4–13.
48. Fitzpatrick RE, Rosatan EF. Reversal of photodamage with topical
growth factors: a pilot study. J Cosmet Laser Ther 2003;5(1):25–34.
49. Hussain M, Phelps R, Goldberg DJ. Clinical, histologic, and ultra­
structural changes after use of human growth factor and cytokine

73
INTRODUCTION
Facial aging is complex and occurs at all tissue levels,
from the underlying skeletal scaffolding, through the
musculature, adipose tissue, and skin. Advances in aes­
thetic medicine now allow us to not only recognize spe­
cific changes in these tissue layers, but also address and
in some cases correct the clinical signs of aging at its
respective anatomic site.
The skin ages through two main processes: intrinsic
and extrinsic aging. Intrinsic aging is the result of genetic
background and chronology. It is an inevitable conse­
quence of aging seen in all anatomic locations of skin
regardless of exposure to ultraviolet (UV) light. Changes
characteristic of intrinsic aging include decreased elastic­
ity, decreased skin turgor, and loss of hair. On histology,
the skin demonstrates flattened rete ridges and dermal
atrophy [1]. Extrinsic aging of the skin is the result
of external factors such as UV exposure, alcohol use,
tobacco use, and nutrition. These are largely controllable
factors and therefore extrinsic aging is not necessarily
inevitable. UV exposure is the primary driver of extrin­
sic aging, with some estimates attributing over 80% of
facial skin aging to the sun [2]. Extrinsically aged skin
appears primarily in sun-exposed areas such as the face,
neck, chest, and extensor arms, and is often referred to as
“photo­aging”. Clinically it appears as rhytids, dyschro­
mia, lentigines, loss of elasticity, skin fragility, telangiecta­
sias, and purpura. In more severe cases actinic keratoses
and skin cancer begin to develop.
Aging of the skin, particularly that of photoaging, is
readily apparent to both patient and practitioner and a
common reason to visit a cosmetic physician. Because
the pathologic process of photoaging is primarily limited
to the epidermis and upper dermis, it is readily ame­
nable to treatment with a wide variety of lasers and light
sources. In 2014, over a half a million laser skin resur­
facing procedures were performed in the United States,
a 218% increase from 2000 [3]. The remainder of this
chapter will address the use of lasers to resurface the skin
and treat signs of aging. The focus of this chapter is to
review the principles and clinical applications of lasers in
the treatment of aging skin. A full understanding of the
physical properties of lasers used in medicine allows the
practitioner to best adjust the settings to each patient and
clinical application.
LASER PRINCIPLES
The word laser is an acronym for Light Amplification
by Stimulated Emission of Radiation. Lasers contain
four key components: (1) an excitable medium; (2) an
energy source; (3) mirrors forming an optical cavity; and
(4) a delivery system. When energy is applied to the
lasing medium, photons are emitted that stimulate further
photon emission equal in energy and wavelength. This
results in the emission of photons that are in phase both
temporally and spatially; thus, the light emitted by a laser
is one single wavelength, or monochromatic. This is a
key attribute of lasers and why devices that emit a range
of wavelengths, like intense pulsed light, are not lasers
but should be referred to as light sources. Emitted light
from lasers is completely in phase, meaning all peaks and
troughs of the wave are in line. Thus, the light is termed
coherent. This property allows the laser to be focused to
a spot size as small as the wavelength itself. Additionally,
the beam of light from a laser is collimated, meaning it
travels in a parallel, nondivergent path unlike that of
traditional light sources
Skin Optics and Selective Photothermolysis
When light from a laser strikes the skin there are four pos­
sible interactions: (1) reflection; (2) scattering; (3) trans­
mission; and (4) absorption. Reflected light is redirected
away from the skin and therefore no tissue effect occurs.
However, the reflected light can cause ocular harm to
those around. Reflection is least when light strikes per­
pendicular to the skin. Scattering of light occurs when
the beam meets tissue and spreads in different directions.
Scattering limits the effective depth of penetration of
lasers. In general, larger spot sizes have less scatter, result­
ing in a greater depth of penetration. Transmission is the
direct, unaltered penetration of light through tissue. The
final light-skin interaction is absorption. This is where
the energy of the photon is absorbed by the skin, leading
to effect on the tissue. This is the desired effect when
delivering a therapeutic treatment.
Absorption within the skin occurs when light strikes
a chromophore. The main chromophores in the skin
are hemoglobin, melanin, and water. When absorption
occurs, a photon transmits its energy to the chromophore
and generates heat. Thermal coagulation, if controlled
and confined, can lead to selective destruction of a variety
of targets in the skin.
In 1983, Anderson and Parish [4] published a seminal
paper on the theory of selective photothermolysis. They
described how with proper laser parameter selection, one
could achieve confined thermal damage of a target struc­
ture while leaving the surrounding tissue intact. To occur,
the wavelength of light must be selectively absorbed by
the target chromophore and be emitted for a duration
less than or equal to the thermal relaxation time of the
C H A P T E R 6 
Skin Resurfacing
H. Ray Jalian, Andrew Breithaupt, and Mathew M. Avram

74
MASTER TECHNIQUES IN FACIAL REJUVENATION
B
A
Figure 6.2  Preoperative (A) and postoperative (B) photographs of a patient who received ablative laser resurfacing.
target. This allows for the confinement of heat. Thermal
relaxation time of a molecule is directly related to the
size and shape of the target. This theory has led to the
development of numerous lasers with specific targets and
clinical applications.
HISTORY OF LASER RESURFACING
Treatment of photodamaged skin with laser resurfacing
has been the gold standard for rejuvenation for over 30
years. Fully ablative resurfacing with continuous-wave
carbon dioxide (CO2) or erbium:yttrium-aluminum-gar­
net (Er:YAG) gained significant popularity in the early
1990s. The primary chromophore for these devices is
water. There are several absorption peaks for tissue
water, as demonstrated in Fig. 6.1. Er:YAG emits light at
2940 nm, allowing for precise vaporization of tissue with
minimal residual thermal damage. This is termed tissue
ablation. CO2 lasers emit light in the far infrared spec­
trum at 10,600 nm and are also absorbed well by water,
resulting in tissue ablation, albeit a slightly larger layer
of residual thermal damage. The larger residual thermal
damage is likely responsible for its superior clinical effect
in improving rhytids.
Fully ablative laser skin resurfacing leads to dramatic
results (Fig. 6.2), but also significant postoperative mor­
bidity and complications. Ablation of the entire epi­
dermis is essentially a well-controlled, partial-thickness
skin burn. With this comes several postoperative days of
copious oozing and crusting. Even with proper wound
care, days to weeks off work and social activity are
often required. During this time there is also significant
105
104
103
10-1
10-2
10-3
100
10
1
1000
2000
3000
9000
10,000
11,000
12,000
Figure 6.1  Absorption spectrum for water in the visible and infrared spectrum. Peaks of absorption correspond to nonablative fractional wave­
lengths 1440 to 1550 nm (•), 1927 nm (■), and classical ablative wavelengths Er:YAG 2940 nm ( ) and CO2 at 10,600 nm (★). CO2, Carbon
dioxide; Er:YAG, erbium:yttrium-aluminum-garnet.

6  Skin Resurfacing
75
thermal coagulation within the dermis and a portion of
the epidermis while leaving the stratum corneum intact,
thus termed nonablative (Fig. 6.3). The array, width,
and density of these columns are dependent on both the
device and parameters chosen.
Histologically, studies demonstrate reproducible events
following NAFR (Fig. 6.4). The MTZs of denatured
collagen along with superimposed epidermal plugs are
infection risk. Once reepithelialization has occurred, the
patients often experience prolonged erythema that can
last 3 to 6 months. Even with experienced laser opera­
tors, the risk of scarring, permanent pigmentary changes,
and demarcation lines with traditional resurfacing remain
high. These adverse effects lead many to explore alterna­
tive methods to address photoaging.
To overcome the multitude of complications with tra­
ditional ablative resurfacing, nonablative technologies
were developed. The goal of these devices was to target
the tissue water within the dermis, resulting in thermal
damage, protein denaturation, and subsequent collagen
synthesis and tissue remodeling. A theoretical advantage
of keeping the epidermis intact would result in a lower
incidence of adverse events, namely infection, pigmentary
alteration, and scarring. A variety of wavelengths were
developed, including 1320- to 1450-nm devices. Indeed,
any device that emits light absorbed by water and that
repeatedly deposits heat in the skin does provide some
degree of nonablative rejuvenation. This is also true for
other nonablative devices classically used to treat super­
ficial dyschromia and telangiectasias including vascular
selective lasers, such as the pulsed-dye laser, and broad-
band light sources [5,6]. While the side effects and com­
plications are significantly lower with nonablative devices
compared with classical ablative lasers, so are the results.
Fractional Resurfacing
A paradigm shift with laser resurfacing occurred with
the introduction of fractional photothermolysis [7].
The concept was pioneered by Anderson and Manstein,
and led to the first marketed device in 2004. Fractional
photo­thermolysis uses narrow beams of high-energy light
applied to the skin in a pixelated pattern. The tiny zones
of treatment, termed “microthermal zones” (MTZs), are
essentially islands of thermally damaged skin surrounded
by normal tissue, allowing for rapid recovery from the
uninjured reservoir. Fractionation can be applied to both
ablative and nonablative lasers.
Since its introduction, fractional photothermolysis has
been widely accepted as the first-line approach for most
patients undergoing resurfacing. With the later introduc­
tion of ablative fractional resurfacing (AFR), combin­
ing features of classical ablative lasers and nonablative
fractional photothermolysis, the armamentarium is even
more equipped to deal with extrinsic and intrinsic aging.
The remainder of this chapter will focus on fractional
resurfacing, including clinical applications, patient selec­
tion, and potential complications.
Nonablative fractional resurfacing (NAFR) received
clearance by the Food and Drug Administration in 2004
for the treatment of periorbital rhytids. Since then,
numerous studies have demonstrated efficacy not only
for rhytids but also for other indications, including dys­
chromia and acne scarring [8–11].
Central to treatment of all these conditions is the mech­
anism of action of NAFR. Various devices with wave­
lengths in the near-infrared spectrum (1400–1600 nm)
are available from several manufacturers. The wave­
lengths of light emitted by these devices are significantly
absorbed by water. The energy delivered causes zones of
Figure 6.3  Ex vivo porcine skin treated with a nonablative fractional
resurfacing device (1550 nm). Note the columns of thermal coagulation
referred to as microthermal zones (rectangle) surrounded by unaffected
epidermis and dermis.
A
B
Figure 6.4  Improvement in periorbital rhytids, skin texture, dyschro­
mia, and skin texture (A) before and (B) following four nonablative
fractional resurfacing treatments (1550 nm).

76
MASTER TECHNIQUES IN FACIAL REJUVENATION
technology is that it allows for combination of superficial
ablation with deep delivery of heat using a variety of
different microneedle arrays that vary in density, width,
and depth. Moreover, the availability of insulated needles
enables delivery of radiofrequency at the distal tip, which
allows for significant thermal injury to several layers of
the dermis while avoiding thermal injury to the epider­
mis. This allows for the treatment of darker skin photo­
types with a theoretical lower risk of postinflammatory
pigment alteration.
PATIENT SELECTION
In assessing a patient for fractional resurfacing, a com­
plete history and physical examination should be part of
the initial consultation. History of photosensitizing disor­
ders, medication history including recent isotretinoin use
in the last 6 to 12 months, and prior gold intake should
be ascertained. In addition, patients should be questioned
regarding history of sclerosing disorders (e.g., sclero­
derma), as these affect the density of adnexal structures
in the skin, which is the reservoir for reepithelialization,
particularly in classical resurfacing. Patients should also
be asked about smoking as this may affect the healing
process. History of labial herpes simplex virus (HSV)-1
should also be elicited for consideration of appropri­
ate prophylaxis prior to procedure. Finally, caution must
be taken with patients who have had prior history of
lifting procedures that may have moved neck skin onto
the face.
As with any cosmetic consultation, patients’ individual
goals should be discussed at the onset of the procedure.
Fractional resurfacing requires multiple treatments, and
even in the best of outcomes, the results rarely approach
that of classical resurfacing. The degree of tightening
or lifting also by no means approaches a facelift, and
patients should also be counseled regarding this.
PROCEDURE
Prior to the procedure, the patient should abstain from
the use of topical retinoids. Sun exposure prior to and
following resurfacing greatly increases the risk of pig­
mentary alteration, and patients should be counseled to
practice good sun protection and minimize sun exposure.
Most patients are able to tolerate NAFR with topical
slowly extruded from the skin [12]. The epidermal debris,
termed microepidermal necrotic debris, or MENDs, are
largely responsible for the immediate clinical improve­
ment seen in pigmentation. This is clinically evident as the
bronzing that patients get about 48 hours after treatment.
It is this exfoliation and extrusion of pigmentation that
results in the rapid improvement in dyschromia and skin
texture following treatment.
Improvement in rhytids occurs more slowly following
NAFR. Indeed, this is somewhat intuitive, as the col­
lagen remodeling process involves a complex cascade of
gene expression, protein synthesis, and subsequent neo­
collagenesis. This has been eloquently demonstrated in
histological studies showing upregulation of heat shock
proteins and procollagen up to 3 months following a
single treatment [13].
NAFR is also effective for the treatment of atrophic
acne scars (Fig. 6.5) and particularly useful in darker skin
phototypes that were at increased risk of prolonged pig­
mentary alteration with prior technologies [14]. Surgical
scars also improve following NAFR, which is particularly
useful for hypopigmented postsurgical scars.
More recently, the introduction of the thulium wave­
length fractional resurfacing (1927 nm) laser allows for
delivery of a superficially penetrating wavelength that
is ideal for the treatment of photoaging [15]. Because
light at this wavelength has a relatively high absorption
coefficient for water, it does not penetrate as deeply into
the skin as other nonablative wavelengths. This is an
ideal laser for patients who have extensive dyschromia
(Fig. 6.6).
AFR was introduced shortly following NAFR. Instead
of depositing heat into the skin, ablative wavelengths of
light (Er:YAG, CO2) delivered in a pixelated array evapo­
rate the skin, creating small columns of vaporization
including epidermal ablation (Fig. 6.7) [16]. Depending
on the device and energies used, columns up to 3 mm
deep of various widths can be created. By removing
tissue, there is an immediate tightening at the time of the
procedure. These devices are more effective at treating
rhytids than their nonablative counterparts, but require
more downtime and have a higher risk of adverse events.
More recently, numerous studies using electrode pin
fractional radiofrequency demonstrate the utility of using
such devices in treating rhytids, scarring, skin tightening,
and tissue lifting (Fig. 6.8) [17,18]. The advantage of this
Figure 6.5  Moderate reduction in acne scarring (A) before and (B) 3 months following three nonablative fractional resurfacing treatments
(1550 nm).

6  Skin Resurfacing
77
Treatment parameters for fractional resurfacing are
largely device dependent, but two main considerations
are treatment energy and treatment density. The energy
selected is correlated with depth. In general, higher energy
settings result in greater depth of laser penetration. The
energy setting should be tailored to the depth of the
pathology treated. Density refers to the percentage of
skin covered with each treatment. Density is correlated
to the “aggressiveness” of the treatment. Higher densi­
ties require longer recoveries. A word of caution: there
is a wide variety in density from device to device. It is
important to be familiar with your particular device and
realize that settings from one device are not necessarily
translatable to another device. Caution should be taken
when treating nonfacial sites. Given the lower density of
adnexal structures, density should be decreased to reduce
risk of adverse events.
COMPLICATIONS
Both NAFR and AFR have lower risks of complications
than classical resurfacing. However, as with any pro­
cedure, complications still occur. Erythema after both
NAFR and AFR is an expected consequence of the pro­
cedure. For NAFR, prolonged erythema is defined as
redness beyond 4 days following treatment. It occurs
in roughly only 1% of patients. With AFR, redness can
anesthesia alone. For AFR, regional nerve blocks can
greatly enhance comfort for patients.
Following treatment, a sunburn sensation is typical and
can last for several hours. Erythema and edema can be
pronounced, particularly with AFR, but healing is quite
rapid, with reepithelialization and sloughing complete by
1 week for facial sites. Recovery is delayed on nonfacial
sites and can take up to 3 weeks for full desquamation.
A
C
D
B
Figure 6.6  (A, B) Improvement in dyschromia on the face 2 weeks following a single treatment with superficially absorbed thulium fractional laser
(1927 nm). (C, D) Similar improvement following two treatments on the chest following fractional nonablative resurfacing (1927 nm).
Figure 6.7  Ex vivo porcine skin treated with ablative fractional resur­
facing device (10,600 nm). Note the columns of tissue ablation bor­
dered by thermally coagulated collagen referred to as “residual thermal
damage”. Note normal dermis and epidermis immediately adjacent to
residual thermal damage.

78
MASTER TECHNIQUES IN FACIAL REJUVENATION
aureus and atypical mycobacteria following these pro­
cedures [21]. Fungal infections are rare, with infections
occurring in roughly 1% of patients. Any patient that
has persistent pain with pustulation following proce­
dures should have a culture performed or be given a
single dose of fluconazole 200 mg for potential candidal
superinfection.
Milia can occur in up to 20% of individuals and can
largely be attributed to the use of occlusive dressings or
emollients following treatment. In those with a prior
history of acne, acneiform eruptions are not uncommon
and can occur up to 10% of the time, though at a much
lower rate than traditional resurfacing. Simple prophy­
laxis with oral doxycycline 1 week prior to and 1 week
following treatment can greatly reduce the occurrence or
extent of eruption.
Scarring can occur following both NAFR and AFR.
Hypertrophic scarring has been reported following both
NAFR and AFR [19,22]. There are several factors that
likely contribute to this, including bulk heating result­
ing from inappropriate cooling, excessive stamping, or
high-density treatments. Certain anatomic locations may
have a slightly higher risk of scarring, including the neck,
periorbital region, and mandible.
CONCLUSION
The advent of laser technology has dramatically changed
the way we are able to treat aging skin. As the technol­
ogy has become more refined, we now have a number of
both ablative and nonablative fractional devices at our
disposal. With proper understanding of the technology,
physicians can choose the correct device and parameters
to give their patient the desired outcome while greatly
minimizing the risk of complications. While the risk may
be small, it remains paramount that any laser operator
be able to anticipate, recognize, and treat complications
should they arise.
persist beyond 1 month in about 12% of patients [19].
While this can be concerning to the clinician and patient,
erythema should be considered a reflection of ongoing
inflammation and subsequent collagen remodeling, and
typically resolves spontaneously with 3 months follow­
ing treatment.
Pigmentary alteration also occurs following fractional
resurfacing. During the normal healing course there is
a “bronzing” that patients develop that is subsequently
sloughed off. This is part of the normal healing process
and represents the extrusion of the MENDs. This typ­
ically occurs within 3 to 5 days following treatment.
Postinflammatory hyperpigmentation can occur fol­
lowing initial desquamation and is a well-known side
effect of both NAFR and AFR. Thankfully, it is most
often self-limited and occurs with a far lower incidence
than with traditional resurfacing. Certain factors can
increase the incidence of postinflammatory hyperpig­
mentation, including device treatment parameters (e.g.,
higher densities), perioperative sun exposure, and Fitz­
patrick skin type. Thankfully, cases of delayed onset
permanent hypopigmentation following either NAFR or
AFR, as occurs with classical resurfacing, have not been
reported.
Reactivation of HSV-1 following treatment occurs
in up to 2% of all treatments performed [20]. In this
context, HSV typically presents as superficial or punched
out erosions that are often painful. There may or may not
be an antecedent classical labial lesion prior to dissemina­
tion onto the treated skin. Patients with a known history
of HSV-1 should receive appropriate prophylaxis at the
time of treatment and continuing through the period
until reepithelialization is complete. Delayed recognition
or improper treatment greatly raises the risk of scarring
postresurfacing.
The incidence of bacterial infection following frac­
tional resurfacing appears to be low; however, there are
increasing reports of methicillin-resistant Staphylococcus
B
A
Figure 6.8  Improvement in periorbital rhytids (A) before and (B) 3 months following a single treatment with bipolar electrode pin fractional
radiofrequency treatment using 3000-µm and 600-µm-depth microneedle arrays.

6  Skin Resurfacing
79
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review. Br J Dermatol 2012;166(6):1160–9.
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controlled trial on the efficacy of fractional photothermolysis on
scar remodeling. Lasers Surg Med 2011;43(4):265–72.
10. Tierney EP, Hanke CW. Review of the literature: Treatment of
dyspigmentation with fractionated resurfacing. Dermatol Surg
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ment complications: a review. Dermatol Surg 2010;36(3):299–306.
21. Xu LY, Kilmer SL, Ross EV, et al. Bacterial infections following
non-ablative fractional laser treatment: a case series and discussion.
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Lasers Surg Med 2009;41(3):185–8.

80
HISTORY
The brow has historically been overlooked in the reju­
venation of the aging face. The focal procedure of facial
rejuvenation has always been the rhytidectomy. Surgi­
cal forehead rejuvenation began at the turn of the 20th
century [1]. Passot [2] has been generally recognized as a
pioneer in the field. Several other surgeons described their
work over the subsequent years [3–6]. The interest in
these procedures waned, as the effects were often found
to be transitory. However, as with most plastic surgery
procedures, interest in brow rejuvenation was renewed in
the latter half of the 20th century, when new techniques
evolved and results improved [7–9].
There has been, and continues to be, significant con­
troversy as to the “correct” technique to rejuvenate the
brow; for example, whether to use an open versus an
endoscopic approach, and currently, in some quarters,
whether the brow can be adequately elevated with non­
surgical techniques such as Botox and fillers. The con­
tention that one operation is superior to the other has
left many surgeons unsure of the appropriate approach.
This confusion has contributed to the subjugation of the
browlift to the less controversial rhytidectomy and bleph­
aroplasty procedures, and thus avoidance of addressing
the aging brow in lieu of correcting the aging face and
periorbital regions.
Historically all brow rejuvenation procedures were
performed via the open technique. Although this pro­
cedure has excellent long-term results, patients and sur­
geons were often hesitant to undergo such an involved
procedure with extensive incisions and recovery time.
With the advent of the endoscopic techniques in the early
1990s, surgical rejuvenation of the upper third of the face
became increasingly popular [10–14]. This trend, coupled
with the advent of noninvasive paralytic agents, brought
brow rejuvenation to the forefront of facial rejuvenation.
PERSONAL PHILOSOPHY
Comprehensive facial rejuvenation merits an appraisal of
all components of the face. This is especially pertinent for
the upper third of the face. This is the focal region of the
face during communication with others. The importance
of the periorbital area is seen in everyday life. Indeed,
it is so common in our observations of others that it is
often overlooked. When speaking to or meeting someone
for the first time, attention is immediately brought to
the periorbital area, much more so than the jowls or the
neck that so bother the aging patient. Patients with brow
ptosis subconsciously raise their brows when viewing
themselves in the mirror. This cannot be done on the
ptotic, sagging tissue of the middle and lower thirds of
the face. Thus the patient masks an issue that others see
at all times. Although simple, this is an often-overlooked
point that must be discussed with the patient.
The importance of brow rejuvenation is vital to facial
rejuvenation. In our practice, this procedure is often seen
as the primary operation to rejuvenate the face. In addi­
tion, if middle- and lower-third rejuvenation is performed
without addressing the brow, the patient may be left with
an overall disharmonious appearance [15].
The primary reason for brow rejuvenation in our prac­
tice is to address the patient’s concern about looking
heavy, tired, or angry, especially in the glabellar area.
The goals of any browlifting procedure are to eradicate
the depressing effect of the musculature of the glabellar
region and to raise the lateral aspects of the brow. A
key benefit of the open approach is the excellent expo­
sure, which allows for precise handling of these prob­
lems. There is no need for overcorrection with the open
approach because the surgeon can be confident that the
results will be long lasting. This is owing to excision,
rather than suspension, of the ptotic tissues.
There have been concerns over the side effect profile
of open browlift techniques. Likewise, endoscopic tech­
niques are being questioned as to the quality and lon­
gevity of the results. Despite the variety of methods to
surgically, or nonsurgically, address this area, it often
remains neglected.
The endoscopic techniques have done a tremendous
amount to reinvigorate interest in the aging upper third of
the face. Surgeons have noted the advantages of smaller
incisions: less downtime; reduced scarring, numbness,
and alopecia; and minimizing the loss of blood [12,16].
However, endoscopic techniques do have selected disad­
vantages. For example, there is still no method of fixation
that is clearly superior to others [17–24,25a]. The tech­
nique has a limited ability to correct severe eyebrow ptosis
and must be utilized only in certain patients [24,25]. In
addition, the endoscopic record is not yet defined [26].
Reports in the literature have confirmed many surgeons’
trepidations about this technique. Only 50% of plastic
surgeons surveyed felt that their results were satisfactory
more than 2 years after the operation [27].
In addition to the longevity concerns regarding endo­
scopic browlifts, there have also been questions regard­
ing its impact on the contour of the brow [32a]. It has
been found that the greatest impact of the endoscopic
browlift is medially not laterally, thus contributing to the
C H A P T E R 7 
The Open Browlift
Mark R. Murphy, MD and Calvin M. Johnson Jr., MD

7  The Open Browlift
81
dreaded “surprised look” and not affecting the lateral
brow where the lift is generally desired [28,29]. This
highlights another advantage of the open browlift tech­
nique. The open approach allows for more control of
the brow contour by way of its differential scalp incision
[30]. Although emphasis has been on endoscopic and less
invasive methods such as the use of botulinum toxin A
and various fillers, the open browlift has a proven record
of providing excellent, lasting results with minimal side
effects. The open browlift maximizes the optimal removal
of the corrugators and excess skin that accumulates with
time [31]. In addition to the traditional coronal and tri­
cophytic approaches, the temporal, or lateral, browlift
is a modification of the open approach by focusing the
incision placement in a vector that optimizes the aesthetic
ideal of lateral brow elevation with no raising of the
medial aspect of the brow [32a,33a]. This approach is
also quite useful when coupling the procedure with a ver­
tical facelift in that it allows for removal of the troubling
redundancy of tissue incurred at the superior, anterior
aspect of the facelift incision.
In our opinion, the main role for the endoscopic
approach is in young patients with a minimal amount of
ptosis. In our practice, however, we often suggest defer­
ring the procedure in younger patients until the concerns
have truly manifested themselves, at which point we
perform what we believe to be the procedure of choice,
the open browlift. We feel the open browlift is the optimal
operation in patients with severe ptosis of the brows,
deep glabellar or midforehead wrinkles, or a preexisting
high forehead, when a trichophytic lift is selected. The
results achieved with this forehead lift are predictable,
natural appearing, long lasting, and aesthetically pleasing
with minimal morbidity [15].
Other surgeons have also reported that the open tech­
nique is more effective in achieving the three main goals
of brow surgery: brow elevation, reduction of transverse
lines, and reduction of glabellar lines [32]. We would
add to this the enhanced ability to contour an asymmet­
ric brow and the aforementioned elimination of excess
tissue in the temple region that is often found after a
vertical facelift. Even those who favor the endoscopic
technique state that some patients will benefit from the
open approach [33].
The negative side effects of open browlift techniques
seem to have been unduly emphasized in the literature.
In an unpublished report on the significance of the side
effects of the open browlift techniques, the authors found
an overwhelming percentage of patients who would rec­
ommend the procedure to a friend or relative. Studies
have also thrown light on various vague detractions of
the open technique. The difference in the rate of alopecia
between the two techniques is small, and sensory loss
has been noted to be higher with endoscopic techniques
[32,34]. In summary, the open browlift technique has a
similar complication rate, a comparable rate of sensory
loss, and a higher patient satisfaction rate compared with
endoscopic techniques [32].
The other issue commonly mentioned when discuss­
ing the open approach to forehead rejuvenation is the
extent of the incision. We feel that this is predominantly
a matter of proper patient education and surgical tech­
nique. In our practices it is rare for patients to opt out of
this approach after a thorough conversation on the ben­
efits of the procedure. Certainly, if patients feel that they
are going to be “scalped,” they will not consent to the
procedure [14,33].
The coronal incision can be completely camouflaged
with the patient’s hair. In the case of the trichophytic
incision, only the anterior aspect is exposed, and this
component of the incision can also be masked with hair
when the patient wears her bangs combed forward. In
both instances the incision generally heals imperceptibly
when proper beveling is employed during the incision and
meticulous technique is applied during the closure. The
patient must be counseled as to the amount of time it
requires for the wound to heal completely. If the patient
does not wish to have an open procedure because of the
incision, the endoscopic approach should be explored
with the patient.
The open technique via the pretrichial route enables
the surgeon to manipulate certain situations in unique
ways. For example, the pretrichial lift allows for shorten­
ing of an elongated forehead. A long forehead disrupts
the harmony of the face and adds to the patient’s age [35].
The forehead-shortening capabilities of the trichophytic
browlift are unobtainable with the endoscopic technique
[36,37]. Detractors argue that the incision placement
prohibits the use of this technique, but many feel that
with proper planning, technique, and execution this
approach yields an excellent aesthetic result [36]. This is
not to say that this procedure may be used in all patients
with an elongated forehead. If the patient is overly self-
conscious of scarring or has a hairstyle that positions the
hair posteriorly, the surgeon would be wise to avoid this
technique.
The decision-making process for the coronal versus the
pretrichial approach has been reported in the literature
[15,38]. We generally agree with these parameters but do
make exceptions in certain cases to the 5-cm rule.
The purpose of this chapter is not to determine which
technique is superior. That is a decision to be made during
the consultation. The open browlift technique should be
familiar to all plastic surgeons rejuvenating the upper
third of the face. Endoscopic and open techniques should
be discussed with all patients. Finally, endoscopic and
open browlift techniques do not address volume changes
that occur in the brow and temple regions because of
bony remodeling and fat atrophy. Volume loss has to be
addressed with fillers or autologous fat grafting and will
be discussed elsewhere in this book.
ANATOMY
To appropriately rejuvenate the brow, the surgeon must
be knowledgeable of its anatomy. The position and move­
ment of the brow are determined by several factors. First
among these are the paired frontalis muscles. The fronta­
lis is the sole elevator of the brow. These paired muscles
have a definitive midline separation (Fig. 7.1) [39]. Each
of these muscles originates from the galea aponeurotica.
This fascia also encases the muscles, and inserts into

82
MASTER TECHNIQUES IN FACIAL REJUVENATION
PREOPERATIVE ASSESSMENT
Numerous studies have considered the ideal appear­
ance of the female eyebrow [43–49]. A variety of factors
determine the aesthetically pleasing brow. An individual’s
ethnicity, age, sex, culture, and adjacent structures all
influence the perceived beauty of the brow. Although
opinions differ on certain facets of the brow, certain desir­
able traits commonly recur: (1) the medial brow should
lie at, or below, the level of the supraorbital rim; (2) the
brow should have an apex lateral slant; (3) the medial
brow should begin in the vertical plane of the inner
canthus and lateral extent of the ala; (4) the brow should
end laterally in line with a tangent drawn from the lateral
ala through the lateral canthus; (5) the brow should be
full and supple with minimal show of the orbital bone
architecture and atrophy of the temple; and (6) the apex
of the brow should lie above either the lateral limbus or
lateral canthus [43–47,50]. Another key feature of brow
beauty is the relationship to the dorsal line of the nose
(Fig. 7.2). When the brow continues this gentle slope
(brow-tip aesthetic line), it adds to the inherent attractive­
ness of the face [7,43,51].
The decision of trichophytic, temporal (lateral) versus
coronal incision will be discussed with the patient during
the preoperative assessment. This decision process begins
with the patient’s desired appearance. This equation must
take into consideration any inherent asymmetries as well
as the patient’s desired contour. Again, this stresses the
flexibility of the open approach. This judgment is based
on the position of the hairline, low versus high, and the
manner in which the patient wears his or her hair [52].
the orbicularis oculi muscles, which then insert into the
eyebrow dermis. Only the lower 20% of the frontalis
muscle is mobile [40].
The brow has four depressor muscles: the procerus,
corrugator, depressor supercilii, and the orbital portion
of the orbicularis oculi (see Fig. 7.1). The depressor
supercilii is located on the medial arc of the orbicularis
and is considered by some to be part of the orbicularis
[41]. This muscle aids the corrugator in depressing the
medial head of the brow. The corrugator musculature
originates from the frontal bone near the superomedial
orbital rim and inserts into the dermis of the forehead
skin behind and immediately superior to the middle third
of the brow [39]. Contraction of the corrugator complex
results in depression of the brow and deep vertical glabel­
lar rhytids. The procerus originates from the nasal bone
and inserts into the lower medial skin of the forehead. Its
contraction leads to the most inferior horizontal rhytid
over the radix of the nose [41].
The galea is contiguous with the superficial temporalis
fascia laterally. The periosteum of the frontal bone is
contiguous with the temporalis fascia. These respective
fascia layers converge just medial to the temporal fusion
line of the skull.
The sensory innervation to the scalp is relatively
straightforward. The two major nerves are the supra­
orbital and supratrochlear, with the supraorbital nerve
supplying the majority of the scalp. The supraorbital
nerve has two main divisions, superficial (medial) and
deep (lateral) [42]. The deep division of the supra­orbital
nerve runs under the deep galeal plane and over the peri­
osteum toward the superior temporal line before taking
a turn superficially through the galeal fat pad on its way
to the skin of the frontoparietal scalp [14]. The super­
ficial division courses from the orbital rim and over the
frontalis muscle, and terminates in the anterior scalp [40].
The superficial branch supplies the sensation to the fore­
head skin and anterior scalp. The superficial branches of
the supraorbital nerve and the supratrochlear nerve both
travel over the superficial surface of the frontalis muscle.
The frontal branch of the facial nerve runs within the
superficial temporalis fascia on its way to innervate the
frontalis muscle.
Depressor supercilii m.
Galea aponeurotica
Corrugator m.
Frontalis m.
Procerus m.
Orbicularis oculi m.
Figure 7.1  The musculature of the brow. m., Muscle.
Figure 7.2  The ideal aesthetic of the brow depends on individual
preferences. The goal is to provide the patient with an elegant slope of
the brow as it evolves into the contour of the nose.

7  The Open Browlift
83
area while sitting upright. Measurements are made of the
brow elevation at three points: medial, central and lateral
brow. It is common to elevate the lateral brow to a much
higher extent than the medial brow. These measurements
will be used as a guide in the operating room as to the
exact amount of tissue to be excised. The surgeon should
add anywhere from 3 to 5 mm of measured elevation
to the amount to be excised when accounting for the
patient’s own tissue mobility and exact location of the
planned incision. The markings for the excision should
lie 4 to 5 cm posterior to the anterior hairline. The lateral
extent of the incision should terminate approximately
1 to 2 cm above the superior insertion of the auricle
to the skull in an attempt to incorporate the superficial
temporal vessel within the flap (Fig. 7.4). If this vessel is
compromised, however, the blood supply to this flap is
substantial. The surgeon should ensure that an adequate
amount of temporal hair is left behind. This is particu­
larly important when this procedure is being performed
in conjunction with a facelift in which a portion of the
sideburn is shaved as well. The incision should parallel
the anterior hairline tapering to a point at the lateral
aspects. We prefer to mark and excise the amount of
tissue to be removed at the beginning of the case rather
than making one incision, anterior or posterior, mobi­
lizing the scalp, and then deciding on the appropriate
amount to excise. We have found we can reliably gauge
the amount to be resected by assessing the mobility of the
scalp and its associated effect on brow position prior to
incision. It is acceptable to decide on the exact amount
of skin to be excised after raising the flap. However, we
have found that precise incising of this thick tissue, as is
mandated when trying to preserve as many hair follicles
as possible, is very challenging after it has been mobilized.
With adequate experience the surgeon is highly success­
ful in anticipating the total skin excision prior to the
initial incision. Generally speaking, the amount of skin
lies between 1 and 2 cm. If the surgeon discovers that he
or she has miscalculated and resected too much tissue, the
posterior scalp elevation can be performed to aid in the
closure. Obviously it is better to err on the side of caution
and remove less excess skin if the surgeon is uncertain as
to the exact amount to be removed.
Of course, the personal preferences of the patient must
also be taken into account.
The key to an accurate preoperative assessment is the
relaxation, manual if necessary, of the brow. It is in repose
that the patient must objectively view the resting position
of the brow. As mentioned earlier, the patient reflexively
raises his or her brow when placed in front of a mirror or
when a photo is taken. The surgeon can manually posi­
tion the brow as it appears at rest with the patient’s eyes
closed and then instruct her to open her eyes slowly. This
maneuver enlightens the patient as to the issues at hand
and furthers confidence in the surgeon as an expert who
truly sees the face in a different manner from the layman.
In addition, if the procedure is being coupled with a face­
lift the surgeon should note that the brow elevation may
be necessary to “complete” the rejuvenation. In today’s
aesthetic field the “natural” look is sought by nearly all
of our patients. In addition, although it may seem coun­
terintuitive to the patient, adding another procedure will
actually assist in attaining the natural look by keeping
the face harmonious.
TECHNIQUE
The sequence of procedures for facial rejuvenation usually
begins with the forehead lift. We rarely perform a solitary
procedure on the brow. Most often it is in conjunction
with an upper and lower lid blepharoplasty and deep
plane facelift. We choose to do the brow first because it
allows for a more conservative, and accurate, upper lid
blepharoplasty. In select cases, such as patients with deep-
set eyes, previous blepharoplasty, or limited redundancy
of upper lid skin, the browlift is all that is needed for
upper-third facial rejuvenation.
Marking and shaving of hair can be performed prior
to or after the administration of the anesthetic. Patients
are often very anxious during this time, and the marking
and shaving of hair amplifies these feelings. We prefer
to do these tasks after the administration of intravenous
anesthesia.
When a coronal approach has been chosen, a fusi­
form segment of tissue is shaved and marked for excision
(Fig. 7.3). The patient is evaluated in the preoperative
Figure 7.3  The standard coronal markings.
Figure 7.4  The coronal markings mimic the anterior hairline and
taper laterally.