Operative Technique in Plastic Surgery – Kevin C.Chung

between (FIG 1A).
■ Ablative Fractional Resurfacing
■ These devices include the Fraxel Repair, Lumenis Active FX and Deep FX,
Sciton Pro-Fractional, Sciton Core, Deka SmartXide, Alma Pixel, and MiXto
SX.
■ They have mid-infrared wavelengths of either 2940 nm or 10 600 nm and
penetrate up to 1.6 mm.
■ They create columns of ablation surrounded by coagulation and leave zones
of spared tissue between (FIG 1B).
■ In some cases, the zone of coagulation can be controlled; in general,
coagulation improves skin tightening effect but may be counterproductive in
darker skin types and hypertrophic scars.
■ Ablative Nonfractional Resurfacing
■ Nonfractional resurfacing can often be done by setting the density on
fractional devices to 100%.
■ At our practice, we use the erbium-doped yttrium aluminum garnet
(Er:YAG) laser for the purpose of localized full ablation. Fully ablative
resurfacing of the entire face carries a higher risk of scarring and permanent
pigmentary loss than does fractional treatment.
PEARLS AND PITFALLS
■ Fractional ablative resurfacing produces much faster healing times and a lower rate
of scarring and hypopigmentation than full-field ablative resurfacing
■ In general, lower densities (of both ablative and nonablative resurfacing) should be
used in darker skin types
■ Ablative resurfacing off the face, including on the neck, must be done with caution
(and generally with much lower energy and density) as fewer sebaceous glands
increase likelihood of scarring
■ Acneiform eruptions after nonablative resurfacing can be treated with a course of
oral tetracyclines such as doxycycline and/or topical antibiotics such as clindamycin

■ Postoperative healing should be largely painless; pain should prompt investigation
and possible empiric treatment for herpetic or bacterial infection
FIG 2 • One day post-treatment. Fractional ablative (A)
and fractional nonablative (B).
POSTOPERATIVE CARE
■ Postoperative care differs among treatments, which produce different degrees
of injury (FIG 2; Table 1).
■ For all modalities, strict sun avoidance and generous emollients are important
until healing is complete.
OUTCOMES
■ Outcomes depend on indication, patient, and device (see Table 1). Some
possible outcomes include
■ Improvement in fine lines (FIG 3)
■ Improvement of hypopigmentation (FIG 4)
■ Improvement of dyschromia (FIG 5)
■ Improvement of under-eye festooning (FIG 6)
■ Smoothing of moderate to severe rhytides (FIG 7)
■ Improvement in acne scarring (FIG 8)
■ Improvement in atrophic surgical scarring (FIG 9)

FIG 3 • Improvement in texture, dyschromia, and fine
lines. Fractional nonablative therapy with 1550 nm was
used with 70 mJ fluence at 40% density. A.
pretreatment and (B) post-treatment.
FIG 4 • Improvement of hypopigmentation. Fractional

nonablative therapy with 1927 nm was used with 10 mJ
fluence at 65% density. A. pretreatment and (B) post-
treatment.
■ Eyelid lift1
■ Clearance of actinic damage2
COMPLICATIONS
■ Complications are outlined in Table 1 for each modality.
FIG 5 • Improvement of dyschromia. Fractional
nonablative therapy with low energy low density 1927
nm was used with 7 mJ fluence at 10% density. A.
pretreatment and (B) post-treatment.
FIG 6 • Treatment of under-eye festoons. Fractional

ablative therapy with 10 600 nm carbon dioxide laser
was used with 70 mJ at 50% density. A. pretreatment
and (B) post-treatment.
FIG 7 • Smoothing of moderate to severe rhytides.
Fractional ablative therapy with 10 600 nm carbon
dioxide laser was used with 70 mJ at 50% density. A.
pretreatment and (B) post-treatment.

FIG 8 • Improvement in acne scars. Fractional ablative
therapy with 10 600-nm carbon dioxide laser was used
with 70 mJ fluence at 50% density. Some neck
retraction was also achieved. A. pretreatment and (B)
post-treatment.

FIG 9 • Improvement in atrophic surgical scar.
Fractional ablative therapy with 10 600-nm carbon
dioxide laser was used with 70 mJ fluence at 60%
density. A. pretreatment and (B) post-treatment.
■ Feared complications of ablative laser include permanent hypopigmentation
and scarring; these are much less likely when energy is fractionated.
■ Postinflammatory hyperpigmentation is an important complication and is
avoided by careful sun protection post-treatment and caution with darker skin
types.
■ Acneiform reactions can occur following nonablative treatment and can be
treated like acne vulgaris with oral tetracyclines and topical antibiotics.
■ Wounding of the skin may predispose to herpes simplex reactivation and
bacterial soft tissue infection warranting antiviral and antibacterial prophylaxis
in certain cases.
ACKNOWLEDGMENT
We thank Julia Pettersen Neckman, MD, for her significant contributions to this
chapter.
REFERENCES
1. Sukal SA, Chapas AM, Bernstein LJ, et al. Eyelid tightening and improved
eyelid aperture through nonablative fractional resurfacing. Dermatol Surg.
2008;34(11):1454-1458.
2. Weiss ET, Brauer JA, Anolik R, et al. 1927-nm fractional resurfacing of facial
actinic keratoses: a promising new therapeutic option. J Am Acad Dermatol.
2013;68(1):98-102.

17
CHAPTER
Section V: Chemical Peel of
the Face
TCA Peel to Face
Steven M. Levine and Daniel C. Baker
DEFINITION
■ The aging face changes in multiple facets.
■ Surgery is the standard to address descent and laxity.
■ Resurfacing is important to treat textural and other surface changes related to
aging and environmental damage.
■ Trichloro acetic acid (TCA) peel is one highly effective, reliable, and low-cost
method to facial resurfacing.
ANATOMY
■ Facial peeling can be performed on the entire face and neck or can be isolated
to specific aesthetic units such as the lower lids or perioral region.
■ The perimeter of any area being treated should be “feathered” to minimize the
creation of a transition between peeled and nonpeeled tissue.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Indications for peeling are broad and can include desire to improve skin
texture, reduce visible fine lines, or ameliorate age spots (such as solar
keratosis).
■ It is important to elicit a history of oral herpes so that these patients can be
pretreated with antiviral medication.
■ Skin type is important to note.
SURGICAL MANAGEMENT

■ TCA peeling can be performed as a stand-alone procedure or in combination
with a face and necklift.
Preoperative Planning
■ The primary consideration for preoperative planning is the patient’s skin tone.
The more pigmentation in the skin, the higher the chance for postpeel
complications such as postinflammatory hyperpigmentation or areas of
hypopigmentation.
■ Some providers choose to pretreat patients with a retinol or bleaching agent for
4 to 6 weeks prior to TCA peel. Neither of the authors use pretreatment.
■ TCA can be used in a variety of strengths. The authors prefer to keep only two
strengths of TCA—25% and 35%.
■ 25% TCA is used for lighter peels and darker complexions (Fitzpatrick grade
III).1
■ 35% TCA is used for heavier or more aggressive peels and lighter
complexions (Fitzpatrick grades I and II).1
Positioning
■ The patient is either supine if under sedation or full anesthesia or sitting
upright in an exam chair while holding a fan if performing a peel on an awake
patient.
Approach
■ The approach to the peel can be accomplished using a variety of application
techniques that yield a controlled, reproducible distribution of chemical to the
skin.
T E C H N I Q U E S
■ Cotton Tip Applicator on Sedated Patient
■ The patient is laid supine on the operating room table.
■ The face is cleaned with alcohol to remove as much oil from the skin.
■ A small amount of eye ointment is placed on the sclera to protect the eyes.
■ An assistant should stand adjacent to the procedure table holding the TCA or

the TCA should be kept on a Mayo stand away from the patient. An open
bottle of TCA is NEVER placed over the patient or in any position where it
can spill on the patient.
■ For the majority of the face, two cotton tip applicator sticks are used to
spread the TCA (TECH FIG 1A).
■ Usually the forehead and nose are more keratinized and require a heavier
coat of TCA.
■ For the lower eyes, a single cotton tip applicator is used to apply the TCA.
The skin beneath the lower lid is stretched with the nondominant hand for
complete placement of the TCA to just before the lash line.
■ Care is taken to “feather” the borders of any anatomic area that means
lightening the amount of TCA applied to reduce the appearance of a
transition zone.
■ The skin will usually frost within 60 seconds (TECH FIG 1B).
■ An area that does not frost or is not uniform can be retreated in the same
manner.
TECH FIG 1 • A. TCA peel is applied using cotton
applicator sticks. B. TCA frost.
■ Cotton Tip Applicator on Awake Patient
■ An identical technique is used on the awake patient with the addition of
patient-held fan to increase comfort during the procedure.
■ Usually, any burning or discomfort lasts less than 60 seconds as the TCA is
neutralized by the skin.

PEARLS AND PITFALLS
Start low and
light
■ Use 25% TCA and apply a thin coat until you get use to
correlating the amount of frosting with the level of skin peel.
Avoid TCA
spills
■ Never hold the bottle of TCA yourself while applying.
Safely
combine
procedures
■ TCA is a an excellent adjunct to a facial surgery procedure
Feathering
■ Always extend the treatment beyond the zone being treated (ie,
beneath the jaw line if treating the full face).
POSTOPERATIVE CARE
■ This procedure is often combined with a facelift in which traditional surgical
preparation of the skin is not required in the setting of the TCA peel.
■ If combined surgery is not planned, a petroleum-based ointment is applied to
the patient’s face immediately after the procedure.
■ Cool packs are also used to reduce swelling.
■ Patients are instructed to remain away from the sun during the acute peeling
period (7–10 days postop).
■ Sun avoidance should ideally be carried out for several months after TCA peel.
■ Patients are instructed to use cool compressed at home for the first 24 to 48
hours.
■ After 48 hours, patients are instructed to use warm compressed to speed the
peeling process.
■ Patients are instructed not to remove any peeled skin themselves (though if
they are in the office, I will often do this for them). The concern is the patient
could be too aggressive and remove skin prematurely.
■ Patients should apply a thin layer of petroleum-based ointment 3 times daily
until the skin is re-epithelialized.
OUTCOMES
■ TCA peel will predictably improve certain fine lines and reduce the
appearance of certain superficial pigmentation issues.

■ The provider needs to start using this technique in a metered fashion to gain
comfort with expectations and limitations.
COMPLICATIONS
■ The most feared complication is TCA entering the eye. If this happens, the eye
should be irrigated with saline or water continuously and an ophthalmologist
should be consulted immediately.
■ Caution must be taken near hair-bearing areas such as the brow because they
can trap TCA in the hair causing a deeper burn in that region than intended.
■ Hyperpigmentation can occur which usually resolves on its own.
■ Sun avoidance is paramount.
■ Lightening agents such as hydroquinone 4% topical can be used if necessary.
■ Hypopigmentation should not occur with 25% or 35% TCA peel in the
patients who do not have dark skin.
REFERENCE
1. Reference to Fitzpatrick classification.

18
CHAPTER
Indications and Technique
for Phenol-Croton Oil Peels
Gehan D’Souza and James Zins
DEFINITION
■ Intermediate and deep chemical peeling imparts injury to the epidermis and
varying depths of the dermis in a controlled manner in efforts to stimulate
epidermal regrowth. Peeling has been shown to rejuvenate facial skin and has
been used to treat acne, rhytides, and photodamage.1
■ Chemical peels are available in a variety of formulas, which produce
superficial, medium, and deep wounds.
■ Superficial peeling techniques are limited to epidermal injury only.1,2
Intermediate and deep chemical peels most commonly involve trichloroacetic
acid (TCA) and phenol-croton oil. Both TCA and phenol-croton oil depth can
be varied by changing the concentration, number of applications, and the
amount of peeling agent applied.
■ Deeper peels, such as the conventional phenol-croton oil formula, are the
most effective in resurfacing skin but are also associated with more severe
complications and may not be appropriate for certain patients.
■ The use of phenol-based chemical peels declined with the advent of laser
technologies.
■ There has been renewed interest in the use of this technique in recent years
with the realization that reducing the concentration and application methods
can reduce complications while maintaining results.3,4
■ The phenol-croton oil formulas use varying concentrations of phenol, croton
oil, Septisol, and water.3
■ Full facial phenol peels require deep sedation or general anesthesia and cardiac
monitoring. Because of the potential for cardiac arrhythmias, full facial
chemical peeling should be done based on anatomic units over a relatively

prolonged period of time (1–1.5 hours).
■ Additionally, these peels pose risk for renal failure and hepatotoxicity.3,5
■ Adjusting croton oil concentration allows for variation in phenol-croton oil
peel depth and achievement of more uniform results on different thicknesses of
skin.3
■ Phenol-croton oil peels are increasingly being used as a medium-depth
peeling modality and can be performed on a spectrum of ages and skin
conditions.4
ANATOMY
■ Phenol-croton oil, while most commonly recognized as a deep peeling
technique, can also be used as a superficial or medium-depth peeling modality
(FIG 1).6
■ Chemical peels are divided into three categories based on the degree of injury
caused by the treatment7:
■ Superficial peels—cause epidermal injury and do not penetrate below the
basal layer
■ Medium-depth peels—ablate the epidermis and varying degrees of the dermis
■ Deep peels—remove the epidermis, papillary dermis, and generally extend to
the midreticular dermis
■ Indications for phenol-croton oil peels include4,6,8
■ Rhytides
■ Melasma
■ Acne
PATHOGENESIS
■ Factors such as environmental damage, actinic damage, smoking, and
radiation.9–11
■ Rhytides form for a variety of reasons. The contraction of the musculature and
attachments of the retinaculum cutis that attaches to the skin acts on the skin to
create a wrinkle with animation.
■ Strategies for preventing rhytides include sun avoidance, smoking cessation,
and treatment of skin with retinoids.11
■ Once rhytides are present in the perioral area at rest, they are difficult to treat.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Medical and surgical history, as well as physical examination should address

general health or risks from current medications (eg, isotretinoin, birth control
pills, or immunosuppressants), possibility of pregnancy, liver disease, history
of herpes simplex virus, history of hypertrophic or keloid scars, history or risk
of hepatitis or HIV, history of radiation exposure, and history of cutaneous
disease at the peel site (eg, rosacea, seborrheic dermatitis, atopic dermatitis,
psoriasis, and vitiligo).
■ Previous injury to the reticular dermis including previous peeling, laser, or
even electrolysis will affect how aggressive one is with peeling depth.
■ Gender differences in perioral wrinkling have been described.
■ Women have a lower ratio of blood vessels to connective tissue than do
men.12 This can also be explained by the differences of follicles, sebaceous
glands, and androgen-dependent hair.13
■ The patient’s skin type using a Fitzpatrick classification is important in
determining the need for suppression of melanin and prevention of
hyperpigmentation.
■ The Glogau photoaging scale determines the depth of the peel.14,15
■ Indications for chemical resurfacing:
■ Photoaging of the skin and rhytides
■ Preneoplastic or neoplastic lesions such as actinic keratosis and lentigines

FIG 1 • Review of basic skin anatomy as it relates to
peel depth.
■ Acne or other underlying skin diseases
■ Pigmentary dyschromias
■ Demarcation lines secondary to other resurfacing procedures
■ Contraindications to chemical resurfacing:
■ Absolute:
• Isotretinoin therapy within the last 6 months or until pilosebaceous units
begin functioning
• Active infection or open wounds (eg, herpes, excoriations, or open acne
cysts)
• Lack of psychological stability and mental preparedness
• Unrealistic expectations
• Poor general health and nutritional status
• Poor physician-patient relationship
• History of abnormal scar formation or delayed wound healing and
therapeutic radiation exposure
• History of certain skin diseases (such as rosacea, seborrheic dermatitis,
atopic dermatitis, psoriasis, and vitiligo) or active retinoid dermatitis;
Fitzpatrick skin types IV, V, and VI are contraindications for medium and
deep-depth peels.
■ Relative:
• Need to proceed with caution with a history of medium-depth or deep
resurfacing procedures within the previous 3 to 12 months
• Chemical peeling at the time of rhytidectomy is practiced by some. This
should not be done with phenol peels. Areas not undermined can be peeled
with phenol peel. Patients must wait 3 months to peel undermined areas.
SURGICAL MANAGEMENT
■ The goal of a phenol peel is to produce controlled partial-thickness skin injury.
This leads to improving skin quality, reduction of fine lines, and coarse
rhytides.
■ Pretreatment (priming) with Retin-A and 4% hydroquinone is helpful to
minimize post-treatment hyperpigmentation. In those with darker Fitzpatrick

skin types, there should be a minimum of 6 weeks of treatment.
■ Hypopigmentation and incidence of hypertrophic scarring are directly
correlated with the depth of injury.
■ In a phenol peel much like a TCA peel, the depth of injury can be controlled
leading to peels from papillary dermis to midreticular dermis depending on the
amount of facial aging. The depth of injury can be altered by changing the
concentration and the number of applications of the peeling agent. The critical
factor is the degree of frosting.
■ Time to healing can vary from 5 days (superficial peel) to 10 to 14 days when
a deep peeling technique is used.
■ Hypopigmentation and hyperpigmentation are the most common
complications.
■ Damage to the melanocytes at the epidermal-dermal junction leads to
hypopigmentation.
■ Hypopigmentation is more noticeable in dark skin patients, so segmental
applications should not be done in these patients.
■ Hyperpigmentation usually results from peeling-induced inflammation with
melanocyte overstimulation. Darker skin patients are more prone to this
complication. This is exacerbated with premature sun exposure.
Preoperative Planning
■ Consultation should be held with the patient to establish realistic goals and
expectations.
■ Peel depth should be determined by assessing and documenting patient’s
Fitzpatrick skin type and photoaging grouping, degree of actinic damage,
sebaceous gland density, dyschromias, suspicious lesions, and scarring.
■ The hands and neck have very few progenitor cells in the reticular dermis. The
scarcity of these cells makes peeling in these areas risky.
■ Gravitational changes can best be treated with facelift.
■ Standard preoperative photographs should be taken for preoperative planning.
■ Informed consent should be obtained and should include an overview of the
healing process and phases, additional surgeries or procedures that may be
necessary, complications, explanations of what can and cannot be
accomplished with the phenol-croton oil peel, and a description of financial
responsibilities, including for revisions.
■ Important considerations for ethnic skin14:

■ Ethnic skin, including that of Latino and Hispanics, may respond
unpredictably to chemical peels and are more prone to melasma and
postinflammatory hyperpigmentation than nonethnic skin types.
Preparation and Positioning
■ Patient is pretreated with tretinoin and hydroquinone for 4 to 6 weeks to
suppress melanin production.
■ Patient is instructed to use acyclovir 400 mg TID 2 days before the procedure
and continued until complete healing observed.
■ Varying concentrations of phenol and croton oil have been used.4
■ Phenol-croton oil can be used as a superficial or medium to deep depth peel.
■ Technique is extremely important. By altering concentration and application
technique (number of swipes or amount of solution applied), different depths
can be achieved at different regions of the face. For example, a light peel,
which uses a lower concentration of croton oil, can be used to peel the lower
eyelids, while a higher concentration of croton oil may be used to peel more
deeply wrinkled areas of the face, such as the perioral region.6
■ Safety checks before peeling:
■ Mark the mandibular ramus, so that peel is not applied caudal to this line.
■ Begin an IV and run fluid.
• Phenol is metabolized in the liver and excreted by the kidneys. Therefore,
patients with liver disease should be treated with increased caution.
■ Monitor with cardiac monitoring equipment, pulse oximeter, and blood
pressure monitoring.
■ Cardiac arrhythmias during chemical peeling have been reported; however,
cause and effect relationship is controversial.
■ Ensure applicator and peeling agent never pass over the patient’s eyes.

FIG 2 • Preoperative markings.
■ Anesthesia:
■ Administer sedation and analgesia by performing facial nerve block and
direct infiltration using a longer acting anesthetic.
■ Epinephrine should be avoided, as it can exacerbate cardiac arrhythmias.
■ Decadron (8–10 mg) or betamethasone (6 mg) may also be administered.
■ Skin preparation:
■ Peel area should have been thoroughly washed the night before and morning
of the surgery, with no residual makeup.
■ Clean peel area using Septisol (hexachlorophene with alcohol) to adequately
degrease the skin. This step is essential for optimal results.
■ The patient’s face is marked (FIG 2).
■ Positioning:
■ The patient should be lying supine.
T E C H N I Q U E S
■ General Region Peel
■ The phenol-croton oil wound agent should be applied using a moistened,
wrung out cotton-tipped applicator, tending to the deep rhytides first.
■ The peeling agent should be applied to aesthetic units over an extended
period of time (1–1.5 hours).
■ Because phenol does not affect hair growth, the agent should be spread into

hair-containing areas.
■ Apply swipes until a proper depth of injury is attained. Pink-white frost
signifies a papillary dermal injury, and dense white frost denotes a reticular
dermal injury. Brown-white frost signifies a deep dermal injury.
■ Allow 10 to 15 minutes between cosmetic units before applying a new coat
to reduce renal and cardiovascular risk. The full procedure may last between
60 and 10 minutes.
■ A thick layer of Vaseline and viscous Xylocaine solution should be applied
to each region of the face as soon as it has been treated with the peeling
agent, to prevent peeled areas from drying out. This acts as an occlusive
dressing and as a pain reliever.
■ Periorbital Peel Technique
■ Ensure that no agent drips into the patient’s eye. Do not pass vials over the
patient in case of spillage.
■ Elevate the patient’s head 30 to 45 degrees.
■ Patient’s tears should be wiped away using a cotton-tipped applicator at the
medial and lateral canthus while holding the patient’s eye open to prevent the
peeling agent from entering the eye.
■ For the lower eyelid, have the patient look up and apply the agent within
millimeters of the eyelash margin by moving from the lateral crow’s feet to
the medial canthal area. For the upper eyelid, have the patient close her eyes
and apply the agent from the lateral to inner canthal area. Avoid applying
product below the superior tarsal plate, as it may lead to prolonged edema.
Be certain to peel the orbital rims to avoid lines of demarcation.
■ Apply an ice pack over the eyes for 6 to 8 hours after the peel to reduce
swelling.
■ Perioral Peel8
■ Applying peeling agent onto the vermilion border to avoid missing lipstick
lines.
■ Manually stretch the skin to create deeper and more even penetration.
■ Use the wooden end of a cotton-tip applicator to apply peeling agent to

individual rhytides (TECH FIG 1).
■ Degreasing the skin by aggressive rubbing with alcohol swab until skin
erythema has proven to be an effective method in treating especially perioral
skin damage.
■ If peeling the perioral area only, make sure to use to proper technique to
avoid lines of demarcation. Apply the peeling agent just beyond the
nasolabial fold, and then brush out the remaining regions of the face.
TECH FIG 1 • Intraoperative photos. A. Upper lid.
Application of agent within millimeters of eyelash
margin by moving from lateral crow’s feet to the
medial canthal area. B. Lower lid. The agent is applied
with the patient looking upward.

■ Taping (for Occluded Peel)
■ Taping increases the depth of injury.
■ Apply precut, 1.5 to 4 cm strips of tape to each cosmetic unit after the
completing the peel.
■ Begin by applying the tape along the inferior border of the mandible in a saw
tooth pattern, which produces a less discrete line. Continue taping outward,
by placing strips 1 to 2 cm parallel to the inferior border of the mandible.
■ The tape mask should be removed as a single unit, approximately 48 hours
after the procedure, when the exudate has elevated the tape.
PEARLS AND PITFALLS
Intraoperative
complications
■ Intraoperative complications may be the result of technical
errors. Monitor for cardiac arrhythmias.
Pretreatment
■ Pretreatment with tretinoin and hydroquinone is helpful to
minimize pigmentation problems in darker-skinned individuals.
Depth
■ Depth of peel is varied by pathology. Frosting is the key element
to getting a good result.
Pigmentation
■ Secondary alternation of skin pigmentation is the most common
complication and should be discussed with the patient.
POSTOPERATIVE CARE
■ Wound care: areas should be kept constantly moist with ointment. Discomfort
is relieved with the use of Vaseline/Xylocaine mixture. This acts as a pain
reliever and occlusive dressing. Expect considerable swelling and drainage.
Erythema duration varies with the depth of injection and Fitzpatrick skin type.
Patients are quite allergic in the early postoperative period. General pruritus
can be decreased by steroid cream. Contact dermatitis should be similarly
treated. Sign of infection is the development of significant pain in patients
otherwise healing well. Infection can be bacterial, fungal, and viral.
■ Retouching of specific areas or repeeling may be necessary after 3 to 6
months for deeper wrinkles.

■ Sleeping: While sleeping, head should be kept elevated using multiple pillows.
■ Bathing/washing: Clean in the shower with unscented liquid soap. Perform a
splashing action, and use fingers only. Do not use any type of exfoliating aide,
such as a washcloth or sponge. Apply a thick coat of moisturizing ointment
after each wash. Wash in the shower after 48 hours if no tape is present.
■ Lifestyle: Avoid the sun completely. Sun exposure can lead to postoperative
skin pigmentation. In addition to sun exposure, becoming pregnant or taking
birth control pills before redness has subsided may cause blotching. Avoid
contact of caps, shower caps, eyeglasses, or visors on peeled areas until the
underlying skin has healed. Patients may return to work as early as 14 days
postprocedure. Makeup and sunscreen may be applied on healed areas.
Exercise should be avoided for 30 days postprocedure, as increased blood flow
could cause microhemorrhaging or red blotching.
OUTCOMES
■ The use of perioral phenol peel combined with facelifting has been found to
add 5.3 years of reduction in apparent age after the combined facelift and
peel16 (FIGS 3 to 6).

FIG 3 • A–C. Two years after phenol-croton oil peel of
the perioral, periocular area, and temples. Phenol peel
used 27.5% phenol, 0.105% croton oil for the periocular
area, and 33% phenol and 1.1% croton oil for the
perioral area. (Preoperative photos of the patient are
shown in FIG 2.)
■ Using validated questionnaires, patient satisfaction was found to be high with
the use of a combined phenol peel and facelift.
■ Perioral phenol-croton oil peel resulted in a significant and objective wrinkle
shown by the reduction in Glogau score.16
■ When carefully assessed, some degree of hypopigmentation occurs with most
patients, and hypopigmentation is subtly progressive. When peeling is
confined to lower Fitzpatrick skin types, it is not disabling.

FIG 4 • A,B. Preoperative patient photos. C,D. Six
months after bilateral rhytidectomy with extended
SMAS and perioral phenol-croton oil peel and fat
injections to the cheeks and nasolabial folds. Phenol
peel to perioral area using 33% phenol and 1.1% croton
oil.

FIG 5 • A–C. Preoperative patient photos. D–F. Six
months after bilateral rhytidectomy with extended
SMAS and perioral phenol-croton oil peel and fat
injections to the cheeks and nasolabial folds. Phenol
peel to perioral area using 33% phenol and 1.1% croton
oil.
COMPLICATIONS
■ Complications following intermediate depth phenol-croton oil peeling are
primarily of four types: preoperative, intraoperative, early postoperative, and
late postoperative.16
■ Preoperative:
■ Poor history—patients on Accutane, electrolysis, or previous peels
■ Lack of pretreatment of dark-skinned individuals
■ Intraoperative:
■ Cardiac arrhythmias have been reported, but no cause and effect relationship
has been established. Patient’s cardiac status should be monitored during the
procedure, and the peel duration needs to be extended over 1 to 1.5 hours.
■ Peeling too deeply—failing to recognize the signs of the depth of peel.
■ Segmental peeling in the area of the face results in splotchy appearance.
■ Early postoperative:
■ Infection—bacterial, fungal, and viral: While bacterial infections from

Staphylococcus and Streptococcus species are more common, infections from
Pseudomonas species, mycobacteria, and fungi are rare. There has been no
literature detailing the need for prophylaxis antibiotics. The characteristic of
an infection is significant pain in the postoperative period.
FIG 6 • A,B. Preoperative patient photos. C,D. Six
months after bilateral rhytidectomy with extended
SMAS and perioral phenol-croton oil peel and fat
injections to the cheeks and nasolabial folds. Phenol
peel to perioral area used 33% phenol and 1.1% croton
oil.
■ Late postoperative:
■ Milia, or benign, keratin-filled cysts that tend to occur around the periorbital
area may occur 3 weeks after the peel. Milia can be physically extracted but
also respond well to topical vitamin A derivatives, which also help to prevent

future outbreaks.
■ Acneform eruptions, or tender, erythematous follicular popular, may occur as
a result of the emollients or ointments being used for postoperative care.
These can be treated with a topical antibiotic (eg, clindamycin, erythromycin,
or systemic tetracycline and erythromycin therapy) and take approximately 5
to 10 days to clear.
■ Hyperpigmentation develops 4 weeks after the procedure. Hypopigmentation
is a late complication and gets progressively worse. While hyperpigmentation
can be treated with topical bleaching agents (eg, 4% hydroquinone) or topical
steroids, there is no effective treatment for hypopigmentation.
■ Prolonged erythema may take between 3 to 6 months to resolve completely.
This occurs most frequently in Fitzpatrick I patients.
■ Hypertrophic scars may result from delayed wound healing. Early
postoperative redness, induration delineates an incipient hypertrophic scar.
This is treated with dilute intralesional triamcinolone injections (5 mg/cc).
ACKNOWLEDGMENT
The authors thank Sonia Havale for her contribution to the preparation of this
chapter.
REFERENCES
1. Fischer TC, Perosino E. Chemical peels in aesthetic dermatology: an update
2009. J Eur Acad Dermatol Venereol. 2010;24:281-292.
2. Larson DL, Karmo F. Phenol-croton oil peel: establishing an animal model for
scientific investigation. Aesthet Surg J. 2009;29:47-53.
3. Hetter GP. An examination of the phenol-croton oil peel. Part I. Dissecting the
formula. Plast Reconstr Surg. 2000;105(1):227-239.
4. Hetter GP. An examination of the phenol-croton oil peel. Part IV. Face peel
results with different concentrations of phenol and croton oil. Plast Reconstr
Surg. 2000;105(3):1061-1083.
5. Landau M. Cardiac complications in deep chemical peels. Dermatol Surg.
2007;33:190-193.
6. Stone PA, Lefer LG. Modified phenol chemical face peels: recognizing the
role of application technique. Facial Plast Surg Clin North Am. 2001;9(3):351-
376.
7. Monheit GD, Chastain MA. Chemical peels. Facial Plast Surg Clin North Am.
2001;9(2):239-255.
8. Stuzin JM, Baker TJ, Gordon HL. Chemical peel: a change in the routine. Ann

Plast Surg. 1989;23(2):166-169.
Accessed August 1, 2016.
9. Caisey L, Gubanova E, Camus C, et al. Influence of age and hormone
replacement therapy on the functional properties of the lips. Skin Res Technol.
2008;14(2):220-225.
10. Laporta R, Mercer N. Quid causit perioral wrinkles? J Plast Reconstr Aesthet
Surg. 2013;66(4):579-581.
11. Kane M. The functional anatomy of the face as it applies to rejuvenation via
chemodenervation. Facial Plast Surg. 2005;21(1):55-64.
12. Paes EC, Teepen HJ, Koop WA, Kon M. Perioral wrinkles: histologic
differences between men and women. Aesthet Surg J. 2009;29(6):467-472.
13. Chien AI, Cheng N. Perioral wrinkles are associated with female gender,
aging, and smoking: development of a gender-specfic photonumeric scale. J
Am Acad Dermatol. 2016;74(5):924-930.
14. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I
through VI. Arch Dermatol. 1988;124:869-871.
15. Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan
Med Surg. 1996;15:134-138.
16. Ozturk CN, Huettner F. Outcomes assessment of combination of face and
perioral phenol-croton oil peel. Plast Reconstr Surg. 2013;132:743e.

19
CHAPTER
Section VI: Dermabrasion
Techniques for
Dermabrasion to the Face
Steven M. Levine and Daniel C. Baker
DEFINITION
■ Surgery is the standard to address descent and laxity in the aging face.
■ Resurfacing is important to treat textural and other surface changes related to
aging and environmental damage.
■ Dermabrasion is a highly effective, reliable, and low-cost method to facial
resurfacing.
■ It is particularly useful for vertical perioral rhytides.
ANATOMY
■ Dermabrasion can be performed on the entire face and neck or can be isolated
to specific aesthetic units such as the glabella or perioral region.
■ The perimeter of any area being treated should be “feathered” to minimize the
creation of a transition between dermabraded and nondermabraded tissue.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Indications for dermabrasion are broad and can include desire to improve skin
texture, reduce visible fine lines, or reduction in age spots (such as solar
keratosis).
■ It is important to elicit a history of oral herpes so that these patients can be
pretreated with antiviral medication.
■ Skin type is important to note.
SURGICAL MANAGEMENT

■ Dermabrasion can be performed as a stand-alone procedure or in combination
with a face and necklift.
Preoperative Planning
■ The primary consideration for preoperative planning is the patient’s skin tone.
The more pigmentation in the skin, the higher the chance for postdermabrasion
complications such as postinflammatory hyperpigmentation or areas of
hypopigmentation.
■ Some providers choose to pretreat patients with a retinol or bleaching agent for
4 to 6 weeks prior to dermabrasion.
■ The authors do not use pretreatment.
■ A marker is used preoperatively to stain the fine lines for which the
dermabrasion is targeting.
Positioning
■ The patient is supine on the procedure table.
■ Usually the head of bed is slightly elevated.
■ The provider should be sitting for maximum stability.
Approach
■ The approach can be accomplished using a variety of techniques that yield a
controlled, reproducible distribution of mechanical resurfacing to the skin.
T E C H N I Q U E S
■ Mechanical Dermabrasion
■ The patient’s face is cleaned with alcohol.
■ Marker was used to reinforce any marks that were removed during the prep.
All rhytides to be addressed should be colored in marker.
■ A small amount (0.1 cc for entire upper lip) of 1% lidocaine with epinephrine
is injected into the dermis of the areas to be dermabraded.
■ Eight minutes is allowed to pass to obtain full effect of the epinephrine.
■ Choose the dermabrasion tip that you feel most comfortable within a specific
area.

■ The authors use the bullet tip for areas above the lip and the barrel for larger
areas like below the lip (TECH FIG 1).
■ You can effectively dermabrade at a variety of speeds.
■ Start slow (5000–10 000 rpm and advance to 25 000 rpm).
■ The key to dermabrasion is to keep the skin on tension and is accomplished
with the nondominant hand.
■ Do not attempt to dermabrade an area that is not under tension.
■ The end point is a combination of pinpoint bleeding and visualization of the
rhytide effacement. The ideal goal is to completely efface the targeted rhytide
before dermabrading too deep and damaging the melanocytes.
■ Care is taken to “feather” the borders of any anatomic area that means
reducing the depth of the dermabrasion to reduce the appearance of a transition
zone.
TECH FIG 1 • A. Dermabrasion tips include a barrel for
larger areas. B. Note the nondominant hand applying
tension to the skin under the dermabrasion tip.
PEARLS AND PITFALLS
Skin tension
is paramount
■ Always place skin on tension prior to dermabrasion. This may
include place a hand intraoral to accommodate tension around the
mouth.
Keep moving
■ Keep the dermabrader moving to avoid getting too deep in any
area.
Safely
■ Dermabrasion is a an excellent adjunct to a facial surgery

combine
procedures
procedure.
Feathering
■ Always extend the treatment beyond the zone being treated (ie,
beneath the jaw line if treating the full face).
Practice
■ Consider using an orange or grapefruit to practice your technique.
POSTOPERATIVE CARE
■ This procedure is often combined with a facelift. In this case, the dermabrasion
should be performed after the facelift.
■ A petroleum impregnated gauze is applied to the dermabraded areas
immediately after the procedure.
■ Cool packs are also used to reduce swelling.
■ Patients are instructed to remain away from the sun during the acute peeling
period (7–10 days postop).
■ Sun avoidance should ideally be carried out for several months after
dermabrasion.
■ Patients are instructed to use cool compressed at home for the first 24 hours.
■ Patients should keep the gauze in place for several days. As the skin re-
epithelializes, the gauze will fall off. When it does, patients should apply a thin
layer of petroleum-based ointment 3 times daily until the skin is re-
epithelialized.
OUTCOMES
■ Dermabrasion will predictably improve certain fine lines and reduce the
appearance of certain superficial pigmentation issues.
■ The provider needs to start using this technique in a metered fashion to gain
comfort with expectations and limitations.
COMPLICATIONS
■ It is important to be aware of the entire surgical field.
■ Often a gauze is near the field to aid the provider in wiping blood from the
operative field. This gauze can easily get caught in the dermabrader and whip
around and hit the patient’s face or eye.
■ Overly aggressive dermabrasion can damage melanocytes and lead to areas of
hyperpigmentation. Sometimes, this can reverse, but often it is permanent.

■ Hyperpigmentation can occur which usually resolves on its own. Sun
avoidance is paramount. Lightening agents such as hydroquinone 4% topical
can be used if necessary.

20
CHAPTER
Section VII: Brow Lifting
Indications and Techniques
for Coronal Brow Lifting
Richard J. Warren
DEFINITION
■ Brow ptosis describes an abnormally low position of the eyebrow complex,
either in whole or in part.
■ Low lying or malpositioned eyebrows may be congenital or acquired through
aging.
■ Brow position and shape convey an impression of emotion. When the entire
brow is low, the patient looks tired. When only the medial brow is low, the
patient appears to be angry, and when only the lateral brow is low, the patient
appears to be sad.1
■ Brow ptosis encroaches on the upper lid sulcus, changing the dynamics of the
upper lid/brow junction. Thus, brow ptosis will affect the assessment of
patients presenting for blepharoplasty, periorbital fat grafting, or senile eyelid
ptosis repair.
ANATOMY
■ Underlying the forehead is the frontal bone. Laterally, the frontal bone is
crossed by a curved ridge called the temporal crest (temporal ridge or temporal
fusion line). This palpable landmark separates the forehead from the temporal
fossa laterally (FIG 1). The temporalis muscle takes its origin from the
temporal fossa.
■ The surgical significance of the temporal crest line is that overlying fascial
layers are tethered to bone in a band immediately medial to the palpable ridge.
This has been called the zone of fixation or the zone of adhesion.2,3 Inferiorly,

where the ridge approaches the orbital rim, the fixation becomes broader and
denser, forming the orbital ligament, also known as the temporal ligamentous
adhesion. Regardless of the surgical technique used, when a full-thickness
forehead flap is mobilized, all fascial attachments to bone must be released,
including the zone of adhesion and the orbital ligament, plus attachments to the
supraorbital rim and lateral orbital rim.4
■ The temporal crest also marks a change in nomenclature as tissue planes
transition from lateral to medial. The deep temporal fascia covers the
temporalis muscle and is attached to bone along the temporal crest. It then
continues medially as the periosteum of the frontal bone. Similarly, the
superficial temporal fascia (also known as the temporal-parietal fascia)
continues medially as the galea aponeurotica.
■ The galea aponeurotica splits into a superficial and a deep layer to encompass
the frontalis muscle. Inferiorly, the deep galea layer separates further into three
separate layers: two layers encompass the galeal fat pad, and a third layer is
adherent to periosteum.2 Superficial to the deepest galeal layer is the so-called
glide plane space, which allows the scalp flap to shift superiorly.

FIG 1 • Galeal attachments must be completely
released to allow a forehead flap to move superiorly.
The firmest attachment is at the temporal ligamentous
adhesion (orbital ligament) but is also present along the
supraorbital rim (supraorbital ligamentous adhesion),
down the lateral orbital rim (lateral orbital thickening)
and along the temporal crest line. In raising the flap, the
temporal branches of the facial nerve will be in the roof
of the dissection immediately above the medial
zygomatic vein (sentinel vein).
■ The galeal fat pad extends across the entire width of the lower 2 cm of the
forehead; medially it encompasses the supratrochlear nerves and much of the
corrugator musculature. The galeal fat pad is separated from the preseptal fat
(retro-orbicularis oculi fat or ROOF) by one of the layers of galea (see above).

Laterally, this galeal layer is thought to be inconsistent, with some individuals
having continuity between the galeal fat pad and the preseptal fat (ROOF).
Within the eyelid, the septum orbitale divides the preseptal fat (ROOF) from
orbital fat.
■ Muscle anatomy plays a significant role in determining eyebrow shape and
position. In addition to the soft tissue attachments, the level of the eyebrow is
the result of a balance between the muscular forces that elevate the brow, the
muscular forces that depress the brow, and gravity.
■ Brow depressors in the glabella originate from bone and insert into soft tissue.
The procerus runs vertically near the midline, the depressor supercilii and
supramedial orbicularis run obliquely, and the corrugator supercilii runs mostly
transversely.
■ The transverse corrugator supercilii is the largest and most significant of these
muscles. Useful landmarks to locate the corrugator are as follows: the
corrugator originates from the orbital rim at its most superomedial corner, right
at the entrance to the orbit. The transverse head passes through galeal fat
becoming more superficial until it interdigitates with the orbicularis and
frontalis under a skin dimple that is visible when the patient frowns.
■ The orbicularis encircles the orbit acting like a sphincter. Medially and
laterally, the orbicularis fibers run vertically and act to depress brow level.
Laterally, orbicularis is the only muscle that depresses brow position.
■ The frontalis is the only elevator of the brow. It originates from the galea
aponeurotica superiorly and interdigitates inferiorly with the orbicularis.
Contraction raises this muscle mass and the overlying eyebrow, which is a
cutaneous structure. The muscle is deficient laterally, so its primary lifting
effect is on the medial and central portions of the eyebrow.
Sensory Nerves
■ Innervation to the upper periorbita is supplied by the supraorbita and
supratrochlear nerves, as well as two lesser nerves, the infratrochlear and
zygomaticotemporal.
■ The zygomaticotemporal nerve exits posterior to the lateral orbital rim
piercing the deep temporal fascia just inferior to the sentinel vein. In coronal
brow lifting, with complete release of the lateral orbital rim, it is often avulsed.
Consequences of this are minimal and temporary.
■ The supratrochlear nerve usually exits the orbit superomedially, although the
exact location is variable. It immediately divides into four to six branches that

usually pass through the substance of the corrugator. These branches then
travel superiorly, on the superficial surface of the frontalis, innervating the
central forehead and first few centimeters of the scalp.
■ The supraorbital nerve exits the superior orbit through a notch in the rim, or
about 10% of the time, through a foramen that is superior to the rim.
■ The supraorbital nerve divides into two segments: superficial and deep. The
superficial branch pierces orbicularis and frontalis, traveling as several small
branches on the superficial surface of the frontalis to innervate the central
forehead as far posteriorly as the first 2 cm of hair. The rest of the scalp, as far
back as the vertex, is innervated by the deep branch that runs between the
periosteum and the deepest layer of galea and then pierces the frontalis near the
hairline to innervate scalp skin.5
Motor Nerves
■ The temporal branch of the facial nerve is the only motor nerve of surgical
concern in this area. The temporal branch enters the temporal fossa as several
(2–4) fine branches that lie on the periosteum of the zygomatic arch in its
middle third. Between 1.5 and 3.0 cm above the arch, these branches become
more superficial, traveling within the superficial temporal fascia
(temporoparietal fascia) to innervate the frontalis, superior orbicularis, and
glabellar muscles.6 A number of different landmarks can be used to predict the
course of the temporal branches. These include
■ The middle third of the palpable zygomatic arch
■ 1.5 cm lateral to the tail of the eyebrow
■ Parallel and adjacent to the inferior temporal septum
■ Immediately superior to the medial zygomaticotemporal vein (sentinel vein)
■ In the coronal brow lift procedure, the dissection should be entirely deep to the
temporal branches of the facial nerve.
PATHOGENESIS
■ The periorbital region is the most expressive part of the human face. Subtle
changes in eyebrow shape can profoundly affect facial appearance.1
■ Because of the importance of periorbital expression, humans have historically
resorted to any means at their disposal to alter their eyebrows. These have
included eyebrow plucking and shaving, makeup, and tattoos.
■ Aesthetically, the eyebrow is only one part of the puzzle in the periorbital
zone. Other variables include the presence of senile eyelid ptosis, the loss of

upper sulcus orbital fat, and the accumulation excess of upper eyelid soft tissue
(skin, orbicularis muscle, and orbital fat).
■ The preferred forehead will be devoid of vertical of transverse lines. It will be
framed superiorly by a well-positioned aesthetically shaped hairline and
inferiorly by well-positioned, attractively shaped eyebrows.
■ The “ideal” eyebrow shape is affected by ethnicity, gender, and the era in
which we live (FIG 2). There are certain themes that define aesthetically
pleasing eyebrow in the 21st century:7
■ The medial eyebrow level should lie over the medial orbital rim.
■ The medial border of the eyebrow should be vertically in line with the medial
canthus.
■ The eyebrow should rise gently, peaking slightly at least two-thirds of the
way to its lateral end; typically, this peak lies vertically above or lateral to the
lateral limbus.
■ The lateral tail of the brow should be higher than the medial end.
■ The male brow should be lower and less peaked.
■ Abnormally low eyebrows can be congenital or acquired over time through
aging.
■ Age-related brow ptosis causes the forehead/eyebrow complex to encroach on
the upper orbit, resulting in a pseudoexcess of upper eyelid skin. In response,
patients subconsciously contract the frontalis to raise the eyebrows, leading to
transverse forehead lines. This is accentuated with the presence of mild senile
eyelid ptosis. Such patients will often present with a request for upper lid
blepharoplasty.
FIG 2 • The attractive eye exhibits a modest amount of

visible upper lid (“tarsal show”); this dimension is about
one-third of the distance from the lash line to the lower
border of the eyebrow. The brow itself starts medially
over the supraorbital rim and vertically in line with the
medial canthus. It angles gently upward, peaking about
two-thirds of the way along the brow toward its lateral
extent. In females, this peak is at or lateral to the lateral
limbus of the eye. In men, this peak is minimal or
absent. Laterally, the “tail” of the brow should end at a
higher point than the medial end of the brow.
■ Other lines in the forehead are caused by the glabellar frown muscles. Vertical
lines are caused by the transversely oriented corrugator, horizontal lines are
caused the vertically running procerus, and oblique lines are caused by the
depressor supercilii and orbicularis.
■ Age-related brow ptosis is not universal. Up to 40% of people have relatively
stable eyebrow position throughout life and are generally not candidates for
brow lift surgery.8
■ Frontalis is the only lifting force to counter balance the various muscles and
gravity that depress the brow level. The lateral portion of the eyebrow is
particularly sensitive to this interplay because frontalis action is attenuated
laterally and also because the security of lateral brow fixation to bone is
inconsistent.9,10 Poor soft tissue attachment with no muscular lift will
inevitably lead to ptosis of the lateral third of the eyebrow.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Most patients will not be aware of the many factors involved in periorbital
aging, and they may not want the multiple procedures required to treat all of
these components. For that reason, identifying the main component of every
patient’s periorbital aging is important. Old photographs are very helpful in
helping the surgeon determine which age-related changes predominate.
■ Assessment is done with the patient awake and upright in the sitting or
standing position. The following issues are evaluated: visual acuity, eyebrow
and orbital symmetry, position of anterior hairline, thickness of scalp hair,
transverse forehead lines, glabellar frown lines, thickness of eyebrow hair,
eyebrow height, axis of the eyebrow (downward or upward lateral tilt), shape

of the eyebrow (flat or peaked), passive and active eyebrow mobility, and the
presence of old scars or tattoos. The upper eyelids should also be assessed for
soft tissue redundancy, for upper sulcus hollowing, and for eyelid level (ptosis
or lid retraction).
■ To identify patients with chronic frontalis contraction, examination should be
done with eyes open and eyes closed. When the eyes are closed, the frontalis
can be made to relax, revealing the true position and shape of the eyebrows. If
the eyebrows are forcibly held in this position when the patient opens their
eyes, the eyebrow-eyelid relationship without frontalis effect will be revealed.
■ A patient may be a candidate to have the entire brow complex lifted or more
commonly to have only part of the eyebrow raised, thus improving eyebrow
shape. Occasionally, in a patient who chronically looks angry, this may involve
raising the medial brow only, but most commonly, it is the lateral third to one-
half of the eyebrow that requires repositioning with little or no lift of the
medial portion.
■ Weakening or eliminating the glabellar frown musculature is a useful parallel
objective.
■ If brow lifting is contemplated, the effect on the upper eyelid complex must be
considered. Previous upper lid blepharoplasty may have left a patient tissue
deficient, so that brow lifting could impair eyelid closure. Also, brow lifting
may reveal the previously unappreciated hollowing of the upper lid sulcus.
NONOPERATIVE MANAGEMENT
■ Numerous nonoperative strategies are available to change eyebrow shape
and/or position.
■ Nonmedical: eyebrow plucking, cosmetic makeup, tattooing
■ Medical, nonsurgical: botulinum toxin injection, synthetic filler injection,
thread lifting
■ Surgical, non-brow lift: transpalpebral frown muscle ablation
SURGICAL MANAGEMENT
Preoperative Planning
■ There are many surgical techniques available to elevate or to reshape the
eyebrow. The coronal approach is a traditional method with a long track record
of proven results.11,12
■ The preoperative discussion is an excellent time for the surgeon to teach the

patient about periorbital aging. To achieve the patient’s objectives, some
concepts that are new to the patient may be introduced. A patient requesting
brow rejuvenation surgery may also be a candidate for blepharoplasty, upper
sulcus fat grafting, or eyelid ptosis repair.
■ This procedure provides maximum visibility and flexibility. Therefore, during
the planning process, the surgeon should develop a mental image of what
portion of the eyebrows are to be lifted, how much lift is required, and if there
is any brow asymmetry to be corrected.
■ With the patient awake and in the upright position, with the forehead in repose,
the desired amount and direction of eyebrow elevation are assessed by
manually elevating the brow complex (FIG 3). Specific vectors have been
described, but more artistic decision-making is preferred.
FIG 3 • With the frontalis muscle in repose, the desired
amount and direction of eyebrow elevation are
estimated by manually elevating the brow complex. The
desired vector of lift can also be determined using this
method.
■ Essential preoperative markings include the incision and the vectors for flap
mobilization.
■ Ancillary markings that are useful include the expected course of the temporal
branch of the facial nerve, the expected location of the supraorbital and
supratrochlear nerves, and the location of the frown muscles (determined with
the patient awake and frowning).

Positioning
■ The patient is placed on the operating table in the supine position with the
head on a small pillow or soft donut.
■ The head of the bead is raised slightly to help reduce venous engorgement in
the surgical area.
■ Intermittent compression devices are applied to the legs, and a heating device
covers the patient.
Approach
■ Possible approaches for an open brow lift are
■ Coronal incision
■ Anterior hairline incision
■ Combination of these two (modified coronal) (FIG 4)
■ Possible planes of dissection are
■ Subcutaneous
■ Subgaleal
■ Subperiosteal
■ The coronal incision is well hidden in the hair of the scalp. There are two
options for the dissection plane: subgaleal or subperiosteal. Of the two, the
subgaleal approach is most often used because it provides a rapid bloodless
plane of dissection with excellent exposure of the frown musculature.
■ The anterior hairline incision puts the surgeon closer to the eyebrows and also
provides excellent visibility. The main disadvantage of the anterior hairline
incision is a potentially visible scar along the anterior hairline. Thoughtful
incision techniques and careful suture techniques will mitigate this problem.
There are three potential planes of dissection: subcutaneous, subgaleal, and
subperiosteal. The subcutaneous plane offers some unique advantages: no
transection of sensory nerves, the separation of skin from underlying frontalis,
thus effacing transverse forehead lines and the direct shifting of the eyebrow,
which is a cutaneous structure.13

FIG 4 • Approaches for an open brow lift include the
classic coronal incision, made about 6 cm behind the
hairline, the anterior hairline incision, and a combination
of the two—a modified version with an anterior hairline
incision combined with a coronal-type approach
laterally.
■ The modified coronal approach (anterior hairline approach with lateral
incision placement like a coronal incision) is much like a coronal procedure
but with a hairline incision used to avoid elevating the anterior hairline in
patients with a high forehead. Like the coronal, this approach lends itself to the
subgaleal plane, although it is technically straightforward to change planes at
the anterior hairline, creating a subcutaneous plane deep to the forehead skin
and a subgaleal plane laterally.

T E C H N I Q U E S
■ Coronal Brow Lift (Subgaleal Plane)
■ Preoperative surgical marking will have been done (see above).
■ The procedure is done under general anesthetic or local anesthetic with
sedation.
■ The head and neck area is prepped and draped with exposure of the entire
face.
■ A local anesthetic mixture composed of 1% lidocaine with 1:100 000
epinephrine and 0.25% bupivacaine with 1:200 000 epinephrine is infiltrated
into the incision line, along the supra- and lateral orbital rims plus some
injection under the scalp flap.
■ After waiting for the epinephrine effect, the incision is made full thickness
through the scalp down to periosteum over the skull centrally and laterally
down to the deep temporal fascia. The scalpel is beveled parallel to the hair
follicles. If an anterior hairline incision is planned, the scalpel is beveled in
such a way that the hair follicles will be partially transected, utilizing the
Camirand principle14 (TECH FIG 1A).
■ The standard coronal incision is designed to be about 6 cm behind the
hairline although this is variable, depending on the height of the forehead.
Laterally, the marking extends to the ear and, in some cases, may be made in
continuity with a facelift incision. The incision can be taken across the top of
the head in a gentle curve, or it can peak slightly in the midline to allow for
some flap rotation.
■ With all coronal brow lift approaches, the superficial and deep branches of
the supraorbital nerve will be transected, as will the anterior branch of the
temporal artery, which will require hemostasis.
■ The flap is easily raised in the subgaleal plane. This can be done with blunt
dissection or with a scalpel blade beveled away from the periosteum (TECH
FIG 1B). Lateral to the temporal crest, the superficial temporal fascia
(temporoparietal fascia) is separated from the deep temporal fascia. Along
the zone of adhesion, just medial to the temporal crest line, soft tissue
attachment to bone is released.

TECH FIG 1 • A. The standard coronal incision
extends across the top of the head from ear to ear,
approximately 6 cm behind the anterior hairline.
Laterally, on either side, it can be curved forward to
allow for greater flap mobility. It can also be designed
to be contiguous with a facelift incision. B. The coronal
flap is raised in the avascular subgaleal plane down to
the orbital rim. Temporal facial nerve branches course
within the flap laterally; cautery and traction in that
area should be done cautiously. C. The corrugator

muscles are demonstrated, taking their origin from the
edge of the supramedial orbital rim. They can be seen
coursing obliquely through galeal fat and become
more superficial until they insert into the
orbicularis/frontalis muscle mass at a skin dimple that
can be seen when a patient frowns. The purple line
marks the midline. The two procerus muscles can be
seen coursing vertically from the origin on the nasal
bones. Behind the tips of the clamps are vertically
running fibers—the depressor supercilii muscles. D.
Once the flap has been released from its deep
attachments, it is mobilized along preplanned vectors.
Normally, most of the flap advancement is done
laterally, with typically 2 to 3 cm of scalp being
excised. Centrally, the excision will be less than half
that. After ablation of frown musculature, in the
presence of an intact frontalis muscle, the medial brow
will rise naturally without the need for tension on the
scalp flap.
■ In approaching the supraorbital rim, care is taken to look for the supraorbital
nerve, which in 10% of cases will exit the skull through a foramen above
(superior to) the supraorbital rim. Traction on the flap with skin hooks and
elevation with L-shaped retractors are useful maneuvers, but care should be
taken to avoid traction damage to the temporal branches of the facial nerve
that travel laterally within the flap.
■ Complete release of the galeal attachment to the supraorbital and lateral
orbital rims is necessary to achieve enough flap mobilization to create lasting
brow elevation. The most adherent zone is the region of the orbital ligament
(temporal ligamentous adhesion). Adequate galeal release along the
supraorbital rim is confirmed when retro-orbicularis fat (ROOF) is observed.
■ Release of attachments to the lateral orbital rim should continue inferiorly as
far as the level of the lateral canthus. When this dissection is done as an
extension of the subgaleal plane, the periosteum will remain intact. The

medial zygomaticotemporal vein (sentinel vein) is routinely encountered and
can either be preserved or, to ensure better access, cauterized. Cautery should
be done carefully due to the presence of the temporal facial nerve branches
running in the flap above this vein.
■ In the midline, in most cases, it is prudent to leave some attachment of the
deepest galea to the periosteum. This will guard against excessive medial
brow elevation. Conversely, in those cases where medial brow elevation is
desired, this area should be released.
■ Once the flap has been freed from the orbital rims, the corrugator supercilii
is identified within the galeal fat (TECH FIG 1C). The muscle is removed in
a piecemeal fashion from its medial origin to the supraorbital nerve laterally.
In removing this muscle, branches of the supratrochlear nerve are
encountered coursing through the substance of the corrugator. These are
small branches accompanied by small vessels that may require cauterization;
loupe magnification is therefore helpful.
■ Depending on the preoperative findings, the paired procerus muscles and the
vertically running depressor supercilii can also be removed, although this will
be a partial, not a complete, removal.
■ Removal of a large corrugator muscle can create a soft tissue deficiency; if
so, a small fat graft is harvested elsewhere and sutured into the soft tissue
defect.
■ After muscle modification and flap mobilization are complete, the flap is
then drawn superiorly along the preplanned vectors. In most cases, the
primary objective is to elevate the lateral half of the eyebrow with less (or no)
elevation of the medial half. The desired flap overlap is normally maximal in
a vector along the temporal crest line. Every case is individualized. Internal
fixation may be done by suturing the advancing superficial temporal fascia
down to the underlying deep temporal fascia at a higher level than it
previously had been. This suturing should be done superior to the expected
course of the temporal facial nerve branches. Typically, 3-0 PDS suture is
used for this fixation.
■ The scalp flap is advanced superiorly over the cut edge of the original scalp
incision. To line up the flap, three short radial incisions made, and temporary
key sutures are placed—centrally and along the temporal crest line
bilaterally. Excess full-thickness flap is removed: typically about 2 cm of
scalp flap laterally and 1 cm or less centrally (TECH FIG 1D).