Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

CHAPTER 9 Skin Resur acing
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What are the advantages o a phenol peel?
It is extremely reliable and has the most consistent depth o penetration, which is into the upper reticular dermis.
T e histological changes are permanent and the e ect is extremely long lasting (> 20 years).

How does one increase the penetration o a phenol peel?
Use a lower concentration o phenol, use o an occlusive dressing (taping). Recent evidence suggests that varying
the amount o croton oil in the preparation may also serve to vary the depth o peel.

Why does using a higher concentration o phenol penetrate less than lower concentrations?
raditionally, it was thought that higher concentrations o phenol are thought to cause more extensive
denaturation o super cial proteins in the skin and there ore lead to a greater extent o nonpermeability to the
remainder o the peel. Lower concentrations o phenol are actually there ore more dangerous to use as they
penetrate more deep into the skin. T ere is, however, some controversy over this issue at present.

How is the treatment area dressed a ter a phenol peel?
Either by an occlusive (taping, Flexan, Vigilon) or by a nonocclusive (petroleum jelly) dressing.

What ingredients make up the Baker/Gordon phenol peel?
Phenol (3 mL o 88% USP), water (2 mL), liquid soap (Septisol; eight drops), croton oil (three drops).

Why is croton oil added? Why is Septisol used?
Croton oil is thought to act as a skin irritant, which acts to deepen the peel; Septisol causes a deeper penetration o
the peel, likely secondary to its tension-lowering (sur actant) properties.

Can phenol be used anywhere else besides the ace?
No. Phenol peels used on non acial areas can result in severe scarring.

What is the most common long-lasting side ef ect o phenol peels?
Hypopigmentation, which can be permanent.

Why does hypopigmentation occur a ter phenol peeling?
While epidermal melanocytes are still present ollowing phenol peeling, they become unable to synthesize normal
amounts o melanin.

What is the most serious medical potential side ef ect o phenol peels?
Cardiotoxicity. T e risk is signi cantly increased when phenol is applied to more than 50% o the acial sur ace in
less than 30 minutes.

What does laser stand or?
Light ampli cation by stimulated emission radiation.

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Plastic & Reconstructive Surgery Board Review

How does a laser cause skin resur acing?
Light emitted by a laser is absorbed by tissue (di erent types o tissue depending on the wavelength o the speci c
laser). T e kinetic energy then turns into heat that coagulates or ablates tissue, depending on laser type and
wavelength utilized.

What property o tissue determines which wavelength will be absorbed?
Di erent chromophores (e.g., hemoglobin, water) within the tissue absorb di erent wavelengths o light.

What are the most important non skin sa ety concerns when using a laser?
Proper eye care and the avoidance o OR res.

Which types o lasers are most commonly used or cosmetic skin resur acing?
T e CO2 and Er:Yag lasers.

How does the CO2 and Er:Yag work to resur ace the skin?
T e CO2 laser (10,600 nm) gets absorbed by water and creates a photothermal e ect to increase collagen
remodeling and contraction o the skin, but causes greater collateral injury leading to increased recovery time as
well as an increased risk o pigment changes.
T e Er:Yag (2,940 nm) laser also gets absorbed by water; however, because o its wavelength it is 10 × more
ef cient than CO2 and works via a photomechanical e ect. T is does cause an increased amount o transudate
and less control o bleeding, however this laser type results in less hyperemia, less coagulation necrosis, a shorter
healing time, and minimal pigment changes.

How does one increase the penetration o a laser treatment?
Increase the pulse energy and/or increase the number o passes.

Is a pretreatment regimen necessary be ore laser treatment?
A pretreatment regimen is not absolutely necessary, however it is extremely important to maximize results.
ypical protocols are the same or chemical peeling, which include Retin-A, hydroquinone, glycolic acid cream,
sunscreens, and moisturizers as well as antivirals/antibiotics.

What is the most common problem ollowing laser resur acing?
Hyperpigmentation.

What are the best ways to avoid signi cant hyperpigmentation ollowing laser resur acing?
Use o a bleaching agent (hydroquinone) preprocedure, discontinuation o hormone therapy, avoidance o sun
exposure postoperatively, treating appropriate Fitzpatrick skin-type patient population.

What is the most common type o laser used or hair removal?
T e Nd:Yag laser. It destroys approximately 90% hair in the anagen phase with each treatment.

CHAPTER 9 Skin Resur acing
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What is dermabrasion?
A procedure that involves a controlled, mechanical skin injury, typically to the level o the papillary dermis,
using a handheld abrading rotating tip. Di erent types o abrading tips may include burrs, diamond raises, and
sandpaper.

What are the advantages o dermabrasion over other skin-resur acing techniques?
It is less costly, easy to learn, and simple to per orm; those that taut its e ectiveness also claim that the depth o
wounding can be more precisely controlled than with other methods.

What are the best conditions treated by dermabrasion?
It is most commonly used to treat perioral lines/wrinkles, acne scars, traumatic scars, and surgical scars. In
addition, rhinophyma has also been success ully treated utilizing dermabrasion.

How does one control the depth o dermabrasion?
Coarseness o the abrading tip, number o strokes, pressure on the tip during strokes, contact time with skin,
altering rotational speed.

Which areas o the ace respond best to dermabrasion or skin resur acing?
Lines in the perioral region.

What is microdermabrasion?
A super cial ablation o the epidermis only. T is is a variation o dermabrasion, however less abrasive crystals
are used and less suction is applied to the skin, so that there is a more subtle overall response; however, sa ety is
increased. T is procedure can be per ormed in spas and nonmedical centers (e.g., hair salons) because o the use o
more gentle instrumentation, which causes less skin injury compared to traditional dermabrasion.
REFERENCES
Baker J, Stuzin JM. Chemical peeling and dermabrasion. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, PA: WB Saunders;
1990:748–786.
Baker J, Stuzin JM, Baker M. Facial Skin Resurfacing. St Louis, MO: Quality Medical Publishing; 1998.
Halaas YP. Medium depth peels. Facial Plast Surg Clin North Am. 2004;12:297–303.
Hetter GP. An examination o the phenol–croton oil peel: part I. Dissecting the ormula. Plast Reconstr Surg. 2000;105(1):227–239.
Hirsch RJ, Daya SH, Shah AR. Super cial skin resur acing. Facial Plast Surg Clin North Am. 2004;12:311–321.
Lynch SA. Chemical peeling and dermabrasion. In: Weinzweig J, ed. Plastic Surgery Secrets. Philadelphia, PA: Hanley & Bel us, Inc;
1999:318–321.
Perkins SW, Castellano R. Use o combined modality or maximal resur acing. Facial Plast Surg Clin North Am. 2004;12:323–337.

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77
Neelesh A. Kantak, MD and
Leonard B. Miller, MD, FACS, FRCS

What is chemical peeling?
T e use o ex oliating agents to remove portions o epidermis and/or dermis, which results in the growth o new
epidermal tissue and the alignment and deposit o new collagen in the dermis.

What are the indications or chemical peeling?
Rhytides, actinic keratoses, lentigines, melasma, acne vulgaris, rosacea, milia, super cial scarring rom acne, and
photodamaged skin.

What e ect does chemical peeling have on the dermis?
Decrease o nonlamellar collagen.

How are the ex oliants categorized? Provide examples.
According to the depth o the wounding they produce:
1. Super cial—involves the papillary dermis (trichloroacetic acid [ CA] 10% to 20%, Jessner’s solution, salicylic
acid, alpha-hydroxy acids, tretinoin).
2. Medium depth—to upper reticular dermis ( CA 35% to 50% + Jessner’s solution, pyruvic acid).
3. Deep depth—to mid-layers o reticular dermis (Baker’s phenol peel, Hetter phenol–croton oil peel).

Name the most common agents used or chemical peeling and their mechanism o action.
1. Phenol: a keratocoagulant, which denatures and coagulates sur ace keratin.
2. CA: trichloroacetic acid.
3. Croton oil: native ingredient causing deep layers o injury in the phenol–croton oil peel.
4. Soap: this acts as a sur actant action, which enhances penetration.
5. Water: slows down keratocoagulation and improves absorption.
6. Salicylic acid: this denatures and coagulates sur ace keratin.
Chemical Peels
CHAPTER 10

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What is the Baker’s ormula?
Phenol (3 mL o 88% USP), croton oil (three drops), liquid soap (eight drops), and water (2 mL).

What is the Hetter phenol–croton oil peel?
It is a re nement o the Baker’s ormula that recognizes croton oil as the active ingredient in the phenol–croton
oil peel and allows titration o the degree o injury to the skin in a measured manner by accurately identi ying the
amount o croton oil in a given solution used on the peel.

What is another name or phenol?
Phenol is also known as carbolic acid and is an aromatic derived rom coal tar.

What is Jessner’s solution?
Resorcinol (14 g), salicylic acid (14 g), lactic acid (14 mL), and ethanol (100 mL).

What are the actors that determine the depth o the peel?
An important actor is the concentration o these solutions being applied. Also important is the mechanism by which
they are applied, the cleanliness o the skin, and the pressure and the number o strokes applied with the applicator.

What is the advantage o using Jessner’s solution be ore application o TCA?
T e primary advantage is that Jessner’s solution removes the super cial layers o keratin, thereby allowing lower
concentrations o CA to be applied to reach the desired dermal depth.

What is salicylic acid (SA)?
Salicylic acid (30%) is a beta-hydroxy acid and was the original peeling agent. It is used or single or multiple
resur acing o moderately photodamaged acial skin.

What is the role o tyrosinase in skin pigmentation?
yrosinase is an enzyme which catalyzes production o melanin rom tyrosine. Hydroquinone and kojic acid are
skin lighteners that work by inhibition o tyrosinase.

When does clinical evidence o peeling begin?
It usually begins on the second post-peel day and can extend up to 12 days, depending on the depth o
penetration and the drugs used.

What is the clinical course o a chemical peel?
Within the rst ew days there is a desquamation o the super cial layers o the epidermis. T en, depending on
the solution applied, there is an injury to the epidermis and layers o the dermis. Over a 3- to 13-day period, there
is reepithelialization o the wound. T e skin initially can have a distinct red hue, which changes, over the ensuing
time, to pink and nally having a normal appearance. T is redness could be present or a number o weeks in a
deep croton oil peel.

CHAPTER 10 Chemical Peels
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What interval between treatments is recommended or salicylic acid peels?
An interval o 4 weeks or total epidermal regeneration.

What are the advantages o salicylic acid peels?
Uni ormity o application, producing a white rost visible to the naked eye, no risk o overpeeling because the
vehicle volitizes in less than 4 minutes and it may also be use ul or treatment o comedones and in ammatory acne.

What is the Fitzpatrick classif cation o sun-reactive skin types and how can it be used?
It is a classi cation system based on color and response to sunlight. ypes I to III are usually good candidates
or chemical peeling, with the exception o red-haired, reckled persons. ypes IV to VI are at risk or unwanted
pigmentation changes, particularly hypopigmentation.

What is the gauge by which the end point o chemical application is determined?
T ere is typically a rost that occurs.

What role does taping have or phenol and TCA peels?
aping increases the depth o treatment by its occlusive action.

What are the methods used to enhance the e ect o a peel?
aping and repeated applications with a 2 × 2 sponge.

What peel should not be used in people o A rican-American descent?
Phenol peel and 35% CA or higher has a signi cant negative ef ect on melanocytes.

Describe the histologic changes associated with photoaged skin.
T ere is thickening o the epidermis with attening o the dermal–epidermal junction, decreased melanocyte
concentration, dermal in ammation with disorganized collagen brils.

What is melasma and how is it treated?
Melasma consists o irregular brown patches on sun-exposed skin, usually at malar prominences and the orehead.
It can be treated with hydroquinone, either alone or in combination with tretinoin and/or topical steroid.
Skin Type
Skin Color

Characteristics
I

White

Always burns, never tans
II

White

Usually burns, tans less than average
III

White

Sometimes burns mildly, tans about average
IV

White/Olive/Light Brown

Rarely burns, tans more than average
V

Brown

Rarely burns, tans profusely
VI

Black

Never burns, deep pigmentation

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How many months a ter discontinuing Accutane treatments can you resur ace the skin?
Six months.

How long to delay chemical peels a ter a aceli t?
T ree months.

What is a eared complication o TCA peeling while the patient is on Accutane treatments?
Hypertrophic scarring and delayed healing.

Can you use a combination o Jessner’s solution and 35% TCA peel at the same time as a aceli t?
Yes.

A patient with deep perioral rhytids is undergoing a aceli t. What is the best treatment o the perioral
rhytids that can be per ormed concurrently with the aceli t?
Phenol–croton oil peel.

What is the importance o pretreatment prior to chemical peel application?
Pretreatment can help allow deeper and more uni orm penetration o the peeling agent. Cleansing with acetone or
isopropanol immediately be ore peeling removes oils and makeup. Use o tretinoin or preconditioning beginning
several weeks be ore peeling helps provide ex oliation, more uni orm penetration o the peel, and promotes aster
reepithelialization.

Can a TCA peel be used on the neck?
No.

Can any type o peeling solution be used on the neck?
Yes, in extremely light concentration o phenol–croton oil peel.

What is the f rst sign o phenol toxicity?
Cardiac arrhythmias. T e duration o associated EKG changes typically lasts less than 20 minutes, though the
hal -li e o phenol, which is renally excreted, is approximately 3.5 hours. Can prevent by dividing ace into
subunits and spacing applications 20 minutes apart.

What e ects does Retin-A have on the skin?
It causes regression o many premalignant lesions o the epidermis, thins the stratum corneum, thickens the
epidermis, causes reduction o ne rhytids and ading o pigmented macules. Histologically, it decreases the
corneocyte cohesion and thus thins the stratum corneum, increases collagen and glycosaminoglycan deposition in
the papillary dermis, provides more vertically organized cellular polarity, and disperses melanocyte granules. Side
ef ects include erythema, photosensitivity, and desquamation.

What is the long-term e ect o Retin-A treatment o sun-damaged skin?
Premalignant lesions regress.

CHAPTER 10 Chemical Peels
81

What is the histologic f nding that is seen with long-term use o Retin-A?
Increase in dermal collagen ypes I, III, and VII.

What percentage o glycolic acid and how many minutes o topical application are used in the setting o melasma?
50% glycolic acid and 2 to 4 minutes.

What percentage and number o minutes o glycolic acid are used or wrinkles, actinic keratoses, and solar
lentigines?
70% glycolic acid applied over a 4- to 6-minute period.

Which peel agent and concentration should be used in a patient with f ne wrinkles who wants very little
down time?
30% glycolic acid.

What indicator is used to determine how long to per orm a glycolic acid peel?
Development o white patches is desirable and indicates epidermolysis, however development o a white rost
indicates deeper destruction o the dermis and is not desirable. Glycolic acid can be washed with water or
neutralized with bicarbonate once desired epidermolysis is achieved.

For moderate acial wrinkles which agent should be used, glycolic acid or TCA?
30% to 35% CA.

Describe the application o a TCA peel.
Peel is applied at concentrations between 20% and 50% depending on depth within reticular dermis desired.
Application is associated with an intense burning. T e clinical endpoint or medium-depth peel is rosting o the skin,
which indicates coagulation o the papillary dermis. Reepithelialization is typically complete by 14 days a ter application.

What are the pros and cons associated with using a TCA peel versus phenol peel?
A phenol peel will provide more dramatic improvement in coarse acial rhytids due to deeper penetration in
the reticular dermis. It will also provide more dramatic results or pigmentary changes in Fitzpatrick I or II
skin. Phenol peels provide twice the depth o penetration and double the collagen production compared to a
deep CA peel. Advantages o a CA peel include lower risk o pigmentary changes, particularly long-term
hypopigmentation that may occur with phenol peels in Fitzpatrick IV, V, and VI patients. CA requires a shorter
recovery period and is not associated with cardiac toxicity.

What is the pretreatment interval o antiviral medications or patients with a history o oral herpes prior to
undergoing a chemical peel?
24 hours prior and 5 days a ter a chemical peel. In the absence o pretreatment, a patient with a history o prior
herpetic lesions has a 50% chance o developing an outbreak and a person with no history o lesions has a 7%
chance o developing an outbreak.

What does tretinoin do to the stratum corneum?
T ins the stratum corneum.

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What is the sequence o changes that occur with tretinoin use?
T inning o stratum corneum occurs within 1 week; clinical improvement in ne wrinkles takes 6 to 12 months
o treatment. Epidermal changes are seen within 6 months o use, however increase in dermal collagen requires at
least 9 to 12 months o treatment.

What e ect does the concentration o tretinoin cream have?
Higher concentrations are associated with aster and more dramatic results but a harsher side ef ect pro le,
speci cally scaling, erythema, and pruritus.

What is the di erence between retinol and tretinoin?
Retinol (Vitamin A) must be converted to tretinoin (all-trans retinoic acid) in order to become biologically active.
Retinol is also destabilized by light, oxygen, and water, and hence topical application o retinol has much lower
bioavailability in the dermis than tretinoin.

What are the three most common complications o a TCA peel?
1. In ection
2. Scarring
3. Changes in skin pigmentation (primarily hyperpigmentation)

In a patient undergoing a phenol peel with history o signif cant liver disease what is the most appropriate
treatment interval?
One-hal o the ace over 30 minutes.

What is the mechanisms o action o retinoids?
Decreased activation o metalloproteinases through inhibition o AP-1 transcription.

In a patient using tretinoin, what is the time period that improvement in f ne acial rhytids is f rst noted?
6 to 12 months.

What are the complications o all types o chemical peeling?
1. Pigmentary change
2. Scarring
3. In ection
4. Prolonged erythema or pruritus
5. Contact dermatitis
6. extural changes
7. Milia
8. Acne
9. Cold insensitivity

CHAPTER 10 Chemical Peels
83

What are the complications arising exclusively rom deep phenol peeling?
1. Atrophy
2. Cardiac arrhythmias
3. Laryngeal edema
4. Exacerbation o concurrent skin disease

Is hyperpigmentation or hypopigmentation most likely to occur a ter a superf cial or a medium-depth peels?
Hyperpigmentation.

What pigmentary changes are likely to occur a ter a phenol peel?
ransient in ammatory hyperpigmentation (3–6 weeks a ter reepithelialization), with risk o long-term
hypopigmentation. T is is more likely to occur in patients with Fitzpatrick ype III or higher. ransient
hyperpigmentation can be prevented by pretreatment with hydroquinone. CA peels of er a lower risk o
pigmentary changes in darker-skinned patients.

What is more caustic, 50% TCA or ull-strength phenol?
50% CA.

What is the incidence o scarring with the traditional Baker’s phenol ormula i used correctly?
Less than 1%.

What are the treatment options o scars a ter chemical peeling?
1. opical non uorinated steroids
2. opical uorinated steroids
3. Steroid-impregnated tape
4. Intralesional steroids
5. Silicone gel sheeting
6. Flashlamp-pumped pulsed dye laser—585 nm
7. Surgical excision
8. Observation

Is TCA toxic to internal body organs i applied to the skin?
No, it is neutralized by serum in the super cial dermal plexus.

What procedure has less risk or pigmentary change, a TCA peel or a phenol peel?
Phenol peel.

What anatomic structure most e ectively neutralizes TCA in patients undergoing TCA peels?
Dermis.

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Plastic & Reconstructive Surgery Board Review

Where is phenol eliminated?
It is metabolized by the liver and excreted by the kidneys.
REFERENCES
Baker J, Stuzin JM. Chemical peeling and dermabrasion. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, PA: WB Saunders;
1990:748–786.
Cortez EA, Fedok FG, Mangat DS. Chemical peels: panel discussion. Facial Plast Surg Clin North Am. 2014;22:1–23.
Fitzpatrick B. T e validity and practicality o sun reactive skin types I–VI. Arch Dermatol. 1988;124:869–871.
Gross BG. Cardiac arrhythmias during phenol ace peeling. Plast Reconstr Surg. 1984;73(4):590–594.
Hetter GP. An examination o the phenol–croton oil peel: part I. Dissecting the ormula. Plast Reconstr Surg. 2000;105(1):227–239.
Hetter GP. An examination o the phenol–croton oil peel: part II. T e lay peelers and their croton oil ormulas. Plast Reconstr Surg.
2000;105(1):240–248.
Hetter GP. An examination o the phenol–croton oil peel: part III. T e plastic surgeons’ role. Plast Reconstr Surg. 2000;105(2):752–763.
Hetter GP. An examination o the phenol–croton oil peel: part IV. Face peel results with dif erent concentrations o phenol and croton
oil. Plast Reconstr Surg. 2000;105(3):1061–1083.
Hubbard BA, Unger JG, Rohrich RJ. Reversal o skin aging with topical retinoids. Plast Reconstr Surg. 2014;133:481e–490e.
Kang S, Fisher GJ, Voorhees JJ. Photoaging and topical tretinoin. Arch Dermatol. 1997;133:1280–1284.
Kilgman AM, Grove GL, Hirose R, Leyden JJ. opical tretinoin or photoaged skin. J Am Acad Dermatol. 1986;15:836–859.
Larson DL. Phenol–croton oil peel: an update. Aesthet Surg J. 2005;25(2):197–200.
Larson DL, Karmo F, Hetter GP. Phenol-croton oil peel: establishing an animal model or scienti c investigation. Aesthet Surg J.
2009;29(1):47–53.
Leyden JJ. reatment o photodamaged skin with topical tretinoin: an update. Plast Reconstr Surg. 1998;102:1667–1671.
Molinar VE, aylor SC, Pandya AG. What’s new in objective assessment and treatment o acial hyperpigmentation? Dermatol Clin.
2014;32:123–135.
Ozturk CN, Huettner F, Ozturk C, et al. Outcomes assessment o combination ace li t and perioral phenol-croton oil peel. Plast
Reconstr Surg. 2013;132:743e–753e.

85
Alan Yan, MD and
Michael J. Yaremchuk, MD

What is a biomaterial?
T e National Institute o Health de nes biomaterial as, “Any substance or combination o substances, other
than drugs, synthetic or natural in origin, which can be used or any period o time, which augments or replaces
partially or totally any tissue, organ or unction o the body, in order to maintain or improve the quality o li e o
the individual.”

What are the characteristics o “the ideal implant”?
1. Inert, causes no oreign-body reaction
2. Resistant to in ection
3. Sterilizable
4. No donor site morbidity
5. Nontoxic, noncarcinogenic
6. No resorption
7. Simpli es procedure (time, complexity)

Under what circumstances is autologous tissue pre erred over alloplasts?
1. Lack o so t tissue coverage
2. Radiation
3. Compromised vascularity
4. Poor quality o surrounding tissue

Why are the long-term results o autologous bone gra ting disappointing in the acial skeleton?
T e ate o onlay bone gra t is unpredictable due to resorption and actors that impact its subsequent remodeling.
Revascularization o the bone gra t makes it susceptible to osteoclast activity, resulting in resorption and volume loss.
T e unctional stresses that the recipient site places on the bone gra t, determined by regional musculoskeletal orces
and de orming orces o the overlying so t tissue envelope, impact the volume persistence o onlay bone gra ts.
Alloplastic Augmentation
of the Facial Skeleton
CHAPTER 11

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Plastic & Reconstructive Surgery Board Review

What are the main classes o biomaterials used in pediatric cranio acial applications?
1. Ceramics and bioactive glass
2. Biodegradable polymers
3. Pre abricated polymers

Name examples o ceramics.
1. Hydroxyapatite
2. Calcium phosphate

Which biomaterial is designed to be replaced by bone?
Bioactive glass is both osteoconductive and osteoinductive.

What is osteoconduction?
Osteoconduction re ers to the ability o a material to serve as a sca old and allow ingrowth o osteoblasts and
gradual ormation o osseous tissue.

What is osteoinduction?
Osteoinduction is the process by which primitive, undi erentiated pluripotent cells are stimulated to develop into
the bone- orming cell lineage.

Name examples o biodegradable polymers.
1. Poly(lactic acid) (PLA)
2. Poly(glycolic acid) (PGA)
3. Poly(lactic-co-glycolic acid) (PLGA) (combination o PLA and PGA)

Name examples o pre abricated polymers.
1. Porous polyethylene (Omnipore; Matrix Surgical, Atlanta, GA; Medpor; Stryker, Kalamazoo, MI)
2. Polymethyl methacrylate (Hard-Tissue Replacement [HTR] polymer; Biomet, Jacksonville, FL)

In what ways can biomaterials be placed in the acial skeleton?
As nonload bearing inlay or onlay or acial augmentation.

What criteria are used to decide whether autologous bone or biomaterials is to be used in the pediatric
cranio acial skeleton?
1. Skeletal maturity.
2. Requirement or inlay or onlay reconstruction.
3. Requirement or load-bearing reconstruction.

CHAPTER 11 Alloplastic Augmentation o the Facial Skeleton
87

What is an appropriate choice o materials i skeletal growth is less than 90% complete, and the reconstruc-
tion needs to grow with the developing cranio acial skeleton?
Demineralized bone and bioactive glass.

At what age is skeletal growth essentially complete in the cranio acial skeleton?
3 years (cranial vault) and 14 years ( acial skeleton).

What is the material o choice in load-bearing reconstruction?
Autologous bone.

What are the indications or alloplastic acial augmentation in adults?
1. Skeletal enhancement
2. Reconstruction o secondary acial skeletal de ormity rom acial trauma
3. Alternative to orthognathic surgery when occlusion is acceptable or has been orthodontically corrected
4. Adjunct to orthognathic surgery
5. Rejuvenation o the mid ace and/or periorbital region
6. reatment o Graves ophthalmopathy (in conjunction with other modalities)
7. For acial masculinization (i.e., in transgendered patients)

What are the most common sites o alloplastic acial augmentation?
1. Chin
2. Mandible
3. Malar
4. In raorbital rim
5. Piri orm aperture

What are the biomaterials commonly used or acial skeletal augmentation in adults?
1. Metals ( or xation)
2. Polymers (silicone, polytetra uoroethylene, acrylic, polyethylene, polymethyl methacrylate)
3. Ceramics (hydroxyapatite)

How does the body respond di erently to silicone and porous implants?
Smooth implants, such as silicone, result in ormation o a smooth-walled capsule. Porous implants allow tissue
ingrowth, have a less dense and well-de ned capsule, and are hence harder to remove, but allow so t tissue
integration.

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Plastic & Reconstructive Surgery Board Review

What are the advantages o silicone?
1. Can be sterilized by steam or irradiation
2. Can be carved with scissors or scalpel
3. Can be stabilized with screw or suture
4. Can be removed easily because o capsule ormation
5. No known clinical or allergic reaction to silicone implants

What are the disadvantages o silicone?
1. Resorption o the underlying acial skeleton (especially the chin)
2. Implant migration and malposition i not xed
3. Visible brous capsule when placed under a thin so t tissue envelope
4. Higher in ection rate than porous polyethylene

What are the major advantages o porous polyethylene (Omnipore, Medpor)?
1. Porosity allows so t tissue ingrowth
2. Allows some exibility and adaptability o the implant
3. Less likely to migrate or erode underlying bone
4. Easy xation with screws
5. Easy contouring with scalpel or power equipment without ragmenting
6. Lower in ection rate than silicone

What are the major disadvantages o porous polyethylene (Omnipore, Medpor)?
Requires dissection o a larger pocket or placement than smooth implants. So t tissue ingrowth makes implant
removal more dif cult.

In what location should implants be placed or adult acial skeletal augmentation?
T ey should be placed in the subperiosteal plane because dissection is sa e to peripheral nerves and is relatively
bloodless. It also allows direct visualization o the acial skeleton and, there ore, more precise augmentation o the
skeletal contour.

What surgical approaches can be used or in raorbital rim augmentation?
Intraoral, extraoral (subciliary, transconjunctival, preauricular, and coronal), or a combination o both.

What structure needs to be identif ed during placement o an in raorbital rim implant?
T e in raorbital nerve as it exits the in raorbital oramen. It is located about 1 cm below the margin o the orbit
in the midpupillary line.

CHAPTER 11 Alloplastic Augmentation o the Facial Skeleton
89

What is the role or paranasal augmentation?
1. Simulates the visual e ect o LeFort I advancement and other skeletal manipulations
2. Increases the projection o the nasal base and opens the nasolabial angle
3. Increases nasal tip projection by elevating the nasal base
4. Lessens the depth o the nasolabial old by e acing it rom below

What surgical approach can be used or paranasal augmentation?
Intraoral incision, the medial extent o which is made just lateral to the piri orm aperture to avoid placing the
incision directly over the implant.

What surgical approaches can be used or malar augmentation?
Intraoral or extraoral (subciliary, transconjunctival, preauricular, and coronal) incision.

What is the most common complication a ter placement o a malar implant?
Asymmetry due to malposition or migration (particularly with smooth silicone implants).

What surgical approaches can be used or chin augmentation?
Intraoral or submental incision.

What are disadvantages o an intraoral incision or placement o chin implants?
1. Superior malposition o implants
2. Lower lip dys unction rom division or detachment o the mentalis muscle
3. Poor visualization o the mental nerve

What is the most common complication a ter placement o a chin implant?
Hypoesthesia o the lower lip ( rom neuropraxia o the mental nerve) is usually transient and typically resolves
with time.

What implants can be used to correct a “negative vector” de ormity?
In raorbital rim implants can provide convexity to the de cient upper mid ace skeleton.

What are the common complications a ter alloplastic acial augmentation?
1. Hematoma
2. Implant-related in ection
3. Extrusion or exposure
4. Implant malposition/migration
5. Facial asymmetry
6. Sensory nerve dys unction
7. Palpability

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Plastic & Reconstructive Surgery Board Review

What is the treatment or implant-related in ections?
1. Implant removal, antibiotics, and appropriate wound care
2. Implants may be replaced in 6 to 12 months
REFERENCES
Albrektsson , Johansson C. Osteoinduction, osteoconduction and osseointegration. Eur Spine J. 2001;10(suppl 2):S96–101.
Cenzi R, Farina A, Zuccarino L, Carinci F. Clinical outcome o 285 Medpor gra ts used or cranio acial reconstruction. J Craniofac Surg.
2005;16:526–530.
Chen N , Glowacki J, Bucky LP, Hong HZ, Kim WK, Yaremchuk MJ. T e roles o revascularization and resorption on endurance o
cranio acial onlay bone gra ts in the rabbit. Plast Reconstr Surg. 1994;93:714–722.
Chim H, Gosain AK. Biomaterials in cranio acial surgery: experimental studies and clinical application. J Craniofac Surg. 2009;20:
29–33.
Doumit G, Abouhassan W, Yaremchuk MJ. Aesthetic re nements in the treatment o Graves ophthalmopathy. Plast Reconstr Surg.
2014;134:519–526.
Gosain AK. Plastic Surgery Education Foundation DA A Committee. Biomaterials or reconstruction o the cranial vault. Plast Reconstr
Surg. 2005;116:663–666.
Gosain AK, Chim H, Arneja JS. Application speci c selection o biomaterials or pediatric cranio acial reconstruction: developing a
rational approach to guide clinical use. Plast Reconstr Surg. 2009;123:319–330.
Hench LL, West JK. Biological applications o bioactive glasses. Life Chem Rep. 1996;13:187–241.
Lin KY, Bartlett SP, Yaremchuk MJ, Grossman RF, Udupa JK, Whitaker LA. An experimental study on the e ect o rigid xation on the
developing cranio acial skeleton. Plast Reconstr Surg. 1991;87:229–235.
Matros E, Momoh A, Yaremchuk MJ. T e aging mid acial skeleton: implications or rejuvenation and reconstruction using implants.
Facial Plast Surg. 2009;25:252–259.
Raschke R, Hazani R, Yaremchuk MJ. Identi ying a sa e zone or mid ace augmentation using anatomic landmarks or the in raorbital
oramen. Aesthet Surg J. 2013;33:13–18.
Ratner BD, Ho man AS, Schoen FJ, Lemons JE. Biomaterials Science. St Louis, MO: Elsevier Academic Press; 2004.
Rubin JP, Yaremchuk MJ. Complications and toxicities o implantable biomaterials used in acial reconstructive and aesthetic surgery:
a comprehensive review o the literature. Plast Reconstr Surg. 1997;100:1336–1353.
Williams DF. Williams Dictionary of Biomaterials. Liverpool University Press; 1999.
Yaremchuk MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg. 2003;111:1818–1827.
Yaremchuk MJ. Making concave aces convex. Aesthetic Plast Surg. 2005;29:141–147.
Yaremchuk MJ, Chen YC. Enlarging the de cient mandible. Aesthet Surg J. 2007;27:539–550.
Yaremchuk MJ, Doumit G, T omas MA. Alloplastic augmentation o the acial skeleton: an occasional adjunct or alternative to
orthognathic surgery. Plast Reconstr Surg. 2011;127:2021–2030.
Yaremchuk MJ, Israeli D. Paranasal implants or correction o mid ace concavity. Plast Reconstr Surg. 1998;102:1676–1684.
Yaremchuk MJ, Kahn DM. Periorbital skeletal augmentation to improve blepharoplasty and mid acial results. Plast Reconstr Surg.
2009;124:2151–2160.

91
Michael J. Frederick, MD,
John Hijjawi, MD, and
Samuel J. Lin, MD, MBA, FACS
BASIC LASER CONCEPTS

What does the acronym LASER stand or?
Light Ampli cation by Stimulated Emission o Radiation.

What are the three unique properties o laser light as opposed to natural light?
1. Coherent—laser light is coherent (all waves are spatially and temporally in phase).
2. Monochromatic—the delivered light is o a single spectral color and o a single precise bandwidth.
3. Intense—laser light delivers the greatest number o photons per unit area.

What is “thermal relaxation time”?
ime required or a tissue to absorb and di use the thermal energy to surrounding tissues.

What is “pulse energy”?
T e energy o one pulse.

So why do these last two acts matter?
T e pulse duration o a laser should be set or LESS time than the thermal relaxation time o the target tissue i
you want the target tissue to be heated and destroyed. I the pulse duration is MORE than the thermal relaxation
time, the tissue will absorb and di use the energy to surrounding tissues be ore it is destroyed.

What is the optimal pulse duration time?
A time that is LESS than the thermal relaxation time o the target tissue, usually hal .

What is “energy”?
T e capacity to do work in joules.
Lasers
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What is “power”?
T e energy delivered divided by the time o application.

What is “power density” (irradiance)?
T e rate o energy delivered per unit area measured in watts per square centimeter.

What is “ uence”?
otal laser energy delivered per unit area expressed as joules per square centimeter. T e volume o tissue removed is
a unction o the amount o energy applied.

What is a continuous wave (CW) laser?
Lasers producing a constant ow o laser energy and thus resulting in signi cant thermal tissue damage. T ey can
be “gated” using a physical shutter to interrupt the ow o energy.

What is a pulsed laser?
T ese lasers produce high-energy, short pulses without the use o a physical shutter.

What is a Q-switched laser?
Q-switching produces particularly high-energy, short-pulse-duration beams.

Lasers are selected based on their ability to be selectively absorbed by target tissues. T ese target tissues
in the skin are known as?
Chromophores.
CLINICAL APPLICATIONS

What is the di erence between ablative and nonablative lasers?
• Ablative lasers remove tissue in a controlled ashion rom the outside in resulting in a wound that the body must
heal.
• Nonablative lasers target speci c chromophores in the skin leaving the epidermis intact.

What is selective photothermolysis?
Selective thermal damage o a pigmented target when suf cient uence at a wavelength is delivered during a time
(pulse duration) equal to or less than the thermal relaxation time o the target. More simply, energy is delivered to
the target more quickly than the target can dissipate it.

When targeting chromophores with selective photothermolysis what is another way other than adjusting the
pulse duration to decrease injury to the surrounding tissues?
Cool the skin.

CHAPTER 12 Lasers
93

Name three primary chromophores in the skin.
1. Hemoglobin
2. Water
3. Melanin

T e pulsed-dye laser (585 nm) is absorbed by which chromophores?
Oxyhemoglobin.

What are the clinical applications o the pulsed-dye laser?
Cutaneous vascular lesions such as:
• port-wine stains
• capillary mal ormations
• telangiectasias
• spider angiomas

What is the di erence between pulsed dye, tunable dye, and ash lamp-pumped pulsed dye lasers?
T ere is no major di erence. T ey are all used to treat vascular anomalies.

What are the advantages o Q-switched lasers?
T ey are highly selective in targeting tattoo pigments rather than the actual tissue (skin) holding the pigment.

What are the disadvantages o Q-switched lasers?
T ey are associated with transient hypopigmentation.

T e Q-switched ruby laser (694 nm) is absorbed by which chromophores?
• Melanin
• Carbon in tattoo pigments

What are the clinical applications o the Q-switched ruby laser?
• Pigmented cutaneous lesions (Nevus o Ota, ca é-au-lait spots)
• Purple, violet, and black ink in pro essional and amateur tattoos
• raumatic tattoos (embedded carbon)

What are the results o ca é-au-lait spot treatment with Q-switched ruby lasers?
While lightening o spots is evident in many patients a ter about our to six treatments, recurrence o the spots is
the rule in most cases.

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A patient comes to you with a dark rectangle on their upper arm. T ey tell you a local surgeon used a
Q-switched ruby laser to try removing a tattoo o the Canadian ag. What happened and will it get better?
Q-switched ruby lasers are contraindicated or red-, white-, and skin-colored pigments because they can convert
the iron in erric oxide to errous oxide, darkening the pigment irreversibly.

What is the ideal laser or removing a blue-green tattoo?
• Q-switched alexandrite laser (755 nm).
• Remember, the blue-green waters o the Nile were right outside our hotel window when we visited Alexandria,
Egypt.

What is the ideal laser or removing red, orange, or brown tattoos?
T e Q-switched Nd:YAG/K P laser (K P is 532 nm and targets red/orange/brown, Nd:YAG 1,064 targets
darker pigments black and blue). As this laser is versatile it is commonly used or tattoos.

Your tattoo removal patient comes in a ter his second treatment with a Q-switched laser urious that his
tattoo is still visible. What do you tell him?
• attoo removal typically takes 3 to 10 treatments—more treatments are o ten required or pro essional tattoos
compared to amateur/traumatic tattoos.
• Good results are reported in 75% to 95% o patients.

What lasers target pigmented lesions?
Any laser that targets melanin: Ruby, Alexandrite, Diode, Nd:YAG, IPL.

What are common lasers used or hair removal and what do they target?
• Nd:Yag (1064 nm), Alexandrite (755 nm), Diode (810 nm), intense-pulsed light
• Melanin

What laser is best or tattoo and hair removal in patients with darker pigmented skin?
Nd:Yag, because o the longer wavelength.

How do lasers cause hair removal?
T e laser heats up the melanin in the hair that then causes damage to the surrounding bulge cells.

In what hair growth phase are lasers most e ective?
Anagen.

What requency is intense-pulsed light?
rick question, it is multiple requencies (590–1,200 nm) and thus noncoherent and not a laser. As it has multiple
wavelengths it can do a variety o things. Over 20 di erent laser companies have developed an IPL device and each
one is slightly di erent.

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What can IPL treat?
Hair removal, melasma, acne vulgaris, telangiectasis, rosacea, lentigines, actinic keratosis, and sebaceous gland
hyperplasia.

What are two common ablative lasers?
CO2 (10,600 nm) and Erbium (2,940 nm).

T e carbon dioxide laser is absorbed by which chromophores?
Water.

What are clinical applications o the carbon dioxide laser then?
CO2 lasers are highly absorbed by water in skin. T is makes them highly e ective or:
• skin resur acing o ne rhytids
• cutting
• coagulation

What is ractional photothermolysis?
Instead o a continuous wave o energy, the light is ractionated causing multiple small columns o injury, leaving
the immediate surrounding tissue una ected.

I I use a non ractionated laser what potential complication can present years later?
Hypopigmentation. Acute complications o prolonged erythema and scarring are also more common with the
non ractionated ablative lasers. Because o this, many people no longer use these lasers.

What is the most common complication o ablative laser treatment?
Hyperpigmentation, which usually resolves in several months but can be permanent.

What Fitzpatrick skin type is most likely to get hyperpigmentation a ter treatment?
ypes 3 and 4.

My patient underwent CO2 treatment 3 weeks ago and her skin is still red. Is this normal?
Yes, this can be normal, topical ascorbic acid has been shown to help.

Is tretinoin or isotretinoin used or skin preparation be ore dermabrasion?
retinoin is used. Isotretinoin (Accutane) is contraindicated or 1 year be ore laser or dermabrasion due to risk o
scarring and delayed healing.

Your patient returns to the of ce with a pain ul vesicular rash around her mouth 4 days a ter a CO2 resur ac-
ing treatment. What should you do?
reat this herpes simplex virus (HSV) outbreak with acyclovir. Consider prophylactic treatment in any uture
patient with a history o cold sores.

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What chromophore is absorbed by the Erbium:YAG laser?
Water; and it does so 10 times more ef ciently than a CO2 laser.

What is the process by which an Er:YAG laser results in ablative resur acing?
A photomechanical process rather than a photothermal process.

What are the primary applications o the Er:YAG laser?
Ablative resur acing o the skin.

What are the advantages o the Er:YAG laser over the CO2 laser in terms o skin resur acing?
• Less thermal damage to surrounding tissue
• More rapid reepithelialization
• 5% to 10% risk o hypopigmentation versus 40% with CO2 lasers

What disadvantage do erbium lasers have?
• T ey result in a transudative wound
• Less dramatic skin tightening than CO2 lasers

What laser is used or treating lymphatic mal ormations?
Erbium laser at 2,910 nm.

Are pulse dye lasers or ractional CO2 lasers used to treat scars?
Both! Pulse dye is used or the red hyperemic scar and can improve the color and pruritus. Fractional CO2 is
thought to relax hypertrophic and keloid scars and make them so ter.

Can lasers be used to treat acne?
Yes, but with variable ef cacy. Hypertrophic erythematous scars can be treated with the pulse dye laser. Atrophic
acne scars show improvement with ablative lasers or “rolling” and “boxcar” scars, but “ice pick” scars require
excision.
REFERENCES
Alster S. Cutaneous resur acing with CO2 and erbium:YAG lasers: preoperative, intraoperative, and postoperative considerations. Plast
Reconstr Surg. 1999;103(2):619–632.
Ashino R, Geronemus RG. Q-switched ruby laser treatment o labial lentigos. J Am Acad Dermatol. 1992;27(5, pt 2):809–811.
Gan SD, Graber EM. Laser hair removal: a review. Dermatol Surg. 2013;39(6):823–38.
Grossman MC, Anderson RR, Farinelli W, Flotte J, Grevelink JM. reatment o ca e au lait macules with lasers. A clinicopathologic
correlation. Arch Dermatol. 1995;131(12):1416–1420.
Khatri KA, Mahoney DL, McCartney MJ. Laser scar revision: A review. J Cosmet Laser T er. 2011;13(2):54–62.
Manstein D, Herron GS, Sink RK, anner H, Anderson RR. Fractional photothermolysis: a new concept or cutaneous remodeling
using microscopic patterns o thermal injury. Lasers Surg Med. 2004;34(5):426–438.

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Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and uture directions. Burns. 2010;36(4):443–449
Sobanko JF, Alster S. Management o Acne Scarring, Part I: A Comparative Review o Laser Surgical Approaches. Am J Clin Dermatol.
2012;13(5):319–330.
ierney EP, Eisen RF, Hanke CW. Fractionated CO2 laser skin rejuvenation. Dermatol T er. 2011;24(1):41–53.
Utley DS, Koch RJ, Egbert BM. Histologic analysis o the thermal e ect on epidermal and dermal structures ollowing treatment with
the superpulsed CO2 laser and the erbium:YAG laser: an in vivo study. Lasers Surg Med. 1999;24(2):93–102.
Wat H, Wu DC, Rao J, Goldman MP. Application o intense pulsed light in the treatment o dermatologic disease: a systematic review.
Dermatol Surg. 2014;40(4):359–377.
Wittenberg GP, Fabian BG, Bogomilsky JL, et al. Prospective, single-blind, randomized, controlled study to assess the ef cacy o the
585-nm ashlamp-pumped pulsed-dye laser and silicone gel sheeting in hypertrophic scar treatment. Arch Dermatol. 1999;135:
1049–1055.

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99
Theodore T. Nyame, MD and
Bernard T. Lee, MD
GENERAL FILLER CHARACTERISTICS

Describe the ideal ller.
1. Sa e/biocompatib e
2. Physio ogic
3. Easi y obtained, stored, and used
4. Long- asting and reversib e
5. Predictab e with minima migration
6. Minima side e ects or comp ications

What is the molecular composition o the biodegradable llers commercially available?
1. Bovine co agen (Zyderm/Zyp ast, Resop ast)
2. Human co agen (Derma ogen)
3. Auto ogous brob asts (LAVIV, A oDerm)
4. Hya uronic acid (Hy a orm ge , Resty ane)
5. Ca cium hydroxy apatite (Radiesse)
6. Po y-L- actic acid (PLLA)

In what acial areas do llers have greater longevity?
Re ative y static areas, such as naso abia o ds, or areas rendered ess dynamic by Botox a ow or more sustained
resu ts. Fi ing dynamic areas o the ace, such as the ips, reduces duration o er e ect.

What should patients avoid 5 days prior to undergoing acial rejuvenation with llers?
1. Vitamin E
2. Gingko bi oba
3. Aspirin and nonsteroida anti-in ammatory
Injectable Fillers
CHAPTER 13

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P astic & Reconstructive Surgery Board Review
AUTOLOGOUS FAT TRANSFER

How should at be harvested, prepared, and injected to ensure maximal e ect?
Gent e harvest o the at with ow-pressure suction coup ed with gravity sedimentation or ba anced centri ugation
he ps to preserve at architecture. Co eman’s technique o sma a iquot injection in mu tip e tissue p anes aids in
revascu arization o the trans erred at.

What percentage o at survives a ter at gra ting?
60% to 80%, depending on the ocation o injection, method, and vascu arity o surrounding tissue.

What are common techniques or processing at a ter harvesting?
Fat can be processed by:
1. Ba anced centri ugation
2. Cotton gauze ro ing
3. Suction tration

Which technique is e ective in removing f uid and oil?
A o the above.

Which technique provides the highest in vivo gra t retention?
A study ooking at at gra t retention in nude mice ound higher in vivo gra t retention and stroma vascu ar
raction yie d was highest with the cotton gauze ro ing method.

What are the disadvantages o this method?
T is method is air y tedious and dif cu t to do or high-vo ume gra ting.
COLLAGEN DERIVATIVE FILLERS

Describe Zyderm I, Zyderm II, and Zyplast.
1. Avai ab e in 1977, Zyderm I, derived rom bovine co agen, is 95% type I and 5% type III co agen. Zyderm II
has a most twice the concentration o bovine co agen o Zyderm I. T ese two ormu ations are injected
in the more super cia dermis to treat ne-to-moderate ines, wrink es, and scars, but they are degraded in
approximate y 3 months time.
2. Zyp ast resu ts rom cross- inking bovine co agen with g utara dehyde and has greater tissue ongevity. It can be
used in the deep dermis or deeper ines and o ds but is degraded in 3 to 6 months time.
3. A ergic reaction or these products with bovine co agen has been reported as high as 5%. T ere ore,
antecedent skin testing with Zyderm I (about 0.1 mL) shou d be per ormed. Skin shou d be observed a ter
severa days and a ter 1 month or signs o a ergic reaction. O specia note, the injection o Zyp ast has
resu ted in retina artery thrombosis.

CHAPTER 13 Injectab e Fi ers
101

How do Cosmoderm/Cosmoplast di er rom Zyderm/Zyplast?
Cosmoderm 1, Cosmoderm 2, and Cosmop ast are ana ogous to Zyderm I, Zyderm II, and Zyp ast but are human
co agen derma ers and do not require skin testing. Cosmoderm is used or more super cia ines, whereas
Cosmop ast is used or more pronounced wrink es. Resu ts ast up to 6 months.

What is Dermalogen?
Derma ogen is derived rom human derma co agen and harvested rom cadaver skin specimens. Derma ogen is
steri ized and processed to inactivate virus and prions. It is purported to undergo neovascu arization and co agen
synthesis.

What are the contraindications o injectable collagen?
Autoimmune disease, deep pock or ice pick scars, immature or indurated scars, and positive skin reactions are the
contraindications.

Why are llers contraindicated or deep ice pick scars or xed scars?
Deep ice pick and xed scars cannot be mobi ized because o scar tissue that extends deep to the subcutaneous
tissue p ane. P acing ing materia wou d e evate the surrounding skin and produces a donut e ect. T e cause o
the tethering shou d be addressed prior to consideration o ers.

What is Evolence?
Approved in 2006, Evo ence is a cross- inked porcine co agen indicated or moderate-to-deep acia wrink es and
the naso abia o d. Evo ence proved superior or the treatment o naso abia o ds to Zyp ast beyond 6 months.
HYALURONIC ACID ANALOGS

What is hyaluronic acid (HA)?
Hya uronic acid is a natura y occurring po ysaccharide in human so t tissues such as skin, carti age, and bone. It is
identica in orm in a mamma ian species. T us, there is no concern or a ergenicity. HA is hydrophi ic and aids
in tissue hydration. It decreases with age, which resu ts in reduced skin turgor, increased wrink ing, and a genera
de ation o tissues.

What is the hal -li e o HA?
T e ha - i e o HA is on y 1 to 2 days.

What is Restylane?
Resty ane is a cross- inked HA rom a bacteria source that can ast rom 6 months to 1 year. Resty ane can be used
or moderate-to-severe acia wrink es and the naso abia o d. It shou d be injected at the mid-to-deep dermis.

Describe Hyla orm and Hyla orm Plus.
Approved in 2004, Hy a orm and Hy a orm P us are avian HAs indicated or mid-to-deep dermis correction o
moderate-to-severe acia wrink es and the naso abia o d. Hy a orm P us has a arger partic e size than Hy a orm.
Resu ts can ast up to 1 year.

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What is Captique and how does it di er rom Hyla orm?
Approved in 2004, Captique di ers rom Hy a orm in that it is obtained rom a bacteria source. It is indicated or
mid-to-deep dermis correction o moderate-to-severe acia wrink es and the naso abia o d. Resu ts may ast up to
1 year.

What is Juvederm?
Approved in 2006, Juvederm is a derma er that asts up to 12 months and is indicated or correction o
moderate-to-severe acia wrink es and o ds. Juvederm U tra is thinner, whi e Juvederm U tra P us is thicker.
Juvederm U tra P us can be used to restore vo ume but shou d be injected in the deep derma or subderma eve .

What is Perlane and how is it di erent rom Restylane?
Per ane is an HA derivative that is more viscous with a much arger ge partic e size than Resty ane. Per ane shou d
be injected at the deep derma or subderma eve to treat deeper o ds. Resu ts can ast up to 1 year.

What is Belotero?
Be otero is a hya uronic-based derma er that is indicated or correction o moderate-to-severe acia wrink es
and o ds via injection into the mid-to-deep dermis. Resu t may ast rom 6 months to 1 year.
RADIESSE AND SCULPTRA

What is Radiesse, ormerly Radiance?
Radiesse contains ca cium hydroxyapatite beads in an aqueous ge . Fibrous encapsu ation o the hydroxyapatite
partic es produces a ong-term resu t. Radiesse may ast up to 2 years and shou d not be used in the ips.

What is Sculptra?
Scu ptra is composed o injectab e po y-l - actic acid po ymer that provides a gradua increase in derma thickness
and acia vo ume. Resu ts may ast up to 2 years. It is FDA approved on y or the treatment o HIV-associated
ipodystrophy o the ace.
PERMANENT FILLERS

Discuss intrinsic problems o injecting permanent llers.
Permanent ers can ead to permanent comp ications that are dif cu t to treat or correct. Moreover, areas treated
with such substances may not age in the same way as the rest o the ace.

What is Arte ll?
Arte is the rst and on y permanent er approved by the FDA and avai ab e or use in the United States. It
contains po ymethy methacry ate in bovine co agen and idocaine. Arte is indicated or the correction o the
naso abia o d. It is not to be used or ip augmentation or in known ke oid ormers.

CHAPTER 13 Injectab e Fi ers
103
LESS POPULAR FILLERS AND FILLERS NOT FDA APPROVED

What is Cymetra?
Cymetra is an injectab e micronized orm o A oderm. Its ongevity is at most 6 months and is more expensive than
HA derivatives. Its consistency is irregu ar and umpy. It is indicated or ips, naso abia o ds, and deep wrink es. It
is contraindicated in patients with autoimmune connective tissue disease and in poor y vascu arized surgica sites.

What is Fascian?
Fascian is an injectab e human cadaveric ascia (e.g., ascia ata) that stimu ates co agen ormation and asts up
to 6 months. It has an irregu ar consistency and arger partic e size, which makes precise injection more dif cu t.
Fascian can be used as a vo ume enhancer or the naso abia o d.

What is Gore-Tex?
Gore- ex is expanded po ytetra uoroethy ene (eP FE), which wi persist in tissue. However, it must be trimmed
to t the area to be augmented and pa pabi ity can be an issue.

What is Autologen?
Auto ogen is an ace u ar, co agen ber er extracted rom human dermis in which the specimen is obtained
rom an individua during another surgery. Its production requires individua processing and is cost y.

What is Isolagen?
Not FDA approved. Iso agen is a cu tured auto ogous brob ast er, which invo ves harvest o a derma specimen
rom the patient and severa weeks’ cu ture time. It has a de ayed response, as new co agen must be produced rom
these brob asts a ter injection over a period o months. Studies or the product have shown persistence up to 4 years.

Can silicone be used as a dermal ller?
Si icone is not FDA approved or cosmetic use.

Describe various methods to reduce discom ort o ller injections.
1. Re rigerant sprays be ore need e insertion can b unt pain perception at the super cia eve . T is item shou d
not be used on mucosa sur aces.
2. Vibration massagers and ice are use u adjuncts. Pinching the skin at the time o injection can a so reduce pain.
3. Sma er-gauge need es (e.g., 30 or 32 gauge) with a tubercu in syringe can reduce injection pain. opica
anesthetics shou d be app ied 30 to 60 minutes be ore injection and shou d not be used on mucosa sur aces.
4. Articaine 4% (Septocaine), which has a higher pH than idocaine, causes ess pain on injection.
5. In raorbita b ocks or naso abia o ds and upper ips and menta b ocks or marionette ines and ower ips
provide anesthesia with minima distortion.

Discuss the di erences o anterograde and retrograde injection o llers.
1. Anterograde injection may yie d a so ter orward movement through tissues and b unt the impact and pain o
the need e tip. Some be ieve it pushes vesse s away to prevent inadvertent trauma.
2. Retrograde injection may he p avoid intravascu ar injection and may be use u in thin areas so that additiona
dissection pathways are not produced on injection.

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Describe linear threading, anning, and cross-hatching and their utility in even/symmetric ller injection
and dispersal.
1. Linear threading can be done anterograde or retrograde and is most use u or the vermi ion border and the
naso abia o d.
2. Fanning invo ves even y spaced de ivery in a c ockwise or counterc ockwise manner.
3. Cross-hatching uti izes a series o threading injections made in a grid ike pattern to optimize er use and
create a more even contour.

Describe techniques to avoiding swelling and bruising.
Care u avoidance o visib e super cia vesse s is critica . Patients shou d avoid medications with anticoagu ant
e ect at east severa days be ore treatment. Firm pressure a ter treatment as we as postinjection ice packs can
reduce swe ing and bruising.

Describe common cosmetic complications o ller use.
Asymmetry, sur ace irregu arities, undercorrection, and overcorrection are a re ative y common and are technique
and experience dependent.

How can one avoid nodule ormation?
Use sma er-gauge need es (30 or 32 gauge) to contro the amount o er injected. Do not overcorrect areas and
do not inject too super cia y. Massage can be used to distribute er more even y.

Describe nodule management.
Home massage by the patient is a conservative approach. Corticosteroid injection as we as puncture and
aspiration may a so be use u . Hya uronidase can be used or HA ana ogs. Excision is the na option.

Comment on intravascular injection prevention and management i intravascular injection occurs.
S ow injection with ow pressure can be he p u . Injection o the angu ar artery during naso abia o d correction
and supratroch ear artery injection during g abe a rejuvenation are two areas o concern. Sudden pain or
b anching o the area cou d be a warning sign o an intravascu ar injection. Once it occurs, a topica vasodi ator
such as nitrog ycerin can be app ied. One can inject hya uronidase or HA ers. Some have recommended
ow–mo ecu ar-weight heparin dai y or 1 week. Conservative treatment is the ru e as these in requent y resu t in
u -thickness tissue necrosis.

Describe a reasonable approach to mid ace treatment with llers.
Ma ar contour shou d be restored rst. T is resu ts in a i ting and vo umizing e ect that can reduce the
appearance o the naso abia o ds. Furthermore, this can reduce the need to treat the tear trough or orbitoma ar
area.

Describe additional ller applications.
Fi ers can be used or the nasa dorsum and tip due to surgica depression or age-re ated atrophy. Fi ers at the
base o the co ume a can be used to i t the nasa tip. Fi ers can be use u in smoothing the appearance o chin
imp ants. T ey a so have uti ity in p umping the sagging ear obe.

CHAPTER 13 Injectab e Fi ers
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REFERENCES
Ashino R. Overview: so t tissue augmentation. Clin Plast Surg. 2000;27(4):479–487.
Be otero Ba ance [package insert]. Merz Aesthetics, Inc.; 2012.
Broder KW, Cohen SR. An overview o permanent and semipermanent ers. Plast Reconstr Surg. 2006;118(3S):7S–14S.
Carruthers JD, G ogau RG, B itzer A. Facia Aesthetics Consensus Group Facu ty. Advances in acia rejuvenation: botu inum toxin type A,
hya uronic acid derma ers, and combination therapies—consensus recommendations. Plast Reconstr Surg. 2008;121(5):5S–30S.
Cheng J , Perkins SW, Hami ton MM. Co agen and injectab e ers. Otolaryngol Clin North Am. 2002;35(1):73–85.
Cohen SR, Ho mes RE. Arteco : a ong- asting injectab e wrink e er materia : report o a contro ed, randomized, mu ticenter c inica
tria o 251 subjects. Plast Reconstr Surg. 2004;114(4):964–979.
Co eman SR. Structura at gra ts: the idea er? Clin Plast Surg. 2001;28(1):111–119.
Epp ey BL, Dadvand B. Injectab e so t-tissue ers: c inica overview. Plast Reconstr Surg. 2006;118(4):98e–106e.
Fagien S, K ein AW. A brie overview and history o temporary ers: evo ution, advantages, and imitations. Plast Reconstr Surg.
2007;120(6S):8S–16S.
Fisher C, Grahovac L, Scha er ME, Shippert RD, Marra KG, Rubin JP. Comparison o harvest and processing techniques or at
gra ting and adipose stem ce iso ation. Plast Reconstr Surg. 2013;132(2):351–361.
Frank P, Gend er E. Hya uronic acid or so t-tissue augmentation. Clin Plast Surg. 2001;28(1):121–126.
G att BS, Bucky LP. Expert commentary on injectab e ers in acia aesthetic surgery. In: Maurie o JA, ed. Techniques of Cosmetic Eyelid
Surgery. Phi ade phia, PA: Lippincott Wi iams & Wi kins; 2004:148–152.
Jordan DR. So t-tissue ers or wrink es, o ds, and vo ume augmentation. Can J Ophthalmol. 2003;38(4):285–288.
K ein AW, Fagien S. Hya uronic acid ers and botu inum toxin type A: rationa e or their individua and combined use or injectab e
acia rejuvenation. Plast Reconstr Surg. 2007;120(6S):81S–88S.
Kontis C. Contemporary review o injectab e acia ers. JAMA Facial Plast Surg. 2013;15(1):58–64.
Lemper e G, Ru an PP, Gauthier-Hazan N. Avoiding and treating derma er comp ications. Plast Reconstr Surg. 2006;118(3S):
92S–107S.
Rohrich RJ, Ghavami A, Crosby MA. T e ro e o hya uronic acid ers (Resty ane) in acia cosmetic surgery: review and technica
considerations. Plast Reconstr Surg. 2007;120(6S):41S–54S.

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107
Douglas M. Sidle, MD

What is the genetic basis o male pattern alopecia?
Likely a single, dominant, sex-linked autosomal gene called “AR” on the X chromosome is the most important
gene. An increased level o 5-alpha-reductase activity has been noted in susceptible ollicles.

Are testosterone and estrogen levels elevated in patients with male pattern alopecia?
No, testosterone and estrogen levels are normal as are adrenal and liver unctions. estosterone has never been
linked directly to male pattern hair loss (MPHL). Its metabolite dihydroxytestosterone, however, is the principal
causative agent.

In what areas o the scalp is androgenic (or androgenetic) alopecia most evident?
Androgenic alopecia is most evident in the rontal and crown areas o the scalp.

What a ects the expressivity o the alopecia gene?
A normal adult male serum androgen level and age.

What are the phases o the hair ollicle growth cycle and what are the characteristics o each phase?
T e anagen phase lasts 3 to 10 years and is the time o active hair growth, approximately 90% o the scalp’s hair
are in this phase at any given time.
T e catagen phase lasts 2 to 3 weeks and is the time o hair loss.
T e telogen phase lasts a ew weeks to 4 months and there is no hair growth. Approximately 10% o the scalp’s
hair is in this phase.

What phase is associated with male pattern alopecia?
It is associated with a prolonged telogen (no growth) phase and a shortened anagen (active growth) phase.

What enzyme is associated with male alopecia?
Genetically susceptible ollicles have increased 5-alpha-reductase activity.
Hair Removal/Hair
Transplantation
CHAPTER 14

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Plastic & Reconstructive Surgery Board Review

What is the action o 5-alpha-reductase?
Converts testosterone into dihydroxytestosterone at the ollicle level.

What is the mechanism o action o nasteride (Propecia)?
Inhibition o 5-alpha-reductase activity. Balding scalps have been shown to have higher levels o 5-a pha reductase
and DH than nonbalding scalps.

What are the Norwood and Hamilton grading systems or male alopecia?
T e most common classi cation system or describing male alopecia was rst described by Dr. Hamilton but
later modi ed slightly by Dr. O’ ar Norwood. It is now called the Norwood–Hamilton scale. It is based on the
appearance o hair loss at the anterior hairline and the vertex. It has seven classi cations regarding the potential or
urther hair loss.
1: No hair loss
2: Mild temporal recession
2A: Frontal recession—mild
3: Moderate temporal recession
3A: Frontal recession—moderate
3V: Moderate vertex loss
4–6: Progressive involvement o the vertex and temporal areas
7: Complete loss o rontal and vertex regions

What is the hair loss classi cation system or emale pattern hair loss?
T e most common classi cation system or describing FPHL is the Ludwig Scale.

What are the most common causes o hair loss in women?
Androgenic alopecia is the most common cause, just as it is in men.
elogen e uvium occurs when the body goes through something traumatic such as childbirth, malnutrition, or
major surgery.
Anagen e uvium occurs when an insult occurs to the hair ollicle disrupting mitosis or metabolic activity, such as
during chemotherapy.

Describe the concept o donor site dominance?
In 1959, Orentreich described the term “Donor Dominance.” Donor site dominance is the ability o hair gra t to
maintain the integrity and its characteristics independent o the recipient site. It applies to all patients and all scalp
areas with alopecia. T us hair taken rom the occiput will react to circulating androgens the same even though it
is transplanted to an area o the rontal scalp where signi cant hair loss has occurred due to sensitivity to those
androgens.

Where is the best donor site area or hair transplantation?
T e occipital area is typically the best donor site. Occipital hairs have the longest li e span. T e ideal donor strip
or a ollicular unit transplant (FU ) is a line drawn between the tops o each ear across occipital protuberance.

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What is the di erence between ollicular unit transplantation (FU ) and ollicular unit extraction (FUE)?
FU and FUE are both methods o per orming micro- ollicular gra ting. T e main procedural di erence is that in
FU the ollicular unit gra ts are harvested in a long thin strip rom the donor area, whereas in FUE the gra ts are
extracted individually. T ere ore, in FU there is a linear donor scar that can be visible i the patient wears their
hair very short. However, FUE is not “scarless” either; there can be thousands o tiny 1 mm scars rom each punch
excision o the ollicular unit. Ultimately, FUE is more di cult to per orm, but the scar can be less visible. T e
results o the hair transplant procedure are the same with both techniques.

What is a microgra t?
A microgra t contains one or two hair ollicles.

What is a minigra t?
A minigra t contains three or our hair ollicles. A large minigra t contains ve to six hair ollicles.

What is a standard hair gra t (also known as a “punch” gra t)?
A round gra t 3.5 or 4.5 mm or larger with 8 to 30 hair ollicles.

Where should standard gra ts be used?
raditionally, they were used in areas where maximum hair density is desired, but the practice has allen out o
avor.

What is the disadvantage o standard punch gra ts?
Multiple procedures. Patients with dark hair and air skin may have a “doll-like” appearance.

How long should you wait be ore repeat transplantation procedure or treatment o male pattern alopecia?
T e surgeon should wait 4 months because the transplanted hair grows or up to 1 month and then enters the
telogen phase, which lasts another 2 to 3 months.

Can a hair grow without the hair bulb?
T e hair bulb is not necessary or hair growth. I the upper two-thirds o the hair ollicle are transplanted 30% o
them will produce new hair.

How should you counsel your patients about the timing o hair growth a ter gra ting?
Hair growth or 1 month, then hair loss and normal hair growth a ter 3 months.

What is the rate o hair growth 6 months a ter gra ting?
Normal permanent hair growth at 1 cm/month.

What is the best technique or anterior hairline and vertex restoration in a patient with dark hair and air
scalp i the surgeon wants to create the most natural looking hair?
Microgra ts and minigra ts. T ese are essentially the standard o care today.

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Why is this?
Large “punch” gra ts o dark hair against the scalp o a light-skinned patient are particularly obvious and
susceptible to a “doll-like” appearance. Microgra ts or minigra ts can be:
1. placed into slitlike incisions avoiding scars
2. placed at irregular intervals mimicking the natural hairline
3. have a more acceptable appearance during healing than punch gra ts

When discussing hair transplantation with a patient, what are the most important complications that must
be considered?
Donor scar widening. T is is the most common complication o hair transplantation. T is occurs in the donor
strip area a ter FU . It most commonly occurs a ter multiple rounds o harvesting in a tight scalp. It is most
esthetically evident when there is a widened donor scar in an area o ne sparse hair. Scalp laxity plays a role here
as well.
Recipient site olliculitis. T is can range rom the very common “cysts” that orm over some transplanted hairs as
the hair begins to grow between 2 and 3 months. Cysts can be unroo ed. But a rank olliculitis o a severe nature
can permanently damage both native and transplanted hairs. Staphylococcus aureus is the most common pathogen
and is treated with antibiotics.
Unnatural appearance. It is the obligation o the surgeon to create a hairline that will age artistically with
the patient or many years. Considerations o age, ethnicity, sex, and availability o donor material must all be
undertaken.
Managing patient expectations. Due to the progressive nature o normal MPHL, esthetic hair transplantation
should always involve a discussion about the progressive nature o the disease. It is rare or a 30-year-old patient
to require only one hair transplant in their li etime i they want to maintain a youth ul hairline. A discussion o
the progressive nature o the disease and the possibility o uture procedures is a requisite when discussing FU or
FUE with patients.

What is the indication or scalp reduction?
It is indicated in the patient with a stable bald area in the crown or vertex region o the scalp and reasonably dense
hair in the temporal and occipital regions. T is procedure can signi cantly reduce the amount o gra ting that
needs to be done.

What are some common pit alls o scalp reduction?
Anterior undermining should be avoided to prevent elevation o the eyebrows. Serial excision is o ten required
as each excision is limited to approximately 3 to 4 cm depending on the patient’s scalp elasticity. In all cases, the
patient is le t with a linear or curvilinear scar that will never grow hair. T is can be quite visible as the hair tends to
part along these scars. For this reason, scalp reduction procedures have allen out o avor.

What are some disadvantages o scalp reduction?
1. I alopecia is unstable, scars can become obvious as more hair is lost. Z-plasties or hair gra ts can be used to
camouf age such scars.
2. Landmarks such as the eyebrows can be distorted.
3. It is not indicated in patients with residual central hair requiring reconstruction o the anterior hairline.

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What are the disadvantages o tissue expansion o the scalp?
Multiple procedures and anterior scars. During the expansion process the patient is not pleased with their
appearance due to the size o the tissue expander. T e implant can be pain ul to expand or worse, become in ected
or extrude.

What is the main advantage o tissue expansion or treatment o alopecia?
T e hair ollicles will be oriented correctly and as much as 50% o the skull can be covered. issue expansion is
o ten reserved or the motivated patient who has a large bald area due to cicatrix.
HAIR REMOVAL

What does the acronym LASER stand or?
Light Ampli cation by Stimulated Emission o Radiation.

What are three unique properties o laser light as opposed to natural light?
1. Coherent—laser light is coherent (all waves are spatially and temporally in phase).
2. Monochromatic—the delivered light is o a single spectral color and o a single precise bandwidth.
3. Intense—laser light delivers the greatest number o photons per unit area.

What is “thermal relaxation time”?
ime required or a tissue to absorb and di use the thermal energy to surrounding tissue.

What is “pulse energy”?
T e energy o one pulse.

So why do these last two acts matter?
T e pulse duration o a laser should be set or LESS time than the thermal relaxation time o the target tissue i
you want the target tissue to be heated and destroyed. I the pulse duration is MORE than the thermal relaxation
time, the tissue will absorb and di use the energy be ore it is destroyed.

T ere ore what is the optimal pulse duration time?
A time that is LESS than the thermal relaxation time o the hair ollicle, but MORE than the thermal relaxation
time o the surrounding epidermis.

What is “energy”?
T e capacity to do work in joules.

What is “power”?
T e energy delivered divided by the time o application. For lasers, this is typically measures in watts.

What is “power density” (irradiance)?
T e rate o energy delivered per unit area measured in watts per square centimeter.

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What is f uence?
otal laser energy delivered per unit area expressed as joules per square centimeter. T e volume o tissue removed is
a unction o the amount o energy applied.

Lasers are selected based on their ability to be selectively absorbed by target tissues. T ese target tissues in
the skin are known as:
Chromophores.

Name three primary chromophores in the skin.
Hemoglobin, water, and melanin.

What are you targeting in laser hair removal?
T e melanin in the hair ollicle.

Who are the ideal patients?
T ose with dark hair and light skin. T e contrast in color is what is important.

What i the patient has light hair?
Some centers o er a carbon suspension that can be rubbed into the ollicle enhancing absorption.

What are some contraindications to laser hair removal?
1. Current use o photosensitizing agents (i.e., Accutane, Retin-A, tetracycline).
2. Patients with gray hair—no current lasers are e ective at removing gray hair.
3. Patients with a signi cant tan at the time o treatment.
4. Patients with a history o herpes simplex virus should have the possibility o reactivation discussed and be
placed on antiviral medication i treatment is pursued.

What is selective photothermolysis?
Selective thermal damage o a pigmented target when su cient f uence at a wavelength is delivered during a time
equal to or less than the thermal relaxation time o the target. More simply, energy is delivered to the target more
quickly than the target can dissipate it.

How does selective photodermolysis work?
Removes hair that has melanin and is in the anagen (growth) phase. T ere ore, repeat treatments are usually
needed. Also, it prolongs the telogen (inactive) phase. Usually there is hair regrowth a ter a year.

What are the most common wavelengths or laser hair removal?
Alexandrite: 755 nm
Intense pulsed light (IPL): is technically not at laser, but broadband light
Diode array: 810 nm

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Which o these devices works the best or laser hair reduction?
All are equivalent when it comes to e cacy in hair reduction at 6 months (67–72%). However, di erent lasers
are more appropriate or di erent Fitzpatrick skin types. T e diode array may be associated with slightly more
complications.

How long should be the treatment interval?
Laser hair removal requires the presence o a pigmented hair sha t. T ere ore, repeat treatment can be per ormed
as soon as regrowth appears. Regrowth is based on the natural cycle, which varies by anatomic location, but the
average time is 1 month.

Is laser hair removal a painless procedure?
No, hair removal is not a painless procedure. Patients experience discom ort during treatment. A topical or local
anesthetic can be applied be ore treatment.
REFERENCES
Argenta LC, Marks MW, Pesky KA. Advances in tissue expansion. Clin Plast Surg. 1985;12:159–171.
Bell ML. Scalp reduction. Clin Plast Surg. 1982;9:269–278.
Derrick C. Laser-assisted hair removal, emedicine.com, 2004.
Orentreich N, Dorr NP. Biology o scalp hair growth. Clin Plast Surg. 1982;9:197–205.
Price VH. reatment o hair loss. N Engl J Med. 1999;341:964–973.
oosi P, Sadighha A, Shari an A, Razavi GM. A comparison study o the e cacy and side e ects o di erent light sources in hair
removal. Lasers Med Sci. 2006;21(1):1–4.
Umbel CO. Microgra ts and minigra ts: a new approach or baldness surgery. Ann Plast Surg. 1991;27:476–487.
Unger W. reatment or baldness. In: Aston S, Beasley R, T orne CH, eds. Grabb and Smith’s Plastic Surgery. Philadelphia, PA:
Lippincott-Raven; 1997:569–585.
Vales C. Hair replacement surgery. In: JG M, ed. Plastic Surgery. Vol 2. Philadelphia, PA: WB Saunders; 1990:1519.
Voigt W, Castro A, Covey DF, Robinson CH. Inhibition o testosterone 5-alpha-reductase by and antiandrogenicity o allenic 3-keto-
5,10-secosteroids. Acta Endocrinol. 1978;87:668–672.

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115
Peter F. Koltz, MD and
Jeffrey A. Gusenoff, MD
TRUNCAL CONTOURING

Outline the blood supply zones o the abdomen.
1. Zone I is the midabdomen, supplied by deep superior and deep in erior epigastric arcades.
2. Zone II is the lower abdomen, supplied by the super cial and deep circum ex arteries.
3. Zone III is the lateral abdomen/ anks, supplied by intercostal, subcostal, and lumbar arteries.

What zone is responsible or blood supply to abdominoplasty ap?
Be ore surgery, the major blood supply is rom zone I. A ter abdominoplasty, zone I is lost. Blood now enters the
ap primarily rom the lateral aspect via zone III segmental per orators, with some minor collateral ow rom
zone II.

What is the major blood supply to the abdominoplasty ap?
T e lateral intercostal arteries.

What nerve is responsible or numbness o the anterolateral thigh a ter abdominoplasty?
T e lateral emoral cutaneous nerve o the thigh. In several studies o complications o abdominoplasty, the most
common nerve injury was to the lateral emoral cutaneous nerve.

Name the nerves that are at increased risk or entrapment or injury during abdominoplasty.
Iliohypogastric, ilioinguinal, and intercostal nerves are at an increased risk o injury.

What kind o previous abdominal scar can cause postoperative healing problems in an abdominoplasty
patient?
A right upper quadrant subcostal scar may disrupt blood supply rom the lateral intercostal vessels. Avoid
undermining above the scar to avoid wound-healing problems.
Body Contouring
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What is the di erence between mini-abdominoplasty versus ull abdominoplasty?
Mini-abdominoplasty removes a small amount o lower abdominal skin and at. T e position o umbilicus remains
unchanged and the length o the scar is limited. Full abdominoplasty involves removal o excess skin and at rom
the lower abdomen, plication o the rectus diastasis rom xiphoid to pubis, and transposition o the umbilicus.

What is an umbilical oat procedure?
Abdominoplasty with umbilical ascial transection with subsequent resuturing o the umbilicus to the abdominal
wall ascia. T ere is no skin scar around the umbilicus. T e umbilicus typically ends up slightly lower than the
original position. T is technique is typically utilized with mini-abdominoplasty.

What is the optimal treatment or an obese male with a massive pannus?
T e best treatment is simple, transverse, elliptical wedge resection without undermining: panniculectomy.

In a postabdominoplasty patient, what area has the most tenuous blood supply?
T e suprapubic and lower midline regions are at greatest risk or ischemia and necrosis (Zone 1).

Does combining liposuction with abdominoplasty increase the risk o complications?
Yes. T ere is an increased risk o delayed healing (Zone 1), thrombotic emboli, at emboli, skin necrosis, and
at necrosis. Increased complication rates are reported in patients with risk actors such as obesity, smoking, and
diabetes mellitus. Care should be taken to avoid wide undermining or use discontinuous undermining i necessary.

What is the most common complication o combined abdominoplasty and liposuction?
Seroma ormation is the most common complication in this situation. T e risk is higher in those who smoke and
those having diabetes.

What are the main determinants that help to select the optimal procedure or body contouring?
T e optimal procedure is based on the patient’s skin tone and amount o skin excess, abdominal wall musculature/
rectus diastasis, at distribution, and patient pre erence.

How are seromas managed ollowing abdominoplasty?
Aspiration ollowed by placement o closed suction drains. I persistent, sclerosing agents may be used. I this ails,
the cavity may be marsupialized or excised.

Why is smoking a relative contraindication to abdominoplasty?
Smokers are at much higher risk o abdominal ap necrosis and wound-healing problems.

What mechanism is most likely to cause wound-healing complications in abdominoplasty patients who are
recent smokers?
Increased microvascular vasoconstriction with resultant decreased tissue oxygenation. Smoking also increases
carboxyhemoglobin, increases platelet aggregation, increases blood viscosity, decreases collagen deposition, and
decreases prostacyclin ormation, which all negatively a ect wound healing.

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What is a Fleur-de-lis abdominoplasty?
T e typical horizontal excision and scar is combined with excision o a vertical ellipse, which results in an inverted
-shaped scar. Wound-healing problems are lessened by per orming minimal undermining o the aps (see
Fig. 15-1).
Figure 15-1 Fleur-de-lis abdominoplasty.

What is the truncal procedure o choice or a patient who has lost 150 lb (massive weight loss) and when
should the procedure be per ormed?
Lower body li t or belt lipectomy. T is procedure removes the circum erential excess present ollowing massive
weight loss combining an abdominoplasty with a lateral thigh li t and buttock li t. T e procedure should be
delayed until the patient is at least a year out rom a bariatric procedure and weight stable or 3 to 6 months.

What are the sa ety considerations in a patient who requests a total body li t ollowing massive weight loss?
Consideration should be given to mechanical or chemical deep venous thrombosis (DV ) prophylaxis, keeping
the patient warm, padding pressure points, and staging procedures.

What is the initial step in management o a massive weight-loss patient who has become increasingly
disoriented and obtunded 1 day a ter belt lipectomy?
T iamine therapy. Many massive weight-loss patients su er rom malnutrition, including thiamine de ciency,
or B12, which can lead to Wernicke–Korsako encephalopathy. reatment is intravenous administration o
100 mg/d o thiamine, continuing with 100 mg every 8 hours until resolution o symptoms. Administration o
thiamine is low risk and may reverse symptoms.

Patients who have undergone Roux-en-Y gastric bypass surgery commonly have what underlying
def ciencies?
Iron de ciency anemia (most common), vitamin B12 (cobalamin) de ciency, olate, calcium and at soluble
vitamin de ciency (vitamin D is at soluble).

What is the recommended amount o daily protein consumption in patients seeking body contouring?
70 to 100 g per day.

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What is the most common complication in patients undergoing combined procedures in a single stage?
Wound-healing issues (approximately 15%). Seroma is the next most common complication (approximately
10%). In ection, hematoma, and pulmonary embolism occur at rates o less than 5%.

What procedure is associated most requently with postoperative mortality in an ambulatory surgery center?
Abdominoplasty (secondary to pulmonary embolism).

What areas do the lower body li t and belt lipectomy address di erentially?
T e lower body li t (LBL) allows a lower scar placement and better control over gluteal ptosis and de ation (auto-
augmentation) as well as more aggressive treatment o the lateral thigh. T e belt lipectomy will address the gluteal
and lateral thigh in a less aggressive manner but allows more treatment o the upper area o the low back (higher
scar placement). Belt lipectomy also addresses the abdomen by de nition, whereas Lockwood variations do not
necessitate addressing the abdomen in LBL.

What are the most common complications in lower body li t versus belt lipectomy?
Lower body li t: delayed wound healing. Belt lipectomy: seroma (nearly 40%).

What is the overall rate o complications in patients undergoing body contouring a ter massive weight loss?
50%. Wound dehiscence is the most common complication (30%). T is typically occurs early due to patient
mobilization/noncompliance, or late secondary to underlying seroma (second most common complication).

Maintenance o normothermia during the perioperative period is most likely to decrease the risk o what
complication?
Surgical site in ection, hematoma, and seroma. Warming protocols should be utilized including keeping the room
at 70°F, warming blankets, and uid warmers.

A patient who has undergone massive weight loss and desires volume augmentation along with their lower
body li t can obtain volume with addition o what procedure?
Augmentation with gluteal artery per orator ap.

What alternate methods exist or gluteal augmentation?
Silicone implants and at gra ting. Fat gra ting is limited by poor predictability with gra t take and inadequate
donor site volume. T e amount o donor at needed to achieve a pleasing shape is much greater than it seems,
ranging rom 450 to 1,100 mL per side, depending on patient size and gluteal dimension. T e ideal candidate
or autologous buttock augmentation is slightly overweight, but in good health. Silicone implants have higher
in ection risks and are o ten palpable leading to need or explantation. Furthermore, gluteal prostheses carry risks
o rotation, capsular contracture, and displacement.

What is the typical appearance o the breast a ter massive weight loss?
Medialized nipple areolar complex, axillary at roll, at upper pole, low and mobile in ramammary old (avoid
implants or this reason). T is is typically best treated with parenchymal reshaping and dermal suspension
mastopexy, or other techniques utilizing the patient’s own tissues.

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What is pseudogynecomastia?
Collection o at beneath the nipple areolar complex and excess skin that remains a ter massive weight loss (can
also be seen without weight loss). T is is di erentiated rom the glandular collection seen in true gynecomastia.
ARM CONTOURING

What is the mechanism o arm ptosis and what is appropriate management?
T e mechanism is by loosening o connections o super cial ascial system to the axillary ascia. T e operative
treatment is brachioplasty.

What is the common location o incision in a massive weight-loss patient with redundancy o arm skin?
T e skin should be excised through a medial elliptical incision along the inner upper arm rom medial epicondyle
to axillary dome. T is will result in a visible scar when the patient waves. Some pre er a more posterior scar, which
may be visible posteriorly when the arm is at the side.

What is the most common long-term complication o brachioplasty?
Wide/un avorable scar is the most common long-term complication. Hypertrophic scarring is reported to occur in
up to 40% o brachioplasty cases.

What is the most common major complication in brachioplasty?
Injury to the medial antebrachial cutaneous nerve (5%). T e nerve travels with the basilic vein just super cial to
the deep muscular ascia and typically is present super cially in the distal third o the upper arm. Leave 1 cm o at
on deep ascia to minimize injury to the nerve.

What is the most common minor complication?
Wound dehiscence. T is occurs most commonly when combined with liposuction and usually occurs at the
axillary dome. T e most common minor complication o liposuction remains contour irregularities as with all
liposuction procedures. Liposuction only the lateral and posterior arm skin to avoid the thin skin o the medial
arm.
THIGH CONTOURING

What operative technique can decrease the incidence o scar widening and ptosis in a patient undergoing a
crescent medial thigh li t?
Super cial ascial system should be suspended to Colles ascia to decrease scar widening and ptosis. T e crescent
technique can distort the vulva and lead to skin pleating.

For a massive weight-loss patient who has redundant skin in the medial thigh rom the groin to the knee,
what is the treatment o choice?
Vertical medial thigh li t, which includes a vertical and horizontal component. ypically the upper third o the
thigh can be addressed with a horizontal scar, the middle third can be addressed with a short vertical scar, and the
distal third can be addressed with a ull scar vertical medial thighplasty.

120
Plastic & Reconstructive Surgery Board Review

To decrease the risk o seroma ormation, care must be taken to preserve the area def ned by the inguinal
ligament and which o the ollowing additional structures?
Adductor longus muscle and sartorius muscle. T e incidence o seroma ollowing medial thigh li t ranges rom 4%
to 20%. T e concentration o lymphatics draining the lower extremity is very high within the emoral triangle and
dissection in this region should be very super cial to avoid lymphedema.
LIPOSUCTION

Name and describe the di erent types o subcutaneous inf ltration techniques.
Dry, wet, superwet, and tumescent are the our commonly described techniques.
Technique

Inf ltrate/ Aspirate

Estim ated Blood Loss (%)
Dry

None

20–45
Wet
200–300 mL/area
4–30
Superwet

1:1

1
Tumescent

2–4:1

1

What is the composition o typical tumescent solution?
T e tumescent ormula combines 1 L o LR or 0.9% normal saline with 50 cc o 1% lidocaine and 1 cc (1 amp)
o 1:1,000 epinephrine (2.5 cc o 8.4% sodium bicarbonate is sometimes added).

One liter o tumescent solution composed o Ringer’s lactate solution mixed with 20 mL o 2% lidocaine
and one ampule o epinephrine with a concentration o 1:1,000 has what amount o lidocaine in the
mixture?
400 mg. Each liter o solution contains 400 mg o lidocaine with a concentration o 0.04% and 1:1,000,000
epinephrine. It is generally accepted that a dose o lidocaine up to 35 mg/kg is sa e when injected into the
subcutaneous at with solutions containing epinephrine, although doses up to 50 mg/kg have been utilized.

What is the most common inf ltration technique?
T e superwet and tumescent techniques. When per orming large volume liposuction, the superwet technique is
o ten avored to avoid volume overload.

What volume o aspirate constitutes “large volume”?
Lipoaspirate greater than 5 L is considered “large” volume and warrants closer observation and monitoring. Large
volume liposuction should be per ormed as an inpatient according to the ASPS Committee on Patient Sa ety,
2004.

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Name the “zones o adherence” o lower extremity as they pertain to liposuction.
T e ve zones o adherence are in erolateral iliotibial tract, gluteal crease, lateral gluteal depression, distal posterior
thigh, and middle medial thigh.

What is the most common postoperative complication o liposuction?
Contour irregularities. T is is most commonly due to liposuction in a super cial plane.

Are the at cells removed during liposuction permanently lost?
Yes. However, the remaining at cells may undergo hypertrophy.

What is the most common cause o death ollowing liposuction?
T romboembolism (1/5,000 in the outpatient setting). Most occur in the rst 24 hours. O all deaths, 23%
thromboembolism, 15% abdominal wall per oration, 10% anesthesia, 8% at embolism, 5% in ection.

Are liposuction and abdominoplasty considered weight-loss operations or obese patients?
No, these are body-contouring operations and should not be con used with weight-loss operations.

What is the mechanism o action o ultrasound-assisted liposuction?
Intense ultrasonic energy disrupts adipocyte cell membranes via microbubble ormation causing cavitation or
lique action. It does not disrupt the brous connective tissue that surrounds at cells. It may cause some skin
tightening due to thermal injury–-it should be used with tumescent technique to minimize unwanted injury.

What complications occur more requently in ultrasonic liposuction compared to traditional suction
lipectomy?
Seroma and skin burn.

What are some symptoms o lidocaine toxicity?
T e rst symptoms are neurological with dizziness, tinnitus, and lethargy. With increasing blood levels, patients
experience delirium, seizures, coma, and cardiac arrest.

What is the relative e ectiveness o nonsurgical treatment with mesotherapy as compared to suction
lipectomy?
Mesotherapy is not as e ective as suction lipectomy, and it is not FDA approved. In mesotherapy, a variety o
medications are injected into the mesoderm, the layer o at and connective tissue below the skin. T e most
common medications utilized or lipolysis are phosphatidylcholine and isoproterenol. Currently, there are no
clinical reports demonstrating the e ectiveness o mesotherapy in body contouring.

What is the most accurate estimate o the percentage o uid inf ltrate that remains in the body at the end o
a liposuction procedure?
70%. T is is important or uid management and should include maintenance uid (amount to replace daily
requirements plus NPO de cits), aspirate removed, and uid in ltrated (estimated to be 70% becoming
intravascular).