9.e1
The unsatisfactory outcome
Fig. 1.12 Example list of medication patient is told to avoid preoperatively.
9.e2
CHAPTER 1 • Managing the cosmetic patient
Fig. 1.13 Example presurgery anesthesia evaluation form.
PRE-ANESTHESIA EVALUATION
Paces Plastic Surgery and Recovery Center
Please complete all questions, front & back, and sign date of planned surgery ____ _____ ____
_________________________ ___ ____
yrs ____/____/_____ ______ ______ __________________________
Patient Name sex age date of birth
height weight occupation
___________________________________ _______________ ___________________________________________
Your primary care physician phone #, & / or address
Last physical exam _______________________ by ____________________________________________________
_
Is there any chance that you are now pregnant? ___ If you menstruate, what was the first day of your last menstrual period? _____
list ALL allergies allergies
drugs, tape, iodine, latex, etc. your reaction to them drugs, tape, iodine, latex, etc. your reaction to them
list prescription medicines reason you take this dosage list prescription medicines reason you take this dosage
List all over-the-counter medicines, natural or herbal products you take_________________________________________________
If you have had anesthesia before, list those surgeries and approximate dates
year operation year operation year operation
Did you experience nausea with anesthesia? ____ other problem s related to anesthesia?____________________________________
Has anyone directly related to you had a high fever or breathing problems related to anesthesia? _______
Do you experience motion sickness?_______ (This can increase your risk for nausea after surgery.)
CIRCLE ALL THAT APPLY IF YOU HAVE OR HAVE HAD THE FOLLOWING:
yes no…Heart condition: angina, chest pain, previous heart attack, irregular heart beat, high blood pressure, murmur,
heart failure, other_____________________
yes no …Heart treatment procedures, pacemaker, internal defibrillator, stent placement, or other heart operations or
heart tests ___________________________________________________________________
yes no …Have you had any breathing problems: sleep apnea, asthma, emphysema, chronic chest colds, recent
pneumonia bronchitis, flu, sinus infection or recent cold, or do you cough most or every day?
yes no… Have you had any treatment for your lungs or to improve your breathing?
yes no… Have you had major dental work: caps, veneers, crowns, bridges, dentures?
9.e3
The unsatisfactory outcome
Fig. 1.14 Example discharge advice form.
9.e4
CHAPTER 1 • Managing the cosmetic patient
Fig. 1.14, cont’d
9.e5
The unsatisfactory outcome
Fig. 1.14, cont’d
Continued
9.e6
CHAPTER 1 • Managing the cosmetic patient
Fig. 1.14, cont’d
9.e7
The unsatisfactory outcome
Fig. 1.14, cont’d
Continued
9.e8
CHAPTER 1 • Managing the cosmetic patient
Fig. 1.14, cont’d
9.e9
The unsatisfactory outcome
Fig. 1.14, cont’d
Continued
9.e10
CHAPTER 1 • Managing the cosmetic patient
Fig. 1.14, cont’d
9.e11
The unsatisfactory outcome
Fig. 1.14, cont’d
Continued
9.e12
CHAPTER 1 • Managing the cosmetic patient
Fig. 1.14, cont’d
9.e13
The unsatisfactory outcome
Fig. 1.14, cont’d
10
CHAPTER 1 • Managing the cosmetic patient
has an unsatisfactory result, I see the patient more frequently
in my clinic (even though the staff and I might want to see
the patient less!). I attempt to provide emotional support and
reassurance to the patient. If it is appropriate to the situation,
I will express regret that the outcome was not what the patient
wished. Throughout these visits, any possible consultation
fees are waived. It is helpful to have other staff (for example,
your most senior nurse) attend all the consultations with you
and develop a rapport with the patient if possible. The patient
may tell the nurse information that he or she would not tell
you, and if the relationship between you and the patient
breaks down, the nurse can be helpful in relaying information
to the patient. For similar reasons, the patient should be
encouraged to bring a friend or family member along to the
consultations.
For everyone’s safety and to avoid later confusion, ensure
that you document all visits and discussions clearly in the
patient record. It can be helpful to send the patient a letter at
the end of each consultation summarizing any discussions
that were held and any decisions that were made.
Conclusion
Patient selection in plastic surgery is challenging. Patient
evaluation can be difficult to teach during residency and
unfortunately is often learnt through trial and error while in
practice. Your ability to recognize patients who are unsuitable
for surgery physically, or who may not cope emotionally with
the surgery, is an integral part of running a successful practice.
Time spent with patients preoperatively, ensuring that they
understand the potential benefits, risks, and complications,
pays dividends postoperatively as their expectations are more
likely to be met. As plastic surgeons, our prime responsibility
is to the safety of our patients, as well as their comfort and
satisfaction. I will not undertake surgery that I do not feel is
in the best interest of my patients. Focusing on the welfare of
the patient, utilizing good communication skills, and carrying
out a thorough evaluation of the patient preoperatively can
prevent postoperative dissatisfaction.
you see and appreciate what the patient is unhappy about? If
you cannot, then you will never be able to fix it or make the
patient happy. If you can see the deformity or defect that the
patient is unhappy with, further surgery may be indicated.
Otherwise, it may be appropriate to refer the patient for a
second opinion, to a specialist colleague, or even to a psychia-
trist for further assessment.
Managing the unhappy patient
Managing the dissatisfied patient is challenging and time-
consuming. It requires patience and tact on the part of the
plastic surgeon. Most patient dissatisfaction is based on failure
of communications and poor patient selection, rather than
technical errors.31 Obviously, improving your patient evalua-
tion and selection skills can help limit the number of unhappy
patients you deal with. However, when unhappiness occurs,
underlying the dissatisfaction is normally a breakdown in
rapport between the patient and surgeon.20 This means that
effective communication is the key in managing these patients.
Spend time listening with empathy and compassion to
patients’ concerns. Try to elicit the specific reason(s) for the
dissatisfaction and make sure that their issues are heard,
accepted, and understood.32
Managing a colleague’s unhappy patient
The unhappy patient could be your own or a colleague’s. It is
important never to criticize your colleagues on a personal or
professional basis, or to criticize what took place during the
previous surgery. The patient should be managed as any new
patient to your practice would be, with a full history and
physical evaluation. Almost always, I can explain to the
patient what I find, say that I’ve seen it before, and explain
how it can be revised. Sometimes the patient simply requires
a second opinion, in which case I encourage the patient to
return to the primary surgeon if they still have a rapport. If
the patient insists that s/he will not return to the primary
surgeon, then I will discuss the cost of the surgery. As the
primary surgery was not with me, any revisional surgery will
cost the patient the full fee. I explain that the patient will likely
receive a lesser fee if s/he returns to the primary surgeon. If
the patient wants to schedule surgery with me, I make every
effort to contact the primary surgeon for information and
receive old notes (including preoperative photographs) if
possible. Bear in mind that you cannot contact the other
surgeon or discuss the patient’s care with anyone without the
patient’s consent.
Managing your own unhappy patient
As mentioned above, the key to improving patient satisfaction
is improved communication. When a patient is unhappy or
Bonus images for this chapter can be found online at
Fig. 1.6 Example letter to friends and family regarding surgical discount.
Fig. 1.7 (A,B) Examples of preconsultation medical questionnaires.
Fig. 1.8 Example photographic consent form.
Fig. 1.9 Example of a generic follow-up letter after consultation.
Fig. 1.11 Example surgery consent form.
Fig. 1.12 Example list of medication patient is told to avoid preoperatively.
Fig. 1.13 Example presurgery anesthesia evaluation form.
Fig. 1.14 Example discharge advice form.
2. Bashour M. History and current concepts in the analysis of facial
attractiveness. Plast Reconstr Surg. 2006;118:741–756. Bashour provides
an interesting discussion of the history of facial attractiveness with
reference to the neoclassical canons, anthropology, and cephalometrics. He
provides insights into social psychology and the components of facial
attractiveness.
7. Perrett DI, May KA, Yoshikawa S. Facial shape and judgements of
female attractiveness. Nature. 1994;368:239–242.
Access the complete reference list online at
11
Conclusion
11. Hildebrandt KA, Fitzgerald H. The infant’s physical attractiveness:
its effects on bonding and attachment. Infant Ment Health J. 1983;4:3.
20. Gorney M, Martello J. Patient selection criteria. Clin Plast Surg.
1999;26:37–40. The authors discuss the features of a suitable compared
with an unsuitable patient for cosmetic surgery, and provide their visual
representation graph of deformity vs concern level, to aid in patient
selection.
21. Gorney M. Mirror, mirror on the wall: the interface between illusion
and reality in aesthetic surgery. Facial Plast Surg Clin North Am.
2008;16:203–205.
23. American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric
Association; 2013.
24. Ende KH, Lewis DL, Kabaker SS. Body dysmorphic disorder. Facial
Plast Surg Clin North Am. 2008;16:217–223. The authors provide an
excellent description of body dysmorphic disorder and how to identify it in
patients presenting to a cosmetic surgery practice. Management strategies,
including psychiatric referral and treatment prior to considering surgery,
are covered.
27. Sarwer DB. Awareness and identification of body dysmorphic
disorder by aesthetic surgeons: results of a survey of American
Society for Aesthetic Plastic Surgery members. Aesthet Surg J.
2002;22:531–535.
30. Goode RL. The unhappy patient following facial plastic surgery:
what to do? Facial Plast Surg Clin North Am. 2008;16:183–186. Goode
covers how to be a better patient selector and how to manage an unhappy
patient. He clearly covers his program for dealing with a patient who has
a flawed result, as well as one who has a good outcome but is still
unsatisfied.
32. Sykes JM. Patient selection in facial plastic surgery. Facial Plast Surg
Clin North Am. 2008;16:173–176. Sykes summarizes the process of
patient selection and refusing services to plastic surgery patients with
useful management suggestions and comments on the role of the plastic
surgeon.
11.e1
References
References
1. Greer DM. Psychiatric consultation in plastic surgery: the surgeon’s
perspective. Psychosomatics. 1984;25:470.
2. Bashour M. History and current concepts in the analysis of facial
attractiveness. Plast Reconstr Surg. 2006;118:741–756. Bashour provides
an interesting discussion of the history of facial attractiveness with
reference to the neoclassical canons, anthropology, and cephalometrics. He
provides insights into social psychology and the components of facial
attractiveness.
3. Cunningham MR, Roberts AR, Barbee AP, et al. “Their ideas of
beauty are, on the whole, the same as ours”: consistency and
variability in the cross-cultural perception of female physical
attractiveness. J Pers Soc Psychol. 1995;68:261–279.
4. Langlois JH, Roggman LA. Attractive faces are only average.
Psychol Sci. 1990;1:115–121.
5. Langlois JH, Roggman LA, Musselman L. What is average and
what is not average about attractive faces? Psychol Sci.
1994;5:214–220.
6. Alley TR, Cunningham MR. Averaged faces are attractive, but very
attractive faces are not average. Psychol Sci. 1991;2:123–125.
7. Perrett DI, May KA, Yoshikawa S. Facial shape and judgements of
female attractiveness. Nature. 1994;368:239–242.
8. Kampe KK, Frith CD, Dolan RJ, Frith U. Reward value of
attractiveness and gaze.[Erratum appears in Nature. 2002;416:602].
Nature. 2001;413:589.
9. Aharon I, Etcoff N, Ariely D, et al. Beautiful faces have variable
reward value: fMRI and behavioral evidence. Neuron.
2001;32:537–551.
10. Housman SB. Psychosocial aspects of plastic surgery. In: McCarthy
JG, ed. Plastic Surgery. 1. Philadelphia: WB Saunders Company;
1990:113–118.
11. Hildebrandt KA, Fitzgerald H. The infant’s physical attractiveness:
its effects on bonding and attachment. Infant Ment Health J. 1983;4:3.
12. Cosmetic Surgery National Data Bank Statistics, Consumer Attitudes
Survey; 2010. Available at <
files/Stats2010_1.pdf>.
13. PRNewsWire. New study reveals one in five women plan to pursue
cosmetic surgery. Seattle, USA: RealSelf.com; 2015. Available from:
<
-one-in-five-women-plan-to-pursue-cosmetic-surgery-300034188
.html>.
14. Lee S-Y. The effect of cosmetic surgery realty shows on women’s
beliefs of beauty privileges, perceptions of cosmetic surgery, and
desires for cosmetic enhancements. Am Commun J. 2014;16:1–14.
15. West K. How to take the perfect selfie? Millennials under 30 getting
cosmetic surgery for better social media pics. New York: FashionTimes.
com; 2015. Available from: <>.
16. 2016 Cosmetic Surgery National Data Bank Statistics, American Society
for Aesthetic Plastic Surgery. Available at <
sites/default/files/ASAPS-Stats2016.pdf>.
17. Mathews K. 72% of young women want plastic surgery. RealSelf.com;
2011. Available from: <
women-plastic-surgery-poll-finds#.VWzhf0bdejK>; 2011.
18. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of
hematoma requiring surgical evacuation following male
rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg.
2005;116:1973–1985.
19. Courtiss EH. Patient counseling. In: Gradinger G, Kaye B, eds.
Symposium on Problems and Complications in Aesthetic Plastic Surgery
of the Face. St Louis: Mosby; 1984.
20. Gorney M, Martello J. Patient selection criteria. Clin Plast Surg.
1999;26:37–40. The authors discuss the features of a suitable compared
with an unsuitable patient for cosmetic surgery, and provide their visual
representation graph of deformity vs concern level, to aid in patient
selection.
21. Gorney M. Mirror, mirror on the wall: the interface between illusion
and reality in aesthetic surgery. Facial Plast Surg Clin North Am.
2008;16:203–205.
22. Hay GG. Psychiatric aspects of cosmetic nasal operations. Br J
Psychiatry. 1970;116:85–97.
23. American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric
Association; 2013.
24. Ende KH, Lewis DL, Kabaker SS. Body dysmorphic disorder. Facial
Plast Surg Clin North Am. 2008;16:217–223. The authors provide an
excellent description of body dysmorphic disorder and how to identify it in
patients presenting to a cosmetic surgery practice. Management strategies,
including psychiatric referral and treatment prior to considering surgery,
are covered.
25. Rinker B, Donnelly M, Vasconez HC. Teaching patient selection in
aesthetic surgery: use of the standardized patient. Ann Plast Surg.
2008;61:127–131, discussion 32.
26. Hanes KR. Body dysmorphic disorder: an underestimated entity?
Australas J Dermatol. 1995;36:227–228.
27. Sarwer DB. Awareness and identification of body dysmorphic
disorder by aesthetic surgeons: results of a survey of American
Society for Aesthetic Plastic Surgery members. Aesthet Surg J.
2002;22:531–535.
28. Herruer JMMD, Prins JBPD, van Heerbeek NMDPD, et al. Negative
predictors for satisfaction in patients seeking facial cosmetic
surgery: a systematic review. Plast Reconstr Surg.
2015;135:1596–1605.
29. Sykes JM. Managing the psychological aspects of plastic surgery
patients. Curr Opin Otolaryngol Head Neck Surg. 2009;17:321–325.
30. Goode RL. The unhappy patient following facial plastic surgery:
what to do? Facial Plast Surg Clin North Am. 2008;16:183–186. Goode
covers how to be a better patient selector and how to manage an unhappy
patient. He clearly covers his program for dealing with a patient who has
a flawed result, as well as one who has a good outcome but is still
unsatisfied.
31. Blackburn VF, Blackburn AV. Taking a history in aesthetic surgery:
SAGA–the surgeon’s tool for patient selection. J Plast Reconstr
Aesthet Surg. 2008;61:723–729.
32. Sykes JM. Patient selection in facial plastic surgery. Facial Plast Surg
Clin North Am. 2008;16:173–176. Sykes summarizes the process of
patient selection and refusing services to plastic surgery patients with
useful management suggestions and comments on the role of the plastic
surgeon.
2
Establishing a cosmetic practice
Richard J. Greco and Nicole J. Jarrett
The world of cosmetic surgery is constantly changing. Com-
petition is more intense from other plastic surgeons, well-
trained alternative board certified surgeons, and even family
doctors. Even the most accomplished technical plastic surgeon
could go broke if their business is not run appropriately. The
days of opening a practice, putting out a sign, and only having
a phone number and staying alive are gone.
A practice has to create systems to deal with each segment
of patient care: marketing to patients, making a good “first
impression”, delivering adequate information to educate
them, leading follow-up and arranging for the patient to come
in to discuss their concerns, the “ideal patient consultation”,
and finally helping them manage the timing and financing of
their procedure. This chapter is not intended to help decide if
a patient is an ideal candidate, but we will discuss how one
can earn the right to be their surgeon and how to manage a
cost-effective cosmetic surgery practice.
It would be wonderful if we could just show up, talk to
interested patients, evaluate their concerns, help them plan
the best course of action, and perform the surgery in a friendly
and accommodating environment. Later that day we could
see happy postoperative patients – satisfied with their results
– and listen to them recount how we have helped enrich their
lives. Few of us get to experience this exact scenario. Someone
or some organization has to perform all the behind-the-scenes
work to market and attract the patient, educate them about
their options, help them make the appointment to see the
plastic surgeon, work through the scheduling and financial
aspects of their decision, and help provide or arrange for the
availability of a suitable surgical facility. That is what the
managing of a cosmetic practice is all about – the details.
Defining the scope of practice
The first things to be decided are what exactly will be offered
to the patients and the practice philosophy. Will the practice
be purely cosmetic or a mixture of cosmetic and reconstruc-
tive? If for purely cosmetic surgery, is the plan to create a
niche? Will non-operative and operative procedures be per-
formed? Will hair transplants be performed? Once it has been
decided what the practice will offer, a Mission Statement
should be created that describes to staff, patients, and the
world what the practice will stand for and who it will serve.
The scope of practice, approach to patient care, and values
will establish a brand in the community, which will be useful
to help guide advertisement efforts and help to decide how
to best structure the practice. All components must be aligned
with the surgeon’s desires and Mission Statement. Identifying
oneself as a board-certified plastic surgeon is an important
message about the surgeon’s credentials and why the surgeon
is prepared to help the patient.
Attracting patients
There are many ways to attract patients to a practice. Where
a surgeon is in their practice life and how well known a
surgeon is in the area or nationally will influence what is
required to grow the practice. The best “new cosmetic patient”
is a previous patient who knows and trusts the surgeon –
whether it was from a previous cosmetic or reconstructive
procedure. They will have the highest likelihood moving from
consultation to surgery. The second best new patient is one
referred by a previous patient or a direct referral from their
doctor, family, friends, or aesthetician. The surgeon is receiv-
ing secondary validation or transference of the patient’s trust.
Marketing the practice to new patients should be done in
a fashion consistent with the Mission Statement and in areas
in which one has elected to grow the practice. Before market-
ing begins, make sure that the office and system is ready to
handle the sudden inflow of calls and inquiries. The worst
mistake one can make is to spend a fair amount of money to
attract new “leads” and then to make them angry by giving
them a poor experience or bad first impression. Next, it is
important to study the demographics of the target population
– the group that represents the pool of individuals who are
most likely to become one’s patients. Once the demographics
13
The physical environment of the office
can control. Enlist the practice staff in finding selected “raving
fans” or happy patients who can tell a great story about how
the surgeon has helped change their lives by helping to
achieve their goals of enhancement through skill and in a safe
and compassionate way. These can be procedure-specific and
located either on the practice’s landing page for that procedure
or on other pages that the potential patient would be looking
at, such as the before and after gallery page.
Second chances to enhance a patient’s “first impression”
will occur when they get the package of information, when
they walk into to practice and see the waiting room (is it clean,
comfortable, well acquainted?), and when they are met by the
receptionist (does she introduce herself and greet the patient
by name?). Other factors that will continue to either build
their trust or distrust will include how long they have to wait
to be seen, where they first meet the surgeon (in the surgeon’s
private office or an exam room), whether they are clothed
or unclothed (and feeling vulnerable) when they meet the
surgeon, the physical dress and appearance of the staff and
surgeon, and lastly the body language, demeanor, and man-
nerism of the surgeon.
Print or electronic supplemental
patient educational material
The patient has called the office, spoken with the office staff,
and is waiting for more information. Is any information
sent out to these prospective patients? Sending a “welcome
package” is an opportunity to set another good first impres-
sion. It should include more detailed information about the
procedures they are interested in, information validating their
selection of surgeon and practice, directions to the location
they are being seen, new patient registration forms, and any
practice policies they need to be aware of. The “welcome
package” could be mailed printed materials or a well-designed
email with links to specific videos on the website for them to
watch (Appendix 2.1
). Review the materials that are sent
– do they represent the practice well and provide all the
information the patient needs?
Appendix 2.1 appears online only.
Pre-consultation phone call
I call all of my new patient consults the night before their
appointment. I ask them if their scheduled appointment time
is still convenient and if they know where our office is located.
It takes less than a minute, yet reduces my “no show” rate
and demonstrates the “extra” level of service that the patient
will receive when choosing our practice to care for them. It
also makes a lasting impression on patients, many of whom
will tell their friends and families about their experience at
our office.
The physical environment of the office
The décor of an office is usually an expression of the practice’s
personality. It must be clean, organized, well lit, and well
are understood, they can be used to decide what the best
medium to reach them is and how to make them aware of
their options and educate them on how the practice can help
them. In almost every situation, the goal will be to encourage
the individual to visit the practice’s website or communicate
with the office staff. In either situation, the goals should be
to create a good first impression, offer exceptional customer
service, provide excellent education, the opportunity to
arrange an appointment to learn more, and have their ques-
tion and concerns answered.
Even if a surgeon’s goals are only to perform surgery,
having introductory procedures or ancillary services that will
attract new patients into their office will begin the building of
trust in the practice and staff, and allows patients to see what
level of service and expertise will be provided. When they are
ready to have surgery, they will likely be comfortable with the
surgeon’s team.
First impressions are vitally important
to the cosmetic patient
We only get one chance to make a good first impression, and
it is difficult to change it after it has been made. The value of
making a great first impression cannot be overstated. Richard
Branson once said, “In the same way that I tend to make up
my mind about people within thirty seconds of meeting them,
I also make up my mind about whether a business proposal
excites me within thirty seconds of looking at it.” So the first
impression is either creating trust or creating doubt.
Today, first impressions are made from websites, print ads,
or the way that a receptionist answers the phone. As prospec-
tive patients surf the web, they take a quick glance of how a
practice presents itself – in 5 to 10 seconds they decide whether
a practice is worthy of a deeper look – or if they will just back
click to the next listing. Patients are hungry for information and
very savvy, with an unbelievable number of ways to research
their options. This includes reviewing a surgeon’s credentials
and training, patient testimonials, doctor rankings and reviews,
malpractice history, medical board or society sanctions, and
word of mouth from doctors, friends, and family. Therefore,
the surgeon should be very familiar with what patients see
when they go to the practice’s website. They should also test
how patients are treated when they call the surgeon’s office by
having someone unknown to the office call for information.
Patient reviews are the “new advertising”. Instead of
waiting to react to a negative review, practices that pro-
spectively motivate happy patients to post reviews about
their experience with will not only have their search engine
optimization improved, but will also improve lead conversion
because well-written reviews are a very effective form of sec-
ondary validation and over 90% of customers are influenced
by them.1 Over two-thirds of consumers trust online reviews
as much as personal recommendations and will increase a
practice’s lead conversions by over 50%.2 Google reports
that businesses with a “3 star or greater rating” obtained 41
of 47 mobile clicks, and a Harvard Business School study
discovered that a “one-star increase on Yelp leads to a 5–9%
increase in revenue”.3
Professionally filmed video “patient testimonials” are
another great source of secondary validation that the surgeon
13.e1
The physical environment of the office
APPENDIX 2.1 Sample Welcome Letter
Dear ________,
I appreciate the opportunity to follow up with you in regards to
your inquiry. Here is some basic information regarding a breast
augmentation, then if you still have questions I welcome the
opportunity to speak with you at your convenience.
Dr. Greco would need to consult with you at your convenience.
He sees patients in the Savannah office on Thursday afternoons,
Monday and Friday mornings and in the Bluffton, SC office on
Tuesday afternoons. His consult fee is $___. The estimate for the
procedure is just that, but will be confirmed once you’ve been seen.
The estimated cost for a breast augmentation with saline implants is
$____ and with silicone implants is $____. The procedure takes
approximately 1–112 hours. A small incision is made in the fold
under your breasts and the implants are inserted. Closure takes
place and you are put in a post-augmentation bra. Your implants will
sit a little high until they drop into your pocket. All of the
postoperative healing will be explained in detail during your consult.
I am certain you will be very pleased with Dr. Greco, his staff, our
facility, your result, and the service you receive. Here are a few links
to our website, where you can view “The Patient’s Experience”
(),
check out some before and after pictures (http://
gallery.html), and review Dr. Greco’s outstanding credentials (http://
). Spend as
much time on the website as you’d like… there’s plenty more to
see.
Thank you for making the initial contact with our office. I look
forward to speaking with you soon. I’m here to address any
questions or concerns you may have about cosmetic surgery.
Sincerely,
Jil Trower
Patient Care Coordinator
for Dr. Richard Greco
The Georgia Institute for Plastic Surgery
5361 Reynolds Street
Savannah, GA 31405
(912) 644-8257 Direct
(912) 355-8000 Main
(912) 355-8403 Fax
JTrower@mycosmeticsurgeon.md
14
CHAPTER 2 • Establishing a cosmetic practice
Consultation room experience and
use of technology to enhance the
experience
The patient is brought into the examination room with their
companions. We want to offer them a comfortable, “spa-like”
experience, so we provide them with soft, clean cloth spa
robes to wear. Paper gowns are uncomfortable for patients.
We then start our patient education by allowing the patients
to watch procedure-specific videos. They can explore the
computer and watch other videos if they desire. After they are
done, we come in and start the physical exam. It is very
important to be highly sensitive to the patient’s privacy and
modesty.
Our goal is to provide each individual an “ideal patient
consultation”. We want to be seen as an educator and advocate
for the patient, not a salesperson. I like to evaluate the patient,
take appropriate pictures, then let the patient close their robes
and sit down next to us as we look at the photos together on
a computer screen. Most patients have no idea what they, or
their body, looks like – especially from behind. I ask questions
as to what they see in the photographs that concern them.
THEY bring up most of the deformities, then I can tell them
how we can help. When I can, I prefer not to be the one
pointing out areas of concern.
Using cutting edge technologies such as 3D imaging or
morphing software and illustrative anatomic drawings not
only educates the patient and their significant other, but
it demonstrates the value the surgeon brings to them over
other less current individuals. Demonstrating an individual
patient’s results to them instantly from a digital library vali-
dates the surgeon’s abilities and demonstrates what the
surgeon perceives will be a potential result for them. It is
important to show them average and good results and tell
them what can be expected for their problem.
If other areas of concern are brought up, they can immedi-
ately watch a procedural video and before and after photos
without leaving the room. In the best situation, they can be
allowed to revisit the consultation again at home through an
encrypted website with all the photos, morphed images, and
anatomic drawings.
Follow-up procedures that help
the patient decide about proceeding
with surgery
A nurse, patient care coordinator, or office manager needs to
be able to explain the cost for the procedure to the patient and
have the ability to discuss options for financing if necessary.
Patient-specific and professional-appearing estimate sheets
should be prepared that exhibit the costs for the surgeon,
implants, anesthesia, and the facility. A hand-written note
from the surgeon thanking the patient for coming and offering
to answer any further questions is appreciated by them.
Follow-up phone calls should be scheduled to answer any
other unresolved concerns or questions. Be quick to invite the
patients to return as often as necessary until their questions
appointed. The front desk should be open and inviting but
provide privacy. The staff should be friendly and inviting.
Offering current materials to read, something to drink while
they are waiting, and an idea of whether the doctor is running
on time makes the experience comfortable to the patient and
respects their time. Unusually glamorous and ornate facilities
may work in certain environments, but generally patients will
perceive this is excessive and believe that fees will be higher
to support it.
Introducing oneself to the patient
A potential new patient is considering spending a significant
amount of money and they perceive that their time is as valu-
able as the surgeon’s. They are not really interested in a “good
excuse” for running late and expect the surgeon to stay present
and not distracted while they are with them. They do not
want to be ignored for a cell phone call or text.
A board-certified plastic surgeon has passed many stren
uous tests of knowledge and skills and can remain calm
and confident. It is important to be a good listener and
to fully understand the physical concerns that the patient
is describing and the underlying motivations for seeking
help. It is the surgeon’s job to help make the decision as to
whether this patient is a good candidate for the proposed
procedure.
Prospective patients have a preconceived notion of what a
plastic surgeon looks and sounds like. It is important to dress
appropriately and professionally. Although there are times
when I am between procedures that I see patients in my
scrubs, in general, I dress as I would expect from any profes-
sional offering me a service that may change my life forever
and cost many thousands of dollars.
We all have our niche group of patients whom we are
taking care of and have our own individuality. It is important
to fit the part as a surgeon, but we can be ourselves and even
dress to fit into that niche.
All new cosmetic and breast reconstructive patients are
brought into my personal office for first introductions. I
believe that it is important to meet patients while they are fully
clothed. It allows them to realize that we see them as more
than just a body part to be examined. As the nurse escorts
them to my office she casually starts a conversation with
the patient with specific goals: (1) to alleviate the patient’s
anxiety about meeting the doctor, (2) to tell them what will
occur during today’s visit, (3) to allow the individual to
express what their major concerns are, and (4) to validate
the skills, training, and compassion of the surgeon they are
meeting.
When I enter the room I always introduce myself, shake
the patient’s hand, and offer a warm smile. I want them to be
comfortable and able to describe their concerns while fully
clothed. I usually start by asking them what their concerns are
and how I can help them. I always find a way to ask questions
about them as individuals such as their goals in life, where
they work and what they do, and what types of activities they
enjoy. It is important to connect with the patient on multiple
levels and demonstrate our concern and understanding of
them as an individual and their motivations for seeking our
services.
15
Staffing
subtlety reminded, they have many fewer complaints. As they
get further in their recovery, we will make them a set of before
and after photos to take home and share with their friends if
they want. We always ask them if they are willing to allow us
to show other patients their photographs. If so, we also ask if
we can use them on our website or in marketing materials.
We obtain consents for their use. At this time we also ask them
if they are computer savvy, and, if so, would they be willing
to go online and write a review about their experience to help
other patients better understand the procedure, process, and
experience with our office. We provide them with a pre-
printed card with a list of URLs of the most popular patient
rating sites for them to visit.
There are so many different ways that patients communi-
cate today – home phone, mobile phone, text, email, and mail.
It is important to find out what your patient’s preferred
method of contact is and the most current number or address.
Creating access lists for blast emails or newsletters, happy
birthday notices, and special “prior patient” opportunities
efficiently keeps the practice in the patient’s mind in the least
obtrusive way. Having software that automates these func-
tions is ideal.
Postoperative survey
It is important to survey all patients three months after their
procedure. It allows them to get past any difficulties in their
postoperative course but is still early enough to remember
anything that did not meet their expectations. Even the best
designed programs depend on individuals doing their jobs
perfectly and consistently. If any recurrent problems are
mentioned, they can be addressed for future patients.
Solo practice versus group practice
The economics and complexity of practice today make it very
difficult to practice alone. As an example, if a surgeon wants
to have their own operative facilities to provide very personal
and private care – one surgeon will usually lose money, two
will break even, and three or more will make money on the
facility. Sharing office rent, staff expenses, computer systems,
utilities, and volume discounts on supplies may be the only
way to allow surgeons to stay in private practice in the near
future. Sharing marketing expenses, website costs, and the
costs of new technologies will allow for quicker expansion as
a group as well.
Staffing
The staff represent the surgeon all of the time and they are the
most important assets to the practice. Hire for personality.
Staff can be trained to do almost anything, but it is impossible
to change how pleasant they will be to patients and co-
workers. Although in some practice scenarios, such as in an
academic setting, complete control may not be possible, it is
best to try to be clear to staff about the culture one is trying
to foster. The surgeon must lead by example and utilize effec-
tive communication within the team in order to reinforce
these ideas, which can often be accomplished with daily
“huddles” or weekly/biweekly staff meetings.6
have been answered and their anxiety assuaged. Always ask
if their experience met their expectation and whether there is
anything else that we can do to help them.
Good patient care coordinators learn how to ask if there are
any specific issues the patient has in making a decision and
what their ideal timing would be for them to have surgery. In
our experience, it generally takes up to seven interactions with
an interested patient before they decide to proceed forward,
so do not be quick to discount a patient as “disinterested” if
they do not book a procedure right away.4 It is very acceptable
to gently follow up and answer all their concerns, and the goal
is to provide an experience that makes the patient satisfied to
the point that they tell all of their family and friends.5
Operative experience
Now that the patient is well educated and has decided to have
surgery, it is time to deliver the same exceptional experience
for the actual procedure. I personally call all my patients the
night before their surgery to see if they have any last minute
questions or concerns.
The facility should be clean, comfortable, and inviting. The
nurses should be professional and skilled. Their preoperative
space should be private, comfortable, and patients love a Bair
Hugger (3M, Maplewood, MN) while waiting for surgery.
After they are sedated, they will not remember much about
the procedure – but they will remember if they wake up in
pain or nauseated. We augment the patient’s anesthesia with
long-acting local anesthetics and anti-emetic medications.
During surgery, we call the families every hour to alleviate
their fears and update them on their loved one’s progress. If
a patient wants to spend the night, we provide two nurses to
watch them and ask them preoperatively for their favorite soft
drinks, snacks, and soft foods so that we can have them avail-
able. We have the patients fill their postoperative prescriptions
before they arrive and make sure they are educated to their
postoperative wound instructions and care before they leave.
Postoperative experience
I call all the patients the night after surgery to speak to their
caregiver and see if they have any questions. Many of them
will be so appreciative that they will tell their friends (creating
“raving fans”) and will independently refer patients to you.
Each patient is given a nurse concierge and their personal cell
phone number to call at any time with any question. The
patients rarely abuse this but appreciate the ability to be able
to get a question answered without bothering the doctor.
Try to provide a separate entrance for postoperative
patients, get them in a room quickly, and give them a soda or
water while they are waiting to be seen. Patients undergoing
cosmetic surgery do not want to wait long periods of time in
the main waiting area, especially when they are swollen,
bruised, and all wrapped up. Be gentle with the postoperative
care; provide postoperative lymphedema massage and
wound/scar care and instructions.
At the postoperative visits, the nurses should have
the patient’s preoperative photos up on the computer monitor
before they come into the room. Most patients do not remem-
ber what they looked like before surgery. When they are
16
CHAPTER 2 • Establishing a cosmetic practice
1. Gesenhues A. Survey: 90% Of customers say buying decisions are
influenced by online reviews. Marketing Land. Available at:
-long-it-takes-to-resolve-a-customer-service-issue-than-the
-resolution-38756>; 2013. This survey looks at the influence of online
reviews on the decision to buy a product. It found that reviews in general,
whether positive or negative had a significant impact.
2. Anderson M. 88% of consumers trust online reviews as much as
personal recommendations. Search Engine Land. Available at:
-personal-recommendations-195803>; 2014. This is another look at the
influence of reviews on consumers and it found that the majority of
customers trust online reviews.
3. Luca M. Reviews, reputation, and revenue: the case of Yelp.com.
Harvard Business School. Available at: <
6833.html>; 2011.
4. Olesen M. Personal correspondence. 2015.
5. Blanchard K, Bowles S. Raving Fans! Revolutionary Approach to
Customer Service. New York: William Morrow and Company; 1993.
6. Crawford J, Saltz R. Secrets to Success. In: Saltz R, ed. Cosmetic
Medicine & Aesthetic Surgery. St. Louis: Quality Medical Publishing.;
2009:515–520.
Access the complete reference list online at
16.e1
Further reading
Further reading
Anderson K, Zemke R. Delivering Knock Your Socks off Service. 4th ed.
Summit, NJ: Performance Research Associates; 2006.
Lundin SC, Paul H, Christensen J. Fish! A Proven Way to Boost Morale
and Ignite Results. London: Hodder & Stoughton; 2000.
Buford GA, House SE. Beauty and the Business. Garden City, NJ: Morgan
James Publishing; 2010.
3
Essential elements of patient safety in
aesthetic plastic surgery
Drew B. Metcalfe, Gabriele C. Miotto, Galen Perdikis, and Felmont F. Eaves III
SYNOPSIS
■ The importance of patient safety has been acknowledged for
centuries. However, medical errors still happen and are
usually associated with the “Swiss cheese theory” of sentinel
events.
■ Aesthetic surgery is generally elective, and patient safety plays an even
more important role in this setting.
■ The “three pillars of safety” – tools and evidence (evidence-based
medicine; EBM), systems and processes, and culture and
communication – can help us understand patient safety and errors
and how aesthetic surgeons can make changes in their practice to
improve patient safety.
■ Quality is intimately associated with safety, and factors
that improve patient safety are precisely the same factors
that improve the quality of care that we deliver in aesthetic
surgery.
Introduction
The concept of patient safety has existed for centuries. The
Hippocratic Oath, in its original form, contained the charge:
“refrain from doing injury or wrong”, unmistakably acknowl-
edging the potential for harm from medical treatment. Fur-
thermore, the ubiquitous maxim often attributed to the same
author: “primum non nocere” or “first do no harm” also
emphasizes the importance of safety when administering care
to a patient.1 However, the ensuing centuries gave us count-
less examples of medical treatments that proved to be harmful
or even lethal, highlighting ongoing shortcomings with
respect to patient safety.2
In 1999, the Institute of Medicine’s (IOM) Committee on
Quality of Healthcare in America published a landmark
report, To Err Is Human: Building a Safer Health System.3 The
report highlighted the fact that approximately 44 000 to 98 000
people die in hospitals each year from preventable medical
errors.4 It was estimated that the national cost of adverse
events was $37.6 billion with $17 billion of that amount
attributed to preventable adverse events. A poll conducted by
the Kaiser Family Foundation shortly after the release of the
report found that 41% of Americans had been following the
reports of medical errors in the news and 42% believed that
the report identified medical errors as a “serious problem”
that resulted in a large number of preventable deaths.5 A 2004
public opinion survey found that 34% of Americans believed
that they or a family member had experienced a medical error
at some point in their life, and 21% reported that the error had
caused serious health consequences.6
Surgeons have always recognized the importance of patient
safety and have sought to find ways to reduce errors. Many
surgical procedures are performed for the immediate health
of the patient, but aesthetic surgery is generally considered
entirely elective, performed for the purpose of enhancing
appearance rather than treating a life-threatening condition.
Consequently, patient safety plays an even more important
role in aesthetic surgery.
At meetings, surgeons often ask us questions such as “what
is the best protocol for venous thromboembolic (VTE) prophy-
laxis in abdominoplasty?” and “what is the best timing,
choice, and duration of antibiotics for elective procedures?”
In a way, the very nature of these kinds of questions demon-
strates a major misconception of patient safety. Being a safe
aesthetic surgeon cannot be achieved by having bullet point
answers to these kinds of questions. As we will attempt to
demonstrate in this chapter, not only do the answers vary as
to individual patient populations and procedures, they change
over time. Even more importantly, other factors with patient
care may have a far greater effect than knowledge points such
as these. For this reason, we will not attempt to create a
laundry list of how to address specific topics such as VTE
prophylaxis, prevention of surgical site infection, prevention
of anesthesia complications, medical screening, and so forth
– rather, we endeavor to explain the multiple factors involved
in creating a culture of safety which can be used in addressing
patient safety comprehensively.
18
CHAPTER 3 • Essential elements of patient safety in aesthetic plastic surgery
communication. For these reasons, simply admonishing the
individual to be more careful is unlikely to prevent errors
from occurring again.
Traditionally, disseminating knowledge was the logical
next step towards improvement. However, the IOM report
and many others show that the predominance of patient
safety and quality of care issues in modern medicine stem not
from a lack of knowledge but from deficient systems, pro-
cesses, and environments.14,15 According to the Joint Commis-
sion, more than 70% of patient safety sentinel events are
related to these factors.16
The three pillars of patient safety
The concept of the “three pillars” (Fig. 3.1) has been a useful
concept in not only understanding the factors impacting
patient safety and errors, but also in how aesthetic surgeons
can make changes in their practice to improve patient safety.17
This construct reflects back to quality systems used in indus-
try, primarily the Toyota Production System.2 The components
of the three pillars are:
■ Tools and resources, with an emphasis on evidence-based
medicine and best clinical practices
■ Systems and processes
■ Culture and communication
Tools and resources: evidence-based
medicine/best practices
In plastic surgery, we have many tools and technologies
including outstanding surgical facilities, modern instruments,
and many other tangible assets. The individuals with whom
we work – their training, skills and experience – are critical
resources without which care delivery is impossible. Yet, the
most overlooked tool, by far, is our cumulative “bank” of
cognitive knowledge, which includes our understanding of
anatomy, physiology, surgical procedures, and outcomes.
From medical school to residency, we learn from books,
practice experiences, journals, at meetings, and through
interaction with colleagues. However, most of these resources
are permeated with biases, conflicts of interest, and a culture
of experts wherein the opinions of recognized specialty
readers guide practices and decision-making. The emergence
of the evidence-based medicine (EBM) movement is predi-
cated on an understanding of these biases and our need to
anticipate and minimize bias in order to develop better evi-
dence in order to make better decisions. The group at McMas-
ter University, lead by Dr. David Sackett, were the modern
leaders in the EBM movement. Sackett defined EBM as “the
What is patient safety and what is a
medical error?
In order to understand patient safety and errors that can
compromise patient safety, it is important both to define these
terms and understand the domains that they encompass. In
their landmark study, the Institute of Medicine defined patient
safety as freedom from accidental harm. This definition belies
the complexity of sources of potential patient harm. The US
National Patient Safety Foundation provides a more detailed
definition: patient safety is the “avoidance, prevention, and
amelioration of adverse outcomes or injuries stemming from
the process of health care”.7
The term “error”, as applied to medical care, is complex
and problematic. The term can generate a sense of guilt or
shame in well-intentioned providers and lead to unintended
consequences such as avoidance of reporting and fear of liti-
gation.8 Additionally, it is difficult to define and measure, and
as such like many outcomes surrogate measurements are
used; negligence, slips, mistakes, violations, near misses,
potentially compensable events, etc.9 Errors can be classified
in many ways: errors in planning or judgment versus errors
in execution, errors of commission versus errors of omission,
and errors related to outcomes versus errors related to process.
In examining these issues, Gruber and Bohnen have suggested
a definition of error that attempts to consolidate these con-
cepts, defining a medical error as “an act of omission or
commission in planning or execution that contributes or could
contribute to an unintended result.”10
In a sense, therefore, a medical error is anything short of
ideal care, whether it leads to an adverse outcome or not.
Patient safety can subsequently be conceived as the absence
of any error. Both, clearly, are impossible to achieve in any
healthcare environment, including aesthetic surgery. In the
past several years, plastic surgeons have instituted a number
of impactful measures to address safety issues, some of which
will be discussed below, although complications, morbidity,
and mortality continue to occur, indicating that much remains
to be done.
Why do errors happen?
Until recently, medical mistakes were viewed as an “indi-
vidual provider issue”, and the response was typically to
address the poor performance of the responsible provider by
way of punishment, retraining, or other measure aimed at
preventing recurrence of the error on an individual basis.11
However, exhaustive studies in the discipline of human error
involving many industries have demonstrated that it is
impossible to eliminate human error rates to significantly less
than 1 per 200 000 active or working hours, even with the most
sophisticated training and highly functioning individuals,
independent of the industry. Furthermore, this rate increases
for “high” risk activities or industries (such as healthcare),
with error rates of about 1 per every 20 000 hours.12,13 Thus,
according to this data, zero defects do not exist except as a
goal and strategy for error reduction. Although a punitive
response may be appropriate in rare cases of deliberate mal-
feasance, most errors are committed by caring, competent
providers and are due to system failures or failures of
Fig. 3.1 Schematic demonstrating the three pillars of patient safety.
Culture and
Communication
Tools and
Evidence
Systems and
Processes
Patient
Safety
19
The three pillars of patient safety
better evidence finally answer questions such as whether a
vertical or other type of mastopexy procedure is actually
better in the long term? Some of the barriers we face in study-
ing aesthetic surgery are related to a lack of standardized or
appropriate outcome metrics. The development of patient-
derived outcome metrics such as the Breast-Q21 and Face-Q22
have certainly given us insight into patient satisfaction out-
comes, but much remains to be done towards establishing
appropriate metrics, whether they be related to morbidity,
mortality, or patient perceptions of the results of surgery.
Even with knowledge of the best evidence, implementation
of the best practices is often fraught with difficulty and failure.
When planning complex changes in practice, potential barri-
ers at various levels need to be addressed. For example,
barriers to change may include a lack of awareness or knowl-
edge, reinforcement, control, social norms, leadership or
facilities.23 According to Grol and Wensing, planning should
take into account the nature of the innovation, characteristics
of the individuals involved, and the social, organizational,
and economic context of the change.23 Consequently, effec-
tively improving our delivery of safe patient care in aesthetic
surgery requires that the appropriate systems and processes
be in place.
Systems and processes
If cognitive knowledge is the raw material of plastic surgery,
systems are the machinery. Much of our current understand-
ing of systems comes from the work of Charles Perrow and
James Reason. According to Reason, “a system is a set of
interdependent elements interacting to achieve a common
aim. The elements may be both human and non-human
(equipment, technologies, etc.).”14
Systems and processes are the mechanism by which we
apply our tools – skills, resources and best evidence – into
action. They are the way in which we get things done. Systems
and processes – and their implementation – can be simple or
complex, but share common elements (Box 3.1).
As a practical example for the practicing aesthetic surgeon,
consider the following scenario. Based on an assessment of
the literature, it is elected that patients undergoing abdomi-
noplasty will undergo active preoperative warming to reduce
the risk of hypothermia.24 Having made that decision, the
surgeon is surprised when the next patient is found to have
a temperature of 35.8 shortly after induction of anesthesia.
What happened? Although the task was defined, perhaps
there was confusion among the staff of who was responsible
for placing the warming blanket (planning). Perhaps there
was not an available electrical outlet into which the machine
could be plugged (logistics). Perhaps the responsible team
member just forgot (lack of use of checklists).
conscientious, explicit, and judicious use of current best evi-
dence in making decisions about the care of individual
patients.”18 EBM has now been identified as one of the fifteen
most important developments in the history of medicine.19
Sackett and his colleagues reduced the concept of EBM into
five steps:
1. Convert the need for information into an answerable question.
For instance, the surgeon wants to know what venous
thromboembolic (VTE) prophylaxis is best in an
individual patient undergoing abdominoplasty. The
question “What VTE prophylaxis regimen is best for
abdominoplasty patients?” is insufficient. Instead, the
surgeon needs to understand the patient characteristics,
how the surgery will be done, and risk factors in order
to search for evidence that is applicable to that
particular patient population.
2. Identify the best available evidence. Based on the
parameters identified in step 1, a disciplined search is
undertaken to identify the most pertinent information.
MEDLINE and other online sources greatly facilitate
evidence identification.
3. Evaluate the evidence for validity, impact, and applicability to
the question at hand. Critical analysis skills are applied in
the assessment of the evidence. The levels of evidence
can be helpful as an initial guideline to assess the risk of
bias within individual publications, but proper
assessment also requires an analysis of study
methodology looking for flaws, which may compromise
the validity of the information. It is also key to
determine whether this evidence is impactful or
whether it applies to the patient care decision that is
being made. A “level of evidence” pyramid has been
adopted by certain plastic surgery journals as a visual
way of promoting and advancing evidence-based
medicine in the field (Fig. 3.2).20
4. Integrate with clinical experience and individual patient
characteristics and needs. Far from being a “cookie cutter”
approach to aesthetic surgery, a core principal of EBM is
that one integrates the best evidence with the patient’s
individual values, goals, and resources as well as one’s
own skills and experiences.
5. Continually review and refine Steps 1–4. As new evidence
becomes available, some better evidence should displace
older, less valid evidence. On occasion, older,
established treatments will be shown to be inferior or, as
noted by Dr. Sackett, EBM is a way of “helping smart
doctors stop prescribing dumb treatments”.18
Our understanding of the principles of aesthetic surgery is
greater now than at any time in the past, at least in part due
to an emphasis on evidence-based medicine. However, can
Fig. 3.2 The level of evidence pyramid, showing level of evidence (I
through V) and clinical question addressed by the article. Left: Diagnostic
clinical question addressed, with level of evidence of II. Center: Therapeutic
clinical question addressed, with level of evidence of III. Right: Risk clinical
question addressed, with level of evidence of II. (Reproduced with
permission from Sullivan D, Chung KC, Eaves FF 3rd, Rohrich RJ. The level
of evidence pyramid: indicating levels of evidence in Plastic and
Reconstructive Surgery articles. Plast Reconstr Surg. 2011;128:311–314.)
DIAGNOSTIC
THERAPEUTIC
RISK
II
II
III
20
CHAPTER 3 • Essential elements of patient safety in aesthetic plastic surgery
In aesthetic plastic surgery, use of checklists can be imple-
mented during routine patient care delivery. One example of
the use of checklist associating EBM with systems and pro-
cesses is the surgical site infection prevention protocol we
now use at the Emory Aesthetic Center. This protocol was
created using the best current evidence to support the judi-
cious and timely administration of antibiotic prophylaxis for
aesthetic procedures and other interventions that have proven
to reduce surgical site infection (Box 3.2).
Taking a closer look at the surgical site infection (SSI)
protocol and the way it is used, we can identify the compo-
nents of it that contribute to the use of EBM, an effective
system and an effective process in the delivery of care:
1. Checklist is created using the best evidence available
(EBM) on surgical site infection in aesthetic plastic
surgery
2. Checklist is presented to staff and faculty members and
approved for use
3. Checklist is affixed in the operating room in case there
is any question about its components
How to incorporate systems and processes in
aesthetic plastic surgery?
One tool that has proved to be particularly useful in modern
healthcare systems is the creation of checklists. The benefit of
the checklist in healthcare has been demonstrated by the
implementation of a simple central line insertion checklist as
part of the Pittsburg Regional Healthcare Initiative (PRHI).
The CDC estimates that that bloodstream infections arising
from the insertion of a central line affect up to 250 000 patients
a year in the United States, killing some 15% or more.25 Fur-
thermore, the cost of additional care per infection is estimated
in the tens of thousands of dollars. However, between 2001
and 2004, two dozen Pittsburgh hospitals participating in the
PRHI were able to cut the incidence of central line infections
by more than 50%. Some, in fact, reduced them by more than
90%.26 According to the NEJM report,27 the total number
of central line-related complications during the initiative
decreased from 27.3 (95% confidence interval [CI], 25.9 to 28.7)
to 16.7 (95% CI, 15.6 to 17.9), for an absolute risk reduction
of 10.6 (95% CI 8.7 to 12.4). The proportion of patients with
one or more complications decreased from 15.4% to 10.6%
(p<0.001). In-hospital mortality decreased from 1.5% (95% CI
1.2 to 2.0) to 0.8% (95% CI, 0.6 to 1.1), for an absolute risk
reduction of 0.7 percentage points (95% CI, 0.2 to 1.2). The
checklist ensured the use of the best practices in central line
insertion and significantly decreased central line infection
rates and healthcare costs. This benefit has been replicated
since by several heathcare systems and hospitals. If expanded
throughout the US, these improvements alone would save
thousands of lives and billions of dollars.
BOX 3.2 Surgical site infection prevention protocol
1. Identification and treatment of infections remote to the
surgical site prior to elective surgery.
2. Clipping of hair (if necessary) immediately before the
operation. No shaving.
• Orient patient on preoperative visit to NOT shave for 7 days
before surgery
• Include information about non-shaving on patient orientation
package
• Have disposable clipper heads ready to use in the ASC
3. Use established preoperative hand and/or forearm
antisepsis by the surgical team.
• Avagard available
4. Appropriate surgical attire and drapes.
• Consider double gloving
5. Appropriate surgical antimicrobial prophylaxis.
• 1 g of cefazolin given within 30–60 minutes before incision if
patient under 80 kg; 2 g if patient above 80 Kg. If allergic,
600 mg of clindamycin if patient under 80 Kg, 800 mg if
patient above 80 Kg
• Repeat dose 3 hours after initial dose if ongoing procedure
• Antimicrobial prophylaxis should not be continued beyond
24 hours
6. Pre-warming patient for 30–60 min before surgery and
maintenance of normothermia (temperature above 36°C
degrees) during perioperative period.
• Use active warming devices during surgery (air blankets,
warm pads).
• Strongly consider room temperature above 70°F degrees.
• Increase ambient room temperature to 72°F–75°F when
significant patient exposure occurs such as prepping,
draping and re-prepping.
7. Meticulous aseptic technique with chlorhexidine 0.5%–2% in
alcoholic solution for body procedures and povidone-iodine
10% for facial procedures. Perineal area should be prepped
with aqueous solution (either PVI or chlorhexidine).
8. Intraoperative and postoperative serum glucose control in
diabetic patients (target, less than 150 mg/dL).
BOX 3.1 Systems and processes: common elements
Define the task to be done – This should be based on the best
available evidence and desired best clinical practice.
Evaluate the available resources – Is the proper equipment in
place? Are team members properly trained? In order to fulfill the
task, do additional resources need to be procured?
Plan – Working with team members, define a process by which the
task will be done. Who will do the task? When will it be done?
Where will it be done? How will it be done?
Logistics – Logistics are the details of the plan, for instance how to
get the right resources in the right place at the right time.
Training – Team members need to be trained in the new process or
system. They need to know not only their own role but the role
of the other team members. Practice, potentially including
simulation, can significantly increase the reliability of
implementing a new process.
System tools – These include the use of checklists, time outs,
pass-offs, and the development of organizational routines.
Assessment, monitoring and modification – In order to monitor
whether a system is working, the outcome must be measured
by appropriate metrics. When the desired outcome is not
achieved, a root cause analysis can demonstrate where the
system failed and why. Changes in the system can be
implemented through this knowledge, including a reassessment
of the underlying issues, a process known as double-loop
learning. In this way the system is continually improved leading
to ongoing error reduction.
21
Swiss cheese model
that involves damage to a defined system that disrupts the
ongoing or future output of that system” (Fig. 3.3).
Perhaps the most widely known model of safety is the
“Swiss cheese model” proposed by Reason.14,32 This model
represents slices of Swiss cheese as layers of protection or
vulnerability at different levels. A process within the patient’s
care can be represented by an image of several slices of Swiss
cheese stacked together. The holes represent potential active
or latent errors in the care of the patient, while the protective,
solid parts of the cheese represent where errors do not occur.
Although each level of protection is incomplete, as repre-
sented by the holes in any given slice, it is unusual to have
perfectly aligned holes once several slices are stacked together.
For an adverse event to occur, typically several errors must
align in order to pass through each of the layers of protection
without being stopped. If the system provides good protec-
tion, the holes will be small and they will only rarely line
up. However, in some systems, at some times, the holes may
align, allowing errors to propagate and result in harm to the
patient.
One of the most important concepts to come out of this
model is that in complex systems, a single error is rarely
sufficient to cause an adverse event or harm. This model also
highlights the need to focus on more than just perfecting
human behavior (an obviously impossible task), but also on
creating a system with multiple overlapping layers of protec-
tion to minimize the potential for patient harm resulting from
errors. Like knowledge, processes can be taught, improved,
and refined. Systems themselves can become a mechanism for
ongoing safety and quality advancements. Tools like check-
lists, double loop learning, problem-solving techniques, error
4. Nurses and anesthesia staff confirm that all the
preoperative steps of the protocol are followed before
the patient is taken to the operating room
5. Nurses and anesthesia staff confirm that all the
preoperative steps of the protocol are followed in the
operating room
6. A time-out before the procedure confirms that the
preoperative SSI protocol steps were followed
7. A debriefing after the procedure recaps what was done,
promotes problem-solving discussion if needed, and
reinforces organizational routines.
Culture and communication
Of the three pillars, culture and communication may be the
most important. Safety is the product of technical factors
(EBM, systems and procedures) and cultural factors (safety =
T × C). Efforts to promote safety have mostly been focused on
the technical aspects of care and the cultural aspects largely
ignored, leaving our patients at massive risk for errors. When
assessing medical errors, 70% of the time someone knew
something and did not speak up. We assume that people will
speak up in our own practices because we are compassionate
friendly surgeons, but have we ever taken the time to discuss
how we need to communicate as a team, with our team. When
last did you ask your staff: would you speak up if you saw
me about to make an error even if you were not sure? Do you
have a safe comfortable system in place in your practice where
your staff can bring up safety concerns, solutions and even
possible practice improvement suggestions? Empowering
your team to speak up and fostering a safe culture gives them
the ability to detect any gaps in the system, for example in
our practice, the initial lack of warming blankets in the pre-
operative area for prevention of hypothermia. Part of this
effort has been cultivating a work environment of empower-
ment, respect, and team communication that focus on the
importance of the human element.28
In a constrained, “blame” environment, communication
and innovation are stifled. Respect for others – employees,
colleagues, and patients – is a key component in creating the
safest working environment, and thus, the impact of profes-
sionalism – or lack thereof – is real.29 Tools to improve our
culture range from crew resource management to team
building and communication training. Changing the culture
requires complete buy-in from leadership and lead physicians
in practices. It is a longitudinal journey and not a one-time
quick fix. Contemporary efforts to promote a team-based
structure have given us some ground for potential errors
to be discussed in an environment of professional respect
without fear of punitive consequences. Attention to the design
of healthcare systems is likely to be the most effective approach
to preventing errors, mitigating their effects, and reducing the
likelihood of harm.
Swiss cheese model
When errors occur, it is often due to multiple faults that occur
together in an unanticipated interaction, creating a chain of
events in which the faults grow and evolve.30,31 Their accumu-
lation results in an accident, defined by Perrow as “an event
Fig. 3.3 A graphic demonstration of the “Swiss cheese model” of patient safety.
The holes in the cheese represent potential errors. Typically, a sentinel event such
as failure to prevent or treat a venous thrombolic event involves a series of care
points (slices), and only when the errors (holes) align does the event occur. By
developing a culture of safety that embraces evidence, systems, culture and
communication, the error potentials (holes) get smaller and the number of layers
increase.
Patient suffers
a PE, arrests
and dies
Patient tries to call doctor to report
shortness of breath, message left
(COMMUNICATION
and SYSTEM)
Nurse forgets to place SCDs
before the start of anesthesia
(SYSTEM)
Inadequate VTE
prophylaxis used
(EVIDENCE)
Patient doesn’t tell surgeon
she will be travelling the
day of surgery
(COMMUNICATION)
22
CHAPTER 3 • Essential elements of patient safety in aesthetic plastic surgery
In order to optimize patient safety in aesthetic surgery,
professional organizations, training programs, journals, and
most importantly aesthetic plastic surgeons need to change
their attitudes and refocus their emphases on education.
Traditionally aesthetic education has been focused primarily
on procedural technique optimization, however as demon-
strated by the Joint Commission data, this is not where errors
typically occur, as the overwhelming majority of errors are
related to systems, culture, and communications failures.
Optimizing patient safety requires that surgeons embrace
education directed toward how to constantly improve the
evidence used in decision-making, the systems and processes
which they employ to execute these intentions, and the cul-
tures within which they work.
management and the development of organizational routines
can help us improve patient safety in aesthetic plastic surgery.
Conclusions
One important perspective shift of recent years is the recogni-
tion that practice efficiency and quality improvement are
synonymous with patient safety. Factors that improve patient
safety – namely, defined systems and processes, a continuous
quality improvement culture, and safe, communicative, and
professional working environments – are precisely the same
factors that improve the quality of care that we deliver. Safe
care is quality care, and quality care is safe.
3. Kohn LT, Corrigan J, Donaldson MS. To Err is Human: Building a
Safer Health System. Washington, D.C.: National Academy Press;
2000:xxi, 287. This landmark publication highlights the problem of
medical error and outlines the huge implications of these errors.
8. Fish JM. Human error in medicine: promise and pitfalls, part 2. Ann
Emerg Med. 2001;37:419–420. This paper looks at methods of improving
quality and preventing error in emergency medicine. It points out
potential pitfalls that must be avoided.
10. Grober ED, Bohnen JM. Defining medical error. Can J Surg.
2005;48:39–44. In this paper the authors discuss how medical errors
should be measured and point out the difficulty of reporting and
determining the severity of medical errors if there is no method of
standardization.
15. Leape LL. Errors in medicine. Clin Chim Acta. 2009;404:2–5. Although
the main focus of patient safety has been the implementation of safe
practices several approaches have developed. Six major changes are
required: 1. Move from lookoing at errors as individual failures to the
realization that they are caused by system errors. 2. Move from a punitive
culture to a just one. 3. Move from secrecy to transparency. 4. Change
from being provider centered to being patient centered. 5. Move from
reliance on individual performance excellence to interdependent
collaborative interprofessional teamwork. 6. Accountability is universal
and reciprocal, not top-down.
20. Sullivan D, Chung KC, Eaves FF 3rd, Rohrich RJ. The level of
evidence pyramid: indicating levels of evidence in Plastic and
Reconstructive Surgery articles. Plast Reconstr Surg. 2011;128:
311–314. This paper outlines the different levels of evidence and their
implication on reliability and usefulness.
21. Pusic AL, Klassen AF, Scott AM, et al. Development of a new
patient-reported outcome measure for breast surgery: the
BREAST-Q. Plast Reconstr Surg. 2009;124:345–353.
25. Burke JP. Infection control – a problem for patient safety. N Engl J
Med. 2003;348:651–656.
26. Centers for Disease Control and Prevention. Reduction in central
line-associated bloodstream infections among patients in intensive
care units–Pennsylvania, April 2001–March 2005. MMWR Morb
Mortal Wkly Rep. 2005;54:1013–1016.
27. Pronovost P, Needham D, Berenholtz S, et al. An intervention to
decrease catheter-related bloodstream infections in the ICU. N Engl
J Med. 2006;355:2725–2732.
28. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the
operating room: frontline perspectives among hospitals and
operating room personnel. Anesthesiology. 2006;105:877–884.
Access the complete reference list online at
22.e1
References
References
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JAMA. 2000;284:2687–2688.
2. Spear SJ. Fixing health care from the inside, today. Harv Bus Rev.
2005;83:78–91, 158.
3. Kohn LT, Corrigan J, Donaldson MS. To Err is Human: Building a
Safer Health System. Washington, D.C.: National Academy Press;
2000:xxi, 287. This landmark publication highlights the problem of
medical error and outlines the huge implications of these errors.
4. American Hospital Association. Hospital Statistics. Chicago: AHA;
1999.
5. Kaiser Family Foundation. Five years after IOM Report on Medical
Errors, nearly half of all consumers worry about the safety of their
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Research; 2000.
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development in patient safety. Available from: <
.org>; 2005.
8. Fish JM. Human error in medicine: promise and pitfalls, part 2. Ann
Emerg Med. 2001;37:419–420. This paper looks at methods of improving
quality and preventing error in emergency medicine. It points out
potential pitfalls that must be avoided.
9. Leape LL. Error in medicine. JAMA. 1994;272:1851–1857.
10. Grober ED, Bohnen JM. Defining medical error. Can J Surg.
2005;48:39–44. In this paper the authors discuss how medical errors
should be measured and point out the difficulty of reporting and
determining the severity of medical errors if there is no method of
standardization.
11. Wachter RM. Understanding Patient Safety. New York: McGraw-Hill;
2008.
12. Duffey RB, Saull JW. Know The Risk: Learning from Errors and
Accidents: Safety and Risk in Today’s Technology. Burlington:
Butterworth-Heinemann; 2003.
13. Duffey RB, Saull JW. Errors in technological systems. Hum Factors
Ergon Manuf Serv Ind. 2003;13:279–291.
14. Reason JT. Human Error. Cambridge: Cambridge University Press;
1990.
15. Leape LL. Errors in medicine. Clin Chim Acta. 2009;404:2–5. Although
the main focus of patient safety has been the implementation of safe
practices several approaches have developed. Six major changes are
required: 1. Move from lookoing at errors as individual failures to the
realization that they are caused by system errors. 2. Move from a punitive
culture to a just one. 3. Move from secrecy to transparency. 4. Change
from being provider centered to being patient centered. 5. Move from
reliance on individual performance excellence to interdependent
collaborative interprofessional teamwork. 6. Accountability is universal
and reciprocal, not top-down.
16. Chang A, Schyve PM, Croteau RJ, et al. The JCAHO patient safety
event taxonomy: a standardized terminology and classification
schema for near misses and adverse events. Int J Qual Health Care.
2005;17:95–105.
17. Eaves FF 3rd. An integrated model of patient safety and quality of
care. Aesthet Surg J. 2011;31:714–715.
18. Thoma A, Eaves FF 3rd. A brief history of evidence-based medicine
(EBM) and the contributions of Dr David Sackett. Aesthet Surg J.
2015;35:NP261–NP263.
19. Godlee F. Milestones on the long road to knowledge. BMJ.
2007;334(suppl 1):s2–s3.
20. Sullivan D, Chung KC, Eaves FF 3rd, Rohrich RJ. The level of
evidence pyramid: indicating levels of evidence in Plastic and
Reconstructive Surgery articles. Plast Reconstr Surg. 2011;128:
311–314. This paper outlines the different levels of evidence and their
implication on reliability and usefulness.
21. Pusic AL, Klassen AF, Scott AM, et al. Development of a new
patient-reported outcome measure for breast surgery: the
BREAST-Q. Plast Reconstr Surg. 2009;124:345–353.
22. Klassen AF, Cano SJ, Scott A, et al. Measuring patient-reported
outcomes in facial aesthetic patients: development of the FACE-Q.
Facial Plast Surg. 2010;26:303–309.
23. Grol R, Wensing M. What drives change? Barriers to and incentives
for achieving evidence-based practice. Med J Aust. 2004;180:S57–S60.
24. Young VL, Watson ME. Prevention of perioperative hypothermia in
plastic surgery. Aesthet Surg J. 2006;26:551–571.
25. Burke JP. Infection control – a problem for patient safety. N Engl J
Med. 2003;348:651–656.
26. Centers for Disease Control and Prevention. Reduction in central
line-associated bloodstream infections among patients in intensive
care units–Pennsylvania, April 2001–March 2005. MMWR Morb
Mortal Wkly Rep. 2005;54:1013–1016.
27. Pronovost P, Needham D, Berenholtz S, et al. An intervention to
decrease catheter-related bloodstream infections in the ICU. N Engl
J Med. 2006;355:2725–2732.
28. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the
operating room: frontline perspectives among hospitals and
operating room personnel. Anesthesiology. 2006;105:877–884.
29. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes
Questionnaire: psychometric properties, benchmarking data, and
emerging research. BMC Health Serv Res. 2006;6:44.
30. Perrow C. Normal Accidents: Living with High-Risk Technologies. New
York: Basic Books; 1984.
31. Bogner MS. Human Error in Medicine. Hillsdale, N.J.: L. Erlbaum
Associates; 1994.
32. Reason JT. Managing the Risks of Organizational Accidents. Aldershot,
UK: Ashgate; 1997.
SECTION I • Aesthetic Surgery of the Face
4
Skincare and nonsurgical skin rejuvenation
Leslie Baumann and Edmund Weisberg
The cosmetics and cosmeceutical industry has seen numerous
scientific breakthroughs in the last three decades resulting in
a plethora of skincare products on the market. While most
consumers are still buying their skincare products in pharma-
cies and skincare stores, the complicated cosmeceutical science
is confusing, daunting, and easily misrepresented. Box 4.1
shows the 10 steps that a doctor should take before prescrib-
ing a cosmeceutical product for a patient. These 10 steps are
challenging, but physicians have a solid scientific background
that allows them to decipher marketing claims and research
trial results, which is critical to following these 10 steps. As
more ingredients with biologic activity, such as stem cells and
growth factors, become available, it is important to realize that
these products should be used properly. At the time that this
chapter was written, the US Congress was considering a bill
that would increase oversight by the Food and Drug Admin-
istration (FDA) over cosmeceutical ingredients. Whether the
bill passes or not, it is evident that savvy patients will look to
their physicians – especially plastic surgeons and dermatolo-
gists – to prescribe the proper skincare regimen for their skin
type.
Diagnosing skin type
The first step to prescribing the proper skincare regimen for
a patient is to properly diagnose their skin type. The author
has developed the Baumann Skin Typing System (BSTS) that
uses a validated questionnaire to diagnose patients as one of
16 distinct Baumann Skin Types.1,2 This methodology assesses
skin based on four parameters: (1) oily versus dry; (2) sensi-
tive versus resistant; (3) pigmented versus non-pigmented;
and (4) wrinkle-prone versus tight (unwrinkled). The ques-
tionnaire determines the skin’s phenotype in regard to these
four parameters resulting in 16 different skin types, which are
represented by a four-letter designation. To help the patient
remember their Baumann Skin Type, each skin type is associ-
ated with a color and a number (Fig. 4.1). For example,
a patient with dry skin, redness, even skin tone, and fine
lines would be designated as a DSNW (Dry, Sensitive, Non-
pigmented, Wrinkle-prone type), which is Baumann Skin
Type #4 and is assigned a light pink color. Studies have shown
that some patients remember the number of their skin type,
while others remember the color or the four letters. Using this
skin-typing nomenclature facilitates doctor/patient commu-
nication and the process of matching skincare products to the
patient’s skin type.3 This skin-type vocabulary will be used in
the following discussion of cosmeceutical ingredients and the
remainder of this chapter will discuss skincare science as it
relates to the BSTS format. It is important to realize that the
Baumann Skin Type (BST) can fluctuate with the seasons,
hormonal changes, lifestyle changes, pregnancy, medications,
a move to a new geographic location, and other factors.
Patients should retake the questionnaire if they have experi-
enced any of these changes so that their skincare regimen can
be properly adjusted.
Skin type characteristics
Dry (D) skin, or xerosis, is characterized by an impaired
barrier, lack of natural moisturizing factor (NMF), and reduced
sebum production. Dry skin types are more susceptible to
irritation from retinoids, acne medications, and other irritat-
ing ingredients.
Oily (O) skin is characterized by an adequate or elevated
sebum production. Sebum is an oily occlusive substance that
coats the surface of the skin preventing water evaporation and
protecting the skin from irritants.
“Combination skin” usually means one of two things: (1)
an oily T-zone, which would be designated as an oily skin
type in the BSTS or (2) dry in the winter and oily in the
summer. In the latter case, the BST would be different in those
two seasons and the patient would require two separate
skincare regimens to adjust for seasonality (heat and
humidity).
Sensitive (S) skin can be subdivided into four types, each
characterized by inflammation. The four sensitive skin types
Access video lecture content for this chapter online at expertconsult.com
24
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
melasma, and postinflammatory hyperpigmentation. This
designation refers to the evenness of skin pigment and not to
ethnicity or overall skin color.
Non-pigmented (N) skin types in the BSTS have an even
skin tone and do not require skin-lightening ingredients. A
dark-skinned individual with even skin tone would be desig-
nated as an (N) skin type.
Wrinkle-prone (W) skin types are at risk for skin aging
because of age or lifestyle factors such as cigarette smoking,
sun exposure, and tanning bed use. Wrinkle-prone types
should use aging prevention strategies that include daily
sunscreen, retinoids, and antioxidants including ascorbic acid.
Tight (T) skin types are young and do not have a history
of sun exposure, smoking, or other lifestyle factors that render
them more susceptible to skin aging. This skin type does not
require antiaging ingredients; however, daily SPF is always
recommended to minimize risk factors for skin aging and skin
cancer.
Prescribing a skincare regimen based
on skin type
Each of these parameters must be taken into account when
prescribing a skincare regimen. For example, a DSNW (Dry,
Sensitive, Non-pigmented, Wrinkle-prone) skin type that
manifests the sensitive skin subtype of rosacea is a very
common but challenging skin type. DSNWs are characterized
by an impaired skin barrier that allows irritants to easily enter
the skin. They are already susceptible to inflammation so the
irritants can cause a robust reaction. This skin type has diffi-
culty with most antiaging ingredients such as retinoids and
hydroxy acids. Priority must be given to first strengthening
the skin barrier and decreasing inflammation. Once the skin
is stabilized, retinoids can be slowly added.
Once the patient’s skin type is diagnosed and a proper
regimen for that skin type is prescribed, it is important that
the practitioner provide the proper instructions on how to use
the products. For example, if a retinoid is intended to be
added slowly, the physician should give the patient detailed
instructions on how this should be done. DSNWs do well to
use the proper barrier-strengthening cleansers and moistur-
izers for three days before beginning to apply only a pea-sized
amount of retinoid on top of the moisturizer every third night.
After two weeks, the retinoid can be applied every other
night. In another two weeks the retinoid can be applied
nightly. Conversely, ORNWs, who do not exhibit a weakened
skin barrier or a susceptibility to inflammation, can immedi-
ately begin using a retinoid nightly. Providing the proper
patient education will decrease calls to the office and improve
patient outcomes.
Managing expectations from the beginning is essential.
Patients should be advised that they will be seen in 4, 8, 12,
and 16 weeks in addition to yearly. As their skin type changes
or their skin improves, the regimen will be adjusted until they
achieve long-term skincare maintenance status. At these visits,
recommendations will be adjusted, such as increasing the
strength of the retinoid, cessation of skin lighteners, addition
or subtraction of anti-inflammatory ingredients, and altering
the level of moisturization. If the physician practices in a
geographic location that features dramatic shifts in weather,
BOX 4.1 Ten steps to prescribing cosmeceuticals
1. Diagnose your patient’s skin type
2. Know the ingredient science of each ingredient
3. Understand ingredient interactions
4. Understand how the cosmeceutical was formulated
5. Understand how the product was manufactured and packaged
6. Match regimen to the patient’s skin type
7. Choose the order of products so that they act synergistically
8. Educate your patient on the proper use of the product
9. Educate your staff on how to explain the importance of the
products to the patient
10. Follow up with the patient in 4 weeks to adjust the regimen
Fig. 4.1 The 16 Baumann Skin Types. D, dry; N, non-pigmented; O, oily; P,
pigmented; R, resistant; S, sensitive; T, tight; W, wrinkle-prone.
are acne (pimples), rosacea (redness), burning/stinging, and
allergic. Patients often exhibit several types of sensitive skin.
For instance, a patient who has frequent rashes in reaction to
skincare products and develops pimples would have the acne,
allergic subtypes of sensitive skin. It is important to distin-
guish the type of sensitive skin because they each require
different types of cosmeceutical ingredients.
Resistant (R) skin types do not suffer from the four forms
of inflammation described above. They enjoy a strong skin
barrier but require a higher percentage of cosmeceutical
ingredients because their skin is so effective at preventing
penetration.
Pigmented (P) skin types in the BSTS have uneven skin
tone and a propensity to develop hyperpigmentation under
certain stresses. Examples include a history of solar lentigines,
25
Skincare by skin type
are less likely to develop allergic and irritant reactions. Tar-
geted ingredients such as antimicrobials, anti-inflammatories,
depigmenting agents, hydroxy acids, and other ingredients
can be added to cleansers and moisturizers, but the basic
formulations must be appropriate for the patient’s skin type.
Cleansers
Oily types should be prescribed a foaming cleanser that will
remove excess lipids from the skin. Dry types, on the other
hand, need non-foaming cleansers that preserve the skin’s
lipids and moisturizers that supply barrier repair ingredients
to the stratum corneum (Box 4.3). The choice of cleanser and
moisturizer can greatly affect the success of the entire skincare
regimen as well as the surgical outcome.
Moisturizers
Most oily types do not like the feel of both a moisturizer and
a sunscreen on the skin because these feel heavy in the pres-
ence of an adequate or increased amount of sebum on the
skin’s surface. Oily skin types do not need a moisturizer in
the morning but can use a sunscreen instead of a moisturizer
during this period of the day.
Barrier repair
Barrier repair products are the most important category of
moisturizers because they give the skin the components it
needs to moisturize and protect itself. It is well known that to
strengthen the skin’s barrier, three exogenously applied lipids
must be applied be in a 1 : 1 : 1 ratio to form the correct three-
dimensional structure of the skin barrier.6 When the correct
ratios of ceramides, fatty acids, and cholesterol are used,
barrier recovery after insult is accelerated. If only one of these
ingredients is applied, or if they are applied in an incorrect
ratio, barrier recovery is disrupted. Although this knowledge
has been present for decades, there are actually few products
on the market that contain the proper ingredients.
Ceramides
It is difficult to find products with genuine ceramides because
they are expensive. There are actually at least nine different
types of ceramides but ceramide 1 is unique because it con-
tains the anti-inflammatory fatty acid linoleic acid. The first
ceramides used were derived from animals, but this became
an issue when mad cow disease emerged. Plant-derived
ceramides did not exhibit the proper structure needed to
strengthen the barrier. For this reason, synthetic “pseudocer-
amides” were developed. The best, most studied pseudocer-
amide is myristoyl/palmitoyl oxostearamide/arachamide
monoethanolamine. It forms a multi-lamellar emulsion that
exactly mimics the naturally occurring Maltese cross forma-
tions that form the natural skin barrier. This technology is
the patient should be seen seasonally. If physicians convey
from the beginning to their patients that pigmentation issues
will take at least 12 weeks to improve, acne will take at least
8 weeks, and fine lines can require over 6 months of consistent
retinoids, patients will be more compliant with the long-term
follow-up and experience better outcomes. Patients should be
advised that if their skincare regimen stops working for them,
they should return to the office and retake the questionnaire
to determine if their skin type has changed. Giving the patients
information about their particular skin type’s challenges
and treatment plan can improve patient education and
compliance.
The methodology of diagnosing the skin type, prescribing
the regimen, educating the patient, and handling follow-up
visits and regimen adjustments is beyond the scope of this
chapter. This methodology is important as is consistent and
frequent staff training. More information about using this
methodology can be found in detail at STSFranchise.com. The
remainder of this chapter will focus on the science of specific
skin issues and the cosmeceutical ingredients used to treat
these issues.
Skincare by skin type
Dry and oily skin types
Xerosis, or dry skin, is characterized by cracks and fissures
and occurs when the level of water, the primary plasticizer of
the skin, is low.4 Water content in the SC must be at least
10% in order for the skin to appear and feel normal.5 The eleva-
tion in transepidermal water loss (TEWL) that progresses to
xerosis occurs when a defect in the skin’s permeability barrier
permits the evaporation of excess water to the atmosphere.
The etiology of an impaired barrier is generally multifactorial
and includes variables such as harsh detergents, acetone,
cholesterol-lowering drugs, and frequent bathing (Box 4.2).
Patients with dry skin are also at an increased risk of allergic
and irritant dermatitis because their impaired barrier is less
able to keep irritants and allergens out of the skin.
Cleansers and moisturizers greatly influence the skin’s
protective barrier by affecting the amount of sebum and other
lipids in and on the skin. Dry skin needs more lipids added,
while oily skin needs lipids removed. The right balance
and correct type of lipids on the skin are important for healthy
skin and good surgical outcomes. Oily skin types that have
an ample amount of sebum are at a lower risk of developing
skin allergies but are at an increased risk of developing
acne. Dry skin types with adequate amounts of fatty acids,
ceramides, and cholesterol have a stronger skin barrier and
BOX 4.2 Exogenous factors that can lead to dry skin
• Hot water
• Detergents
• Friction from clothing
• Frequent air travel
• Pollution
• Other chemicals
• Air conditioning
BOX 4.3 Barrier repair ingredients
These three ingredients must be present in equal ratios:
Ceramides
Fatty acids, such as stearic acid and linoleic acid
Cholesterol
26
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
from the source plant. Naturally derived oils contain copious
lipids (fatty acids), which the skin requires for the proper
formation and function of cell membranes to prevent TEWL.
Specifically, several natural oils contain fatty acids important
in maintaining the skin barrier such as linoleic acid, an
omega-6 fatty acid present in argan, sunflower, safflower, and
other oils. Linoleic acid is important because skin cells use it
to produce ceramide, an important component of the skin’s
barrier. Also, linoleic acid exhibits anti-inflammatory proper-
ties. Many other hydrating fatty acids such as stearic acid are
found in oils. The presence of fatty acids in a skincare regimen
can greatly affect penetration of other ingredients. For
example, oleic acid in olive oil has a polar structure that
allows it to disrupt the skin barrier by inserting its alkyl chains
into ceramides, rendering the barrier more fluid and easier for
molecules to diffuse through than intact ceramides.17 For this
reason, before using oils it is important to know if they will
strengthen or impair the skin barrier. Argan and safflower oil
strengthen the barrier while olive oil impairs it.
Humectants
Humectants are water-soluble materials with high water
absorption capabilities that are often put into skincare prod-
ucts to “rapidly improve fine lines and wrinkles” by helping
the skin hold onto water. In low-humidity conditions,
however, humectants can paradoxically dehydrate the skin by
attracting water from the deeper epidermis and dermis,
thereby exacerbating dehydration.18 For this reason, humec-
tants should be combined with occlusive ingredients in a dry
environment. Commonly used humectants include glycerin,
urea, sorbitol, sodium hyaluronate (hyaluronic acid), propyl-
ene glycol, alpha hydroxy acids (AHAs), and sugars.
Alpha hydroxy acids
AHAs, so named because they contain a hydroxy group in
the alpha position, function as humectants as well as exfoli-
ants. This versatile family includes glycolic acid (derived
from sugar cane), lactic acid (from sour milk), citric acid (from
citrus fruits), malic acid (from apples), tartaric acid (from
grapes), and phytic acid (from rice).19 Glycolic and lactic acids
are the most commonly used AHAs, were the first to reach
the market, and will be the only ones discussed here. The
cosmetic effects of hydroxy acids include normalization of SC
exfoliation, leading to fewer dry scales on the skin surface, a
smoother surface, and better light reflection.20 AHAs and beta
hydroxy acid (BHA) degrade the desmosomes and affect
corneocyte cohesion at the basement levels of the SC,21 where
they alter pH and promote desquamation. Applying AHAs
and BHA in high concentrations results in the detachment of
keratinocytes and epidermolysis (blisters). Application of
AHAs and BHA at lower concentrations degrades intercor-
neocyte cohesion directly above the granular layer, which
accelerates desquamation and SC thinning. A thinner SC can
confer some disadvantages such as increasing susceptibility
to irritants and allergens and reducing the skin’s protection
from UV exposure.5 Although one study indicated that gly-
colic acid delivered a photoprotective effect,22 subsequent
studies have suggested that increased photosensitivity is
associated with the application of AHAs.23,24 The FDA now
requires that AHA products include a label warning that sun
protection should accompany their use.
known as MLE technology and was developed in Seoul, South
Korea. In addition to strengthening the skin barrier, MLE
technology has also been shown to prevent steroid-induced
thinning of the skin.7 Thus, this technology is very useful for
long-term treatment of patients on steroids such as those with
eczema and psoriasis. Other options to strengthen the skin
barrier focus on increasing the skin’s own production of
ceramide 1. Use of topical formulations containing linoleic
acid such as safflower oil has been shown to increase the
formation of ceramide 1.8
Fatty acids and cholesterol
Fatty acids are found in moisturizers and naturally occurring
oils, such as stearic, linoleic, and palmitic acids. Cholesterol
is made endogenously and naturally occurs in animal fats
including cheese, egg yolks, beef, poultry, and fish. Flaxseeds
and peanuts contain cholesterol-like components called phy-
tosterols. Patients with hypercholesterolemia should minimize
oral intake of cholesterol; therefore, topically applied choles-
terol is a better choice because it does not raise serum choles-
terol levels.
Use of a barrier repair moisturizer containing ceramides,
fatty acids, and cholesterol in a 1 : 1 : 1 ratio is crucial for
patients with dry skin. Using these preparations in the two
days prior to surgery may decrease the incidence of contact
and irritant dermatitis to antimicrobial cleansers and adhesive
tape used during the surgical procedure.
Occlusives
Occlusive ingredients coat the skin to inhibit TEWL and
provide an emollient effect. Sebum, vitamin E (abundant in
sebum), and squalene are naturally occurring occlusive ingre-
dients. Two of the best synthetic occlusive ingredients are
petrolatum and mineral oil; however, these ingredients have
a greasy feeling that may be cosmetically unacceptable to
patients.9 These ingredients have been largely replaced by
botanically-derived oils that contain fatty acids and active
ingredients that confer antioxidant activity or play a role in
inflammation and other cellular processes. In 2004, a random-
ized double-blind controlled trial of 34 patients with mild-
to-moderate xerosis demonstrated that mineral oil and
extra-virgin coconut oil were equally efficacious and safe as
moisturizers, with surface lipid levels and skin hydration
significantly improved in both groups.10
Occlusive agents are effective only while present on the
skin; TEWL returns to the previous level once occlusives are
removed. For this reason, occlusives are typically combined
with humectant ingredients in moisturizers. Other commonly
used occlusive ingredients include lanolin, paraffin, squalene,
dimethicone, propylene glycol, beeswax, soybean oil, grape-
seed oil,11 argan oil, sunflower seed, evening primrose, olive
oil, and jojoba oils.12–16
Oils
The rise in popularity of natural and organic ingredients has
led to the frequent use or inclusion of oils in skincare regimens.
Oil is a nonpolar substance that is liquid (viscous) at room
temperature and is derived from plants, animals, or petro-
chemical sources. An oil can be volatile (easily turns into a
vapor) or nonvolatile. An oil is referred to as an “essential oil”
when it contains the volatile aromatic compounds or “essence”
27
Skincare by skin type
Type 1 sensitive skin: acne
Acne vulgaris is characterized by open or closed comedones
as well as papules and pustules. It is a multifactorial process
involving the pilosebaceous unit that usually occurs in an
eight-week cycle. Acne can be caused by exposure to cosmet-
ics33 or hair products, especially when they contain isopropyl
myristate. Acne medications tend to dry out the skin and
damage the skin barrier. For this reason, dry skin types have
the most difficult time tolerating acne treatments. Proper acne
control depends upon consistent use of acne medications, and
patients become discouraged because it usually takes at least
eight weeks to see improvement. Teenagers, the demographic
group most likely to suffer from acne, are notoriously non-
compliant with acne medications, making successful treat-
ment that much more difficult. Acne can also occur after laser
resurfacing procedures, which is likely due to disruption of
the pilosebaceous unit. In all cases, individually-tailored treat-
ment is required to achieve a satisfactory resolution and cos-
metic appearance for the patient (Box 4.4).
The etiology of acne varies from person to person; however,
three principal factors have been identified: (1) sebaceous
gland hyperactivity; (2) changes in follicular keratinization;
and (3) the influence of Propionibacterium acnes bacteria. Oral
isotretinoin has been proven to decrease sebum production.
Retinoids and hydroxy acids (such as salicylic acid) normalize
follicular keratinization, while blue light, antibiotics, silver,
and benzoyl peroxide (BP) reduce the acne-causing bacteria
P. acnes.
Bacterial resistance is a significant problem in the US and
the world over, and P. acnes is often resistant to erythromycin
and clindamycin. Benzoyl peroxide and silver may help
prevent antibiotic resistance to erythromycin and clindamy-
cin. Benzoyl peroxide is one of the few acne medications
available both over the counter and by prescription in the US
for the treatment of acne.34 Silver, on the other hand, has not
been approved by the FDA for use in acne but is commonly
used in wound healing dressings to speed healing and
decrease wound infection. The use of BP is limited in dry skin
with an impaired barrier because of the risk of irritation. It
reacts with other ingredients such as tretinoin and ascorbic
acid, thereby reducing efficacy of these ingredients. Most
importantly, BP is a source of free radicals to the skin, which
may contribute to glycation, mitochondrial damage, and skin
aging.35,36 Combined use with antioxidants is suggested to
minimize skin damage. Silver has been used for centuries for
Lactic acid
Lactic acid, first used in 1943 for the treatment of dry skin,25
is a popular AHA found in several at-home products as well
as prescription moisturizers for the treatment of severe
ichthyosis or psoriasis. It is a unique hydroxy acid because it
is a component of the natural moisturizing factor (NMF),
which plays an important role in skin hydration. Studies of
the activity of buffered 12% ammonium lactate lotion have
documented the moisturizing ability of lactic acid.26 In addi-
tion, lactic acid imparts antiaging benefits, as implied by a
double-blind vehicle-controlled study finding that an 8%
L-lactic acid formula performed better than vehicle in treating
photoaged skin, with statistically significant improvements in
skin roughness, mottled hyperpigmentation, and sallowness.27
Lactic acid may have a sour milk smell that patients do not
like; therefore, it is not very popular in facial products.
Glycolic acid
Glycolic acid is the most commonly used AHA. In 1996, Ditre
et al. demonstrated that applying AHAs led to a 25% increase
in skin thickness, increased acid mucopolysaccharides in
the dermis, improved the quality of the elastic fibers, and
increased collagen density, as determined histologically.28
Such data were buttressed by Moon et al., who reported that
mice treated with glycolic acid exhibited a significant reduc-
tion in wrinkle score and an increase in collagen production,
which typically decreases with age.29 Increased collagen pro-
duction after treatment with AHAs has been demonstrated in
vivo and in vitro using fibroblast cultures. Glycolic acid treat-
ments increased collagen synthesis as well as fibroblast pro-
liferation in vitro in one study.30 When higher percentages are
used as a chemical peel, glycolic acid, unlike other peels, must
be neutralized after use to prevent burning of the skin. This
makes glycolic acid more difficult to use on large areas of the
body.
Sensitive skin
Sensitive skin has been historically difficult to fully character-
ize. Yokota et al. as well as Pons-Guiraud offered their input
on this convoluted issue by developing classification systems
within the past decade; however, few agree on a typing system
for sensitive skin.31,32 Within the Baumann Skin Typing frame-
work, sensitive skin is classified into four types based on
clinical manifestations: type 1 (developing open and closed
comedones and pimples; known as the acne type or S1 type),
type 2 (facial flushing due to heat, spicy food, emotion, or
vasodilation of any cause; known as the flushing rosacea type
or the S2 type), type 3 (burning, itching, or stinging of any
cause; the S3 type), and type 4 (susceptible to developing
contact dermatitis and irritant dermatitis and often associated
with impaired skin barrier; the S4 type). Although these skin
issues have very different etiologies, they have one thing in
common – inflammation. Patients can suffer from combina-
tions of sensitive skin subtypes at the same time. For example,
an individual may burn and sting and have facial flushing
and redness. This person would be designated as an S2S3
sensitive skin type or a “stinging rosacea skin type”. Acne and
rosacea are the most common sensitive skin subtypes; there-
fore, the remainder of the sensitive skin discussion will focus
on the treatment of acne and rosacea.
BOX 4.4 Acne treatment regimens
• Regimens should contain a salicylic acid cleanser or toner, a
topical antimicrobial, and a retinoid at night.
• It is important to recommend a non-acnegenic sunscreen.
• If the patient needs a moisturizer, choose a non-acnegenic one.
• An antimicrobial should be used twice a day.
• Silver textile pillowcases can be added to decrease P. acnes
levels.
• Before laser resurfacing, retinoids can help prepare the skin for
the procedure and speed healing.
• After laser resurfacing, silver is the best topical option because
the others can slow healing and irritate skin.
28
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
The two main drug therapy targets are vasodilation and
inflammation. There are two new topical alpha agonist block-
ing drugs entering the market that cause vasoconstriction and
have shown great success for rosacea treatment, but these are
prescription medications: brimonidine and oxymetazoline.
Also, a drug known to kill Demodex mites that are thought
to play a role in rosacea is ivermectin. This discussion,
however, will be limited to anti-inflammatory ingredients
found in cosmeceuticals.
Just as there is variability in the type of sensitive skin that
patients may exhibit, there is a wide range of anti-inflammatory
treatments available to treat the symptom common to all
types of sensitive skin. It is important to remember that any
anti-inflammatory ingredient that causes rebound vasodila-
tion should not be used in rosacea patients. For example,
steroids such as hydrocortisone are found in many over-the-
counter skincare “anti-redness” products. They work by
causing a temporary vasoconstriction that is followed by
vasodilation worse than seen at baseline. In other words,
steroids make rosacea worse in the long run and should be
avoided. Vascular laser treatments such as the 595-nm laser
are wonderful options for long-term rosacea treatment and
should be combined with anti-inflammatory ingredients and/
or rosacea medications (Box 4.7).
Type 3 sensitive skin: stingers
Individuals with type 3 sensitive skin suffer from stinging and
burning of the skin. At this time, the etiology of the burning
and stinging is unknown. The stinging sensation may be
accompanied by redness, but often has no visible symptoms.
Each individual seems to sting in reaction to a different sub-
stance. For example, lactic acid has been used as a test to
identify stingers; however, all individuals who suffer from
stinging sensations do not sting upon contact with lactic acid.
The most common ingredients that cause stinging in skincare
products are acids such as ascorbic (vitamin C), benzoic,
glycolic, lactic, and salicylic acids. Sunscreen ingredients such
as avobenzone may cause stinging in susceptible individuals.
When patients are beginning retinoids, they often experience
stinging to everything, including water, in the first weeks of
treatment until their skin acclimates to the retinoid. It is
its antimicrobial and wound healing properties. Silver,
although not approved for this use, is a good adjuvant for
acne therapy because of the lack of irritation and the preserva-
tion of the skin barrier, as contrasted to other acne medications
such as retinoids and benzoyl peroxide.37
Many ingredients in skincare and haircare products can
exacerbate acne (Box 4.5), including sunscreen ingredients.38
Isopropyl myristate is included in some forms of generic
tretinoin and is a well-recognized cause of acne. Friction,
humidity, lack of sleep, increased consumption of sugar and
dairy products, as well as stress have been associated with
acne. Patients should be advised that prevention of acne is the
key to improvement and a consistent skincare routine is
necessary. Using antibacterial cleansers and a silver textile
pillowcase before and after laser resurfacing may prevent
breakouts that occur after the resurfacing procedure. Benzoyl
peroxide, retinoids, and salicylic acid are too irritating to use
on post-laser patients.
Type 2 sensitive skin: rosacea
Rosacea is a chronic and progressive disorder presenting as
central facial erythema, telangiectasia, flushing, and facial
redness. Patients often have papules and pustules, which
make this disorder difficult to distinguish from acne. Aggra-
vating factors vary from person to person and include sun-
light, heat, alcohol consumption, exercise, strong emotions,
and spicy food (Box 4.6).
The precise causal pathways of rosacea remain unknown
and there is much debate in the literature but no consensus.
BOX 4.5 Topical ingredients in skincare and haircare products that
may cause acne12–14
• Avocado oil
• Butyl stearate
• Ceteareth 20
• Cocoa butter
• Coconut oil
• Decyl oleate
• Evening primrose oil
• Isocetyl stearate
• Isopropyl isostearate
• Isopropyl isothermal
• Isopropyl myristate
• Isopropyl palmitate
• Isostearyl neopentanoate
• Lanolin
• Laureth 4
• Lauric acid
• Myristyl myristate
• Octyl palmitate
• Octyl stearate
• Oleth-3
• PPG 2 myristyl propionate
• Red dyes
• Soybean oil
• Stearic acid
BOX 4.6 Rosacea triggers
• Alcohol
• Change of seasons
• Cheese
• Chocolate
• Emotion
• Exercise
• Extreme changes in temperature
• Friction such as facial scrubs and brushes
• Heat such as saunas and warm environments
• Hormonal changes
• Hot (temperature) food and drinks
• Spicy food and drinks
• Stress
• Topical steroids
29
Skincare by skin type
fibrinopeptide enzymes, and free radicals.39 The arachidonic
acid (AA) cascade plays a major role in inflammation because
AA is broken down into inflammation-causing substances
such as prostaglandins and leukotrienes. Two important
pathways involved in the breakdown of AA are the:
1. Cyclooxygenase pathway: results in the production of
prostaglandins.
2. Lipoxygenase pathway: results in the production of
leukotrienes.
Salicylates (aspirin and salicylic acid) work by inhibiting
the cyclooxygenase pathway. Prostaglandin antagonist ingre-
dients include feverfew, licorice extract, and oatmeal, while
turmeric and chamomile are leukotriene antagonists. Horse
chestnut is a vasoconstrictor, as are corticosteroids such as
hydrocortisone. Anti-inflammatory polyphenols are found in
many antioxidants and decrease inflammation by neutralizing
free radicals.
Anti-inflammatory topical treatments
for sensitive skin
Corticosteroids
Corticosteroids suppress the release of arachidonic acid and
its subsequent conversion to eicosanoids.40 They should not
be used in acne and rosacea patients because of the risk of
perioral dermatitis, steroid acne, and rebound vasodilation.
However, they are the treatment of choice when a patient
suffers from the allergic type 4 sensitive skin. Although topical
corticosteroids are generally well tolerated for short-term
treatment of inflammatory skin diseases, long-term use can
engender adverse cutaneous effects such as skin atrophy,
hirsutism, folliculitis, acne, striae, telangiectasia, purpura, and
unwelcome pigmentary changes.41,42 More serious systemic
side effects of chronic topical corticosteroid use have also been
reported, including hypothalamic–pituitary axis suppression,
hyperglycemia, osteonecrosis, glaucoma, and cataracts.43–47
Salicylic acid
Salicylates have been shown in experimental and clinical set-
tings to provide anti-inflammatory activity by affecting the
arachidonic acid cascade.48 Salicylic acid is a beta hydroxy
acid and is discussed in the hydroxy acid section of this
chapter. Salicylic acid shrinks pores temporarily, lowers the
frequency and severity of acne eruptions by diminishing
acne-associated inflammation, and exfoliates keratin debris
from the pores. It is lipophilic so it is able to penetrate the
sebum in the pores much better than other comedolytic
ingredients can. It has therefore become a popular ingredient
in over-the-counter acne products. Salicylic acid is also used
in the treatment of rosacea and other superficial inflammatory
conditions; however, stinging acne types and dry skin types
may not be able to tolerate its use.
Sulfur/sulfacetamide
The medicinal use of sulfur dates back to the time of
Hippocrates (circa 500 BCE),49 and sulfur continues to be
used primarily to treat acne, seborrheic dermatitis, rosacea,
scabies, and tinea versicolor.50 Elemental sulfur and its various
forms (e.g., sulfides, sulfites, and mercaptans) possess antimi-
crobial and antifungal properties in addition to acting as
unknown what nerve receptors play a role in the stinging
sensation. A longer discussion of this subtype of sensitive skin
can be found in Cosmetic Dermatology: Principles and Practice,
2nd edn, Chapter 17 (McGraw-Hill, 2009). Treatment of this
subtype of sensitive skin involves avoidance of the ingredients
that cause stinging.
Type 4 sensitive skin: allergic type
The allergic type of sensitive skin is one of the most difficult
to treat because one must identify the culprit allergen. The
standard of care is patch testing with allergens on the back;
however, the results are often inconclusive. The author has
found that having the patient keep a diary of where they were
and what products they used on their skin is the best way to
identify the allergen if patch testing is not an option. For
example, if they get a rash when they straighten their hair
and use nail polish and mascara, then they are likely allergic
to formaldehyde. To further confuse the picture, allergens
such as formaldehyde can be known by many different names.
Some ingredients are only allergens when exposed to sun,
which is known as a “photoallergy”. Once the culprit allergen
has been identified, the patient should avoid all ingredients
in that allergen family. For example, a patient allergic to
marigold (also known as calendula) and ragweed would also
be allergic to arnica, chamomile, echinacea, and other plants
in the daisy family. It is best to consult a contact dermatitis
expert when you have a patient with an allergy that you
cannot identify. Try and choose products with few ingredients
and understand that organic products are often the cause of
a skin allergy even though many patients with allergies turn
to organic products because they do not realize how allergenic
botanical ingredients can be. Corticosteroids can be used short
term to treat contact and irritant dermatitis, but avoidance of
the allergen and irritant is crucial. If the patient also has dry
skin, then the skin barrier is likely impaired, allowing aller-
gens and irritants to more easily enter the skin. Addition of
barrier repair moisturizers and cleansers may help this skin
type increase resistance to allergens.
Inflammation
The process of inflammation is orchestrated by a large
array of inflammatory mediators including histamines,
cytokines, eicosanoids (e.g., prostaglandins, thromboxanes,
and leukotrienes), complement cascade components, kinins,
BOX 4.7 Instructions for rosacea patients
• Rosacea treatment should combine in-office 595-nm vascular
laser treatments or intense pulsed light with an at-home regimen
consisting of anti-inflammatory and soothing ingredients.
• Topical prescription medications include topical antibiotics such
as metronidazole, anti-inflammatories such as azelaic acid,
vasoconstrictors such as brimonidine and oxymetazoline, and
an antiparasitic drug like ivermectin.
• Oral prescription medications include doxycycline and a
modified form of doxycycline under the brand name Oracea.
• Argan oil, green tea, licorice extract, resveratrol, niacinamide,
feverfew, and caffeine are useful topical ingredients.
• Avoid triggers including facial brushes, scrubs, and heat
exposure.
30
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
burns, post-laser resurfaced skin, and wounds. Argan oil has
a distinct odor that is more pronounced with time (over 3–4
months); therefore, it should be used as fresh as possible.
Licorice extract
Licorice (Liquiritae officinalis) is best known in its confectionery
form of black or red candy. However, it is a botanical source
of systemic or topical medications that have been used in
herbal medicine for approximately 4,000 years.59 Two species
of licorice, Glycyrrhiza glabra and G. inflata, have exhibited
the most therapeutic actions, including anti-inflammatory
effects.16,60 The biologically active metabolite glycyrrhetic acid
reportedly exhibits anti-inflammatory activity in subacute
and chronic dermatoses, and therefore has been used to treat
eczema, pruritus, contact dermatitis, seborrheic dermatitis,
and psoriasis.61 There is evidence that glycyrrhetic acid can
impart a cortisone-like effect, thus suppressing proinflamma-
tory prostaglandins and leukotrienes.62
Licochalcone, the primary active ingredient of Chinese lico-
rice root, G. inflata, has exhibited anti-inflammatory activity
against arachidonic acid-induced mouse ear edema.63,64 In
a study evaluating the effects of five different chalcones,
researchers found that four of the five, including licochalcone
A, hindered the production of proinflammatory cytokines
from monocytes and T cells. The authors concluded that
licochalcone A and some of its synthetic analogs may have
immunomodulatory effects, suggesting their suitability to
treat infectious and other inflammatory diseases.65
Grape seed extract
Grape seed extract is also known as Vitis vinifera, pinebark,
Pinus maritima, and pycnogenol. It is a rich source of the
strong antioxidant oligomeric proanthocyanidins (OPCs),
usually abbreviated as proanthocyanidins. Oral supplementa-
tion has been shown to decrease erythema after ultraviolet
(UV) light exposure and to inhibit nuclear factor-κB-dependent
gene expression, a marker of the UV-induced proinflamma-
tory response.66 This ingredient is used orally and topically to
decrease inflammation.
Niacinamide
Niacinamide, also known as nicotinamide or vitamin B3, is
an important part of the coenzymes nicotinamide adenine
dinucleotide (NAD+) and nicotinamide adenine dinucleotide
phosphate (NADP+). Niacinamide has many beneficial effects
on the skin because it is involved in over 200 enzymatic reac-
tions. For the purposes of this section, niacinamide regulates
poly-ADP-ribose-polymerase 1, an enzyme with an important
role in the expression of inflammatory cytokines. Niacinamide
is discussed further in the pigmentation segment of this
chapter.
Selenium
Selenium, an essential trace element in the human body, is
found in meat, fish, Brazil nuts, shellfish, dairy products,
cereals, and cereal products. It is the essential antioxidant
required to form glutathione peroxidase, one of the most
important natural antioxidant defenses. Glutathione peroxi-
dase protects cell membranes from oxidative deterioration, as
does vitamin E. Studies have shown that vitamin E and
anti-inflammatory agents.51 Sulfur is often combined with
sodium sulfacetamide, a sulfonamide agent that exhibits
antibacterial properties, specifically acting as a competitive
antagonist to para-aminobenzoic acid, an essential component
for bacterial growth.52 Sodium sulfacetamide has also been
shown to be active against P. acnes.53 The keratolytic and anti-
inflammatory effects of sulfur and the antibacterial effect of
sulfacetamide in combination yield an effective topical formu-
lation for the treatment of acne vulgaris, rosacea, and sebor-
rheic dermatitis.54 Many sulfur-containing products had a
rotten egg-type smell until recently after novel better-smelling
sulfur soaps were formulated.
Natural ingredients
Botanically-derived products have gained widespread usage
and interest.55 The following discussion focuses on some of
the botanicals known to confer anti-inflammatory activity. As
with any botanical ingredient, these ingredients may cause
contact dermatitis in type 4 sensitive skin.
Allantoin
Allantoin is a leaf extract of the comfrey plant. It is also called
5-ureidohydantoin or glyoxyldiureide. Allantoin is referred to
in a monograph by the FDA as a skin protectant and is found
in many cosmeceutical formulations including products for
sensitive skin and dandruff. Although it is a frequent compo-
nent of skincare products for sensitive skin, there is sparse
published data on its effects on skin inflammation.
Aloe vera
Aloe vera is one of the most widely used botanical products
in the world and is reputed to possess potent anti-inflammatory
properties. The most likely active anti-inflammatory constitu-
ents include salicylates (delivering “aspirin-like effects”);
magnesium lactate, which is thought to suppress histamine
production; bradykinin and thromboxane inhibitors, which
provide pain reduction; and polysaccharides, particularly
acemannan, which is believed to impart immunomodulatory
activity.56,57 Aloe culled straight from the plant is often used
to treat burns. Health food stores sell aloe juice that patients
drink for “health reasons” but no studies have been conducted
to evaluate efficacy of oral aloe on inflammation.
Argan oil
Argan oil functions as a strong anti-inflammatory ingredient
because of its high levels of linoleic acid, which has been
shown to exert inhibitory effects on the arachidonic acid
cascade thus preventing the production of inflammatory
prostaglandins.58 The presence of linoleic acid helps the skin
produce ceramide-1, which is important for barrier function.
Argan oil also contains antioxidants such as γ-tocopherol,
which is considered the most efficient among the tocopherols
at scavenging free radicals.58 Argan oil is harvested from the
fruit of Argania spinosa, which is a slow-growing tree native
to the arid climate of southwestern Morocco. The pure argan
oil of Moroccan origin has not been associated with acne, but
it is important to realize that there are many impure argan oils
on the market that may contain other types of oil that can
cause acne. For these reasons, high quality pure argan oil
products that originate in Morocco are preferred for patients
with sensitive skin types. Argan oil may also be used on
31
Skincare by skin type
used to treat uneven skin pigmentation include sunscreen,
hydroxy acids, tyrosinase inhibitors, PAR-2 blockers, lignin
peroxidase, and retinoids. It is important to explain to patients
that all skin-lightening treatments will take 12–16 weeks for
results and that sun exposure will immediately cause recur-
rence of the condition.
Tyrosinase inhibitors
Considered the rate-limiting enzyme for the biosynthesis of
melanin in epidermal melanocytes, tyrosinase is the enzyme
that controls the synthesis of melanin. Most products intended
to reduce melanin formation belong to the tyrosinase inhibitor
category. Tyrosinase requires copper to function. Many anti-
oxidants chelate copper, which renders these compounds
with the ability to inhibit tyrosinase. For this reason, some
antioxidants are considered tyrosinase inhibitors.
Hydroquinone
Hydroquinone (HQ) is the most commonly used tyrosinase
inhibitor and is often the primary treatment option for postin-
flammatory hyperpigmentation and melasma.69 The use of
HQ results in the reversible inhibition of cellular metabolism
by affecting both DNA and RNA production and reduces
tyrosinase activity by 90%.70 Although effective alone, HQ is
often combined with other agents such as tretinoin, glycolic
acid, kojic acid, and azelaic acid.71
In the US, HQ is available over the counter in 2% formula-
tions and by prescription in 4% formulations. HQ is a deriva-
tive of benzene, which has prompted concerns about its safety.
In 2001, European countries banned HQ for general cosmetic
purposes, and its use is highly regulated in Asia. However,
HQ has been used for more than 50 years under a doctor’s
supervision for medical conditions worldwide and there has
not been a single documented case of either a cutaneous or
internal malignancy associated with this drug.72 The most
serious adverse health effect observed in workers exposed to
HQ is pigmentation of the eye and, in a few cases, permanent
corneal damage.73 The FDA is primarily concerned about the
development of exogenous ochronosis, a disorder that para-
doxically results in increased skin darkening,74 but only 30
cases of ochronosis have been attributed to the use of HQ in
North America.72 More common side effects of HQ include
contact dermatitis and nail discoloration. Although most
dermatologists agree that HQ is safe and is the most effective
option, the safety debate about HQ within the FDA has
spurred companies to research newer, less controversial skin
lighteners.
selenium act synergistically to impart such protection.67
Selenium also displays anti-inflammatory activity in prevent-
ing inflammatory cytokine production, which can occur in
response to UV exposure, for example, leading to a compro-
mised immune response and photodamage.68 Selenium in the
form of selenium sulfide is often found in dandruff shampoos
and is used as a body wash in the treatment of several der-
matologic disorders such as tinea versicolor.
Summary of sensitive skin
In order to properly treat sensitive skin, it is crucial to deter-
mine which subtype of sensitive skin the patient has. Patients
may suffer from one or more types of sensitivity. Sensitive
skin types often develop inflammation from retinoids and
depigmenting ingredients. It is impossible to diagnose sensi-
tive skin without a series of historical questions because it is
the pattern of skin behavior that accurately determines if the
patient has sensitive skin. Over 40% of Americans believe they
suffer from sensitive skin; however, they rarely know which
subtype of sensitive skin they have. Many acne-prone patients
do not identify themselves as having sensitive skin and may
use formulations, including exfoliation products, that are too
harsh for them. Identifying sensitive skin prior to recom-
mending skincare products to your patients will improve
outcomes. Failure to identify the sensitive skin type can lead
to breakouts, rashes, redness, and stinging that will erode the
patient’s trust and result in harm to the patient/physician
relationship.
Pigmented skin type: uneven skin tone
In the Baumann Skin Tying System, the “pigmented skin
type” is skin with an uneven skin tone, or uneven skin pig-
mentation. Patients with even skin tone are referred to as
“non-pigmented”. In other words, the Baumann Skin Type
classification is based on evenness of skin tone and not on the
color of the skin or ethnicity. The goal in treating pigmented
skin types is to even the skin tone so that the skin is a uniform
color. Melasma is a common disorder seen in pigmented skin
types. It is a frustrating disorder because there is no cure and
it tends to recur. Patient education is crucial when treating
patients with a history of melasma. Care should be taken to
avoid resurfacing procedures and strong chemical peels in
patients with a history of melasma because the chance of
recurrence is very high, especially in patients who are non-
compliant with sun-protective measures. These resurfacing
treatments are often used to treat melasma but the physician
must weigh the risks and benefits. Use of depigmenting
skincare products is suggested prior to resurfacing procedures
to decrease the incidence of melasma. Box 4.8 lists activities
that should be avoided by patients with melasma and a ten-
dency to develop postinflammatory hyperpigmentation.
Skin color is due to melanin pigment, which is produced
in the melanocyte, packaged in melanosomes, and moved
through the protease-activated receptor (PAR)-2 mediated
receptor into the keratinocyte. When excess melanin is pro-
duced, disorders of pigmentation or dyschromia can result
and skin develops an uneven skin tone. Melanin production
is stimulated by several factors including UV light, estrogen,
melanocyte-stimulating hormones (MSH), stress, inflamma-
tion, injury, infrared light, and heat. The categories of products
BOX 4.8 Melasma
Patients with melasma should avoid:
• Sun exposure
• Heat
• Melatonin supplements
• Estrogen supplementation
• Resurfacing procedures
• Strong chemical peels
• Skin inflammation
32
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
blockers do not break down melanin that is already in kerati-
nocytes; therefore, there is a delay before the effects are noted
in 12–16 weeks. Using PAR-2 inhibitors with exfoliating
products such as retinoids can speed up the process.
Niacinamide
Niacinamide, the biologically active amide of vitamin B3, has
been shown to inhibit the transfer of melanosomes to epider-
mal keratinocytes. Clinical trials have revealed that niacina-
mide (also known as nicotinamide) inhibited melanosome
transfer by up to 68% in an in vitro model and can improve
unwanted facial pigmentation.93 The use of a 5% niacinamide
formulation twice daily for 8 weeks has resulted in significant
amelioration in hyperpigmentation, as has the use of 3.5%
niacinamide in combination with retinyl palmitate.94 Of note,
the pigmentation effects of niacinamide have been demon-
strated to be reversible.95 Niacinamide is now included in
many products because of its depigmenting and anti-
inflammatory capabilities.
Soy
Soy contains many components that make it useful as a
cosmeceutical ingredient, including linoleic acid, phospho-
lipids, polysaccharides, B vitamins, tocopherol, phytosterols,
isoflavones (such as genistein), and saponins.96 The fermen-
tation and processing of soy affect the availability of these
components, so it is important to know as much as possible
about the soy in a skincare product. For example, soy with
a lot of estrogenic components (isoflavones) will worsen
skin pigmentation because estrogen upregulates melanin
production. Soy that consists of lower levels of isoflavones
(estrogenic components) but contains soybean trypsin inhibi-
tor (STI) and the Bowmann–Birk inhibitor (BBI) proteins will
decrease skin pigmentation.
Soy is usually divided into two categories: nonfermented
and fermented. Nonfermented soy foods include whole dry
soybeans, soy nuts, fresh green soybeans (edamame), soymilk,
and tofu. Fermented soy products include miso, soy sauce,
natto, and fermented tofu products.97 The fermentation
process breaks down many of the soy components including
the STI and BBI proteins and saponins, but some studies
suggest that the isoflavones are spared and one found that
lactic fermentation increased aglycone, an important bioactive
form of isoflavone.98
Research has shown that soymilk and the soymilk-derived
proteins (specifically, STI and BBI) inhibit the activation of
PAR-2,99 and their use can induce skin depigmentation.100
These small soy proteins are destroyed during fermentation
and other types of processing. For this reason, most products
that contain “soy” on the label do not have the ability to
decrease skin pigmentation as described in the following
studies.
Topical soybean extract has been shown to decrease skin
pigmentation in human trials.101 In a parallel, randomized,
double-blind, vehicle-controlled trial, the efficacy of a propri-
etary soy moisturizer containing STI and BBI on pigmentation,
skin tone, and additional photoaging characteristics was
assessed in 65 women who had moderately severe mottled
hyperpigmentation, lentigines, blotchiness, tactile roughness,
and dullness. After twice-daily application of both the mois-
turizer and the vehicle over 12 weeks, the investigators
Arbutin
Present in the leaves of pear trees and certain herbs (e.g.,
wheat and bearberry), arbutin (C12H16O7) is a naturally occur-
ring β-D-glucopyranoside that is composed of a molecule of
HQ bound to glucose. Traditionally used in Japan, arbutin’s
depigmenting mechanism involves a reversible suppression
of melanosomal tyrosinase activity rather than hindering the
expression and synthesis of tyrosinase.75 The effectiveness
of arbutin as a depigmenting agent is uncertain, however.
Deoxyarbutin, a synthetic arbutin derivative, has exhibited
promising in vitro and in vivo results with a greater inhibition
of tyrosinase than its plant-derived precursor.76
Flavonoids
Many of the more than 5,000 flavonoid compounds manifest
depigmenting activity. Several flavonoids exhibit the capacity
to inhibit tyrosinase directly and act on the distal part of the
melanogenesis oxidative pathway. Resveratrol, well known
in recent years as an important component in red wine,
also induces depigmentation. Oxyresveratrol and gnetol are
similar to resveratrol but are more efficient tyrosinase inhibi-
tors.77,78 Ellagic acid, isolated from strawberries, green tea,
eucalyptus, and geraniums, is a tyrosinase inhibitor that
affects melanogenesis without eliciting cytotoxic reaction.79
Derived from gentian roots, methyl gentisate and gentisic acid
have been shown to inhibit tyrosinase.80
Kojic acid
Kojic acid (5-hydroxy-2-hydroxymethyl-γ-pyrone or C6H6O4)
is a fungal metabolite of various species of Aspergillus, Aceto-
bacter, and Penicillium.81 It suppresses tyrosinase activity,
chiefly by chelating copper, which tyrosinase needs to
funtion.82 Kojic acid has been used extensively in cosmetic
agents, particularly in Japan and countries that do not allow
HQ.83 Its popularity is due in part to its efficacy in inhibiting
tyrosinase but can also be attributed to its preservative and
antibiotic activities that extend product shelf-life.84 In two
separate studies, kojic acid combined with glycolic acid was
more effective than 10% glycolic acid and 4% HQ for the
treatment of hyperpigmentation.85,86 The standard concentra-
tion of kojic acid is 1% because higher doses have been associ-
ated with contact allergy.87,88 However, sensitization to 1%
creams has been reported.86 Derivatives of kojic acid are also
available and have been reported to exhibit enhanced effi-
ciency through increased penetration into the skin.89
Licorice extract
Glabridin (Glycyrrhiza glabra), the primary active ingredient in
licorice extract, inhibits tyrosinase activity in cell cultures
without altering DNA synthesis. Topical applications of 0.5%
glabridin have been shown to inhibit UVB-induced pigmenta-
tion and erythema in guinea pig skin.90 Clinically, G. glabra has
demonstrated efficacy in treating melasma,91 and glabridin
has been shown in one study to exert a superior depigmenting
effect as compared to HQ.92
Melanosome transfer inhibitors/PAR-2 blockers
Protease-activated receptor (PAR)-2 is a G-protein-coupled
receptor that allows the movement of the melanin-containing
melanosome from the melanocyte to the keratinocyte. PAR-2
33
Skin aging
can contribute to the breakdown of these structural compo-
nents of the skin. Skin inflammation itself can result from the
formation of free radicals, which can act directly on growth
factor and cytokine receptors in keratinocytes and dermal
cells.
While the exact mechanisms of growth factors and cyto-
kines in skin aging have not been fully understood, it has been
established that they function together in a complex interplay
involving several types of growth factors and cytokines.111
Better understood, however, is the influence of free radicals
on the aging process. The activation of the mitogen-activated
protein kinase pathways induced by free radicals has been
shown to result in collagenase synthesis, paving the way for
collagen degradation.112 Using antioxidants to inhibit this
pathway is believed to prevent photoaging by thwarting col-
lagenase production. In a study on human skin, Kang et al.
demonstrated that pretreatment with the antioxidants genis-
tein and N-acetyl cysteine hindered the UV induction of the
cJun-driven enzyme collagenase.112 Vitamins C and E, ferulic
acid, coenzyme Q10, green tea, pycnogenol, silymarin, argan
oil, resveratrol, and idebenone are among the various antioxi-
dants featured in multiple skincare products.
Wrinkle-prone skin type
Smoking and exposure to the sun as well as tanning beds are
known to accelerate cutaneous aging. Genetics also play a
role although it is unknown at this time which genes play
a role in skin aging. The Baumann Skin Typing System
uses a questionnaire to determine if a patient’s habits make
them more susceptible to skin aging and, if so, it identifies
them as “wrinkle-prone”. Patients who are labeled a “W”
(wrinkle-prone) skin type are placed on aging prevention
methodologies.
The prevention (and treatment) of cutaneous aging should
begin with a consistent skin regimen that includes daily SPF,
antioxidants, and retinoids. The use of a daily sunscreen with
an SPF of at least 15 is important even in cold climates because
it is well known that cumulative UV exposure leads to aged
skin. Matching the sunscreen to Baumann Skin Type will help
increase compliance. For example, oily types often do not
use sunscreens because they feel too heavy. Eliminating the
morning moisturizer and using a light SPF instead is often the
solution for these oily types. Retinoids are the second most
important part of an effective antiaging regimen. They have
been found to prevent aging and to improve wrinkles by
promoting collagen production and diminishing the matrix
metalloproteinases (MMPs) involved in collagen and elastin
degradation.113,114 Retinoids can be irritating at the start; there-
fore, patients should be given clear use instructions as found
in Box 4.9. Antioxidants, which combat the oxidative stress
and free radicals generated by environmental insults such as
pollution and UV irradiation, are believed to play an impor-
tant role in prevention of aging. Ascorbic acid is an important
antioxidant for antiaging because it also has the ability to
stimulate cells to increase the synthesis of collagen.
Retinoids
Retinoids are a family of compounds derived from vitamin A
that include beta-carotene, carotenoids, retinol, tretinoin,
tazarotene, and adapalene. For several decades, retinoids
determined by clinical observation, patients’ self-assessments,
colorimetry, and digital photography that the soy moisturizer
conferred significant improvement in all metrics, including
overall appearance, as compared to the vehicle.102 This propri-
etary soy is only available in a few skincare brands and is
listed on the label as “active soy”. Although topical soy, in the
correct form, can decrease skin pigmentation, dietary soy does
not because stomach acids break down the STI and BBI
proteins, preventing them from being absorbed when taken
orally.100
Skin aging
The most common skin complaint seen by plastic surgeons is
skin aging. Identifying those who are wrinkle-prone benefits
the patient by alerting them to the benefits of beginning
antioxidants, retinoids, daily sunscreen, and other antiaging
strategies. Cutaneous aging is a result of the complex interplay
between intrinsic and extrinsic factors. Intrinsic aging is
attributed to individual heredity and the natural effects of the
passage of time and is considered inevitable and beyond
voluntary control. Extrinsic aging occurs as a result of exog-
enous insults, such as exposure to UV radiation, cigarette
smoke, other pollution, as well as poor nutrition, and, by
definition, can be avoided. In fact, 80% of facial aging is
attributed to solar exposure alone.103
At a cellular level, UV exposure leads to skin damage
through numerous mechanisms, including sunburn cell for-
mation, thymine dimer development, collagenase production,
and engendering an inflammatory response. These lead to
photoaging, photocarcinogenesis, and photoimmunosuppres-
sion.104 A 2009 paper by Gilchrest et al. suggests that the
photoaging and melanogenesis provoked by UV exposure are
linked to telomere-based DNA damage signaling that may
represent a cancer avoidance protective response.105 Telomeres,
specialized chromosomal components, shorten with age;
telomeric loss or erosion has thus become an important
measure of cellular aging, a veritable internal aging clock.106
The enzyme telomerase, which stabilizes or lengthens telo-
meres, is expressed in about 90% of all tumors but absent in
many somatic tissues.106 One of the few regenerative tissues
to express telomerase, however, is the epidermis.107 Telomer-
ase is believed to act against excessive telomere loss in human
epidermis throughout the lifelong regeneration process.108
Interestingly, exposure to UV radiation, due to its deleterious
effect on DNA and its acceleration of telomere shortening, can
be characterized as influential in intrinsic as well as extrinsic
aging. Signaling through p53 after telomere disruption is also
typically observed in skin aging and photodamage.109 Cur-
rently, there are no skincare products available that target
telomerase.
At the macroscopic level, the development of rhytides,
caused by alterations in the dermal layer of skin, is the most
prominent manifestation of cutaneous aging. Because few
skincare product ingredients can sufficiently penetrate the
dermis to ameliorate deep wrinkles, the prevention of rhytides
is the focus of dermatologic antiaging skincare.110 Specifically,
dermatologists aim to slow the degradation of or replenish
the three main dermal constituents (collagen, elastin, and
hyaluronic acid), all of which are known to decline with age.
Reducing inflammation is paramount here, as inflammation
34
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
effectively. This means that most of the combination formula-
tions do not contain active retinol or tretinoin, especially
when exposed to light.
Although tretinoin has been approved for many years for
the treatment of photoaging, it also plays a role in the preven-
tion of cutaneous aging. UVB exposure significantly upregu-
lates the production of multiple collagen-degrading enzymes
known as MMPs. In turn, the activation of MMP genes leads
to the synthesis of collagenase, gelatinase, and stromelysin,
which fully degrade skin collagen.122 The application of treti-
noin has been shown to inhibit the induction of all three of
these MMPs.114 In addition to stimulating genes that generate
enzymes that degrade collagen, UV exposure has also been
demonstrated to reduce collagen production. Pretreatment of
the skin with tretinoin has been shown to inhibit this loss of
procollagen synthesis. Retinoids have also been demonstrated
to increase collagen synthesis in photoaged humans.113 Topical
application of tretinoin 0.1% to photodamaged skin partially
restores levels of collagen type I. For these reasons, it is
believed that consistent use of topical retinoids is beneficial in
preventing as well as treating photodamage.123
Side effects
Redness, scaling and stinging are the most common side
effects of topical retinoids. When this occurs, the patient will
experience stinging from many products including bland
moisturizers and water. If a patient on retinoids experiences
irritation, the retinoid is the cause unless proven otherwise.
This irritation is known as retinoid dermatitis. It is related to
the type and dose of the retinoid and typically occurs within
2–4 days of initial treatment.124 Although many people initially
believed otherwise, the irritation engendered by retinoids is
unrelated to their photoaging benefits. This was shown in a
study in which two different strengths of tretinoin (0.1% and
0.025%) were compared. Although equally efficacious in the
treatment of photoaging, the degree of irritation differed
substantially between the two treatment groups, with the
0.1% tretinoin-treated group experiencing nearly a threefold
greater incidence of irritation than the 0.025% tretinoin-treated
group.125 The irritation response appears to be receptor-
mediated, as suggested by findings that the topical application
of tretinoin to the skin of transgenic mice deficient in retinoic
acid receptors led to no detectable epidermal hyperplasia or
desquamation.126 For this reason it is preferable to start on a
low-dose retinol and use a smaller amount less frequently to
avoid dermatitis and increase patient compliance. Patients
newly placed on retinoids should be seen in four weeks so
that they can be encouraged to continue this effective therapy.
Antioxidants
Free radicals cause aging by enabling glycation, causing
damage to DNA and mitochondria, and oxidizing lipids in
cell membranes. Antioxidants help prevent this damage by
neutralizing free radicals. There is no “one best” antioxidant.
In fact, antioxidants work best when used together in many
cases. For example, vitamins E and C are stronger antioxidants
when they work together than when either is used alone. For
this reason it is best to try and use as many different antioxi-
dants as possible. In addition, delivery methods should be
varied to include diet, supplements, drinks, and topical
administration. The most common source of antioxidants in
BOX 4.9 Patient instructions for retinoid use
• Always use retinoids at night because the sun breaks them
down.
• Your skin will acclimate to retinoids with time so use sparingly
and be patient.
• Start with the weakest strength (retinol 0.25%) and slowly
increase the dose with each new tube.
• Apply retinoid on top of moisturizer until you are tolerating it
every night for a month, then apply it before the moisturizer.
• Use only a pea-sized amount every third night for the first 2
weeks.
• If no redness or irritation occurs, increase use to every other
night for 2 weeks.
• If no redness or irritation occurs, increase use to every other
night.
• Stop using retinoids one week prior to waxing.
• Only buy retinol products from a source you trust – there are
many counterfeit products online.
• If redness or irritation to retinoids occurs, stop use for 4 days,
moisturize twice a day, and restart slowly. Redness and irritation
indicate that what you are using is too much, too strong or too
often.
• Long-term use of retinoids has been shown to improve wrinkles,
dark spots, and skin texture as well as protect skin from further
aging. It is worth the effort to use retinoids!
have been used topically and systemically to treat dermato-
logic disorders, particularly acne. Dermatologists became
interested in the antiaging aspects of retinoids more than 30
years ago when female acne patients began reporting that
their skin felt smoother and less wrinkled after treatment with
tretinoin.115 Subsequently, a clinical trial demonstrated that
patients treated with tretinoin experienced improvement in
sunlight-induced epidermal atrophy, dysplasia, keratosis, and
dyspigmentation.116 Numerous clinical trials have since con-
firmed these early observations. These data ultimately led to
the FDA approval of tretinoin (brand name Renova) to treat
photodamage. Currently, the only topical agents approved by
the FDA specifically for this purpose are tretinoin (Renova)
and tazarotene (Avage). Since then, studies have demonstrated
that retinol also has effective antiaging properties.
Mechanism of action
Retinoids are a family of hormones that bind the retinoic acid
receptors.117,118 Retinoids can act directly, by inducing tran-
scription from genes with promoter regions that contain
retinoid response elements, or indirectly, by inhibiting the
transcription of certain genes, thus ultimately affecting cel-
lular differentiation and proliferation.119 First-generation reti-
noids (retinol and tretinoin) are unstable when exposed to UV
and other forms of light, and for this reason should be used
at night. This fact led to the myth that topical retinoids make
the skin sun sensitive; it is actually the retinoid that is sensi-
tive to the sun. Third-generation retinoids – adapalene and
tazarotene – have been structurally altered to be more photo-
stable than the first- and second-generation molecules.120
First-generation retinoids and adapalene are also unstable
when exposed to oxidizing agents such as benzoyl peroxide;121
therefore, it is difficult to formulate the two together
35
Skin aging
been demonstrated to protect significantly against UV-induced
damage to murine skin.132
Coenzyme Q10
Found in all cells and involved in energy production,
coenzyme Q10 (CoQ10), also known as ubiquinone, is a power-
ful antioxidant. CoQ10 also plays a significant role in the
energy-producing adenosine triphosphate pathways in the
mitochondria of each cell in the body. Topical CoQ10 has been
demonstrated to penetrate the viable layers of the epidermis
and lower the level of oxidation as well as inhibit the expres-
sion of collagenase in human fibroblasts following UVA irra-
diation.133 Most of the research on CoQ10 has been with oral
administration rather than topical use. Statin drugs used to
lower cholesterol can cause a reduction in naturally occurring
CoQ10 levels, which leads to muscle aches and fatigue.134 Some
studies have suggested that low CoQ10 levels are associated
with an increased risk of melanoma. For this reason, CoQ10
should be considered in patients with a high amount of
sun exposure, especially if they are on cholesterol-lowering
drugs.135 Oral coenzyme Q10 has a caffeine-type effect; there-
fore, supplements should be taken in the morning.
Grape seed extract
The extract that is prepared from the seeds of grapes (Vitis
vinifera) is rich in polyphenolic proanthocyanidins,136,137 which
are potent free radical scavengers found in various berries
(e.g., strawberry, cranberry, bilberry, and blueberry), green
and black tea, red wine, and red cabbage.138 The topical appli-
cation of grape seed extract has been shown to enhance the
sun protection factor in human volunteers.139 Grape seed
extract is thought to be a significantly more potent scavenger
of free radicals than vitamins C and E.140 The bioflavonoids in
grape seed extract appear to foster the body’s ability to absorb
vitamins, thus providing a symbiotic environment for other
nutrients.
Resveratrol
Highly touted for its presence in red wine, resveratrol (trans-
3,5,4′-trihydroxystilbene) is a polyphenolic phytoalexin com-
pound found in the skin and seeds of grapes, berries, red
wine, and other foods. There are two isoforms: the more stable
trans-resveratrol and cis-resveratrol. The topical application of
resveratrol before and after exposure to UVB has been shown
in SKH-1 hairless mice to reduce UVB-induced tumor inci-
dence and to produce a delay in the onset of skin tumorigenesis
in long-term studies.141 In a 2005 study, topical application
of resveratrol prior to irradiation protected against UVB-
mediated cutaneous damage, as manifested by a significant
reduction in UVB-mediated hydrogen peroxide production
and infiltration of leukocytes; skin edema was also suppressed,
as was lipid peroxidation, a marker of oxidative stress.142
Normal human keratinocytes pretreated in vitro with resvera-
trol have also demonstrated an inhibition of UVB-induced
activation of the NF-κB pathway.143 Interestingly, post-
treatment with resveratrol in this study revealed equal protec-
tion to the pretreatment, implying that responses mediated by
resveratrol may not be sunscreen effects. In fact, resveratrol
is known to exert anti-inflammatory activity by inhibiting
cyclooxygenase.144 Resveratrol is incorporated into various
skincare products, including antiaging creams, eye creams,
the human diet is coffee; however, tea, chocolate, wine, as well
as fruits and vegetables are also high in antioxidants. This
section will focus on the topical use of antioxidants, although
oral supplementation is also useful to prevent aging.
Vitamin C
Ascorbic acid, also known as vitamin C, is found in citrus
fruits, blackcurrants, red peppers, and leafy green vegetables.
It functions as an antioxidant and has the additional ability to
stimulate fibroblasts to generate collagen because collagen
production requires the presence of ascorbic acid. Vitamin C
has been demonstrated to disrupt the UV-induced generation
of free radicals by reacting with the superoxide anion or the
hydroxyl radical; this activity spurred its inclusion in various
“after-sun” products in the 1980s.127 The topical application of
vitamin C in animal models has delivered photoprotective
effects, as indicated clinically by a significant reduction in
erythema and tumor formation, and histologically by a
decrease in sunburn cells after both UVA and UVB irradia-
tion.128,129 In swine skin, the topical application of vitamin C
combined with either a UVA or UVB sunscreen has improved
sun protection as compared to sunscreen alone.130
Most currently available topical vitamin C preparations are
unstable and fail to penetrate into the dermis, leaving them
useless. The exposure of vitamin C formulations to UV light
or air results in the molecule adding two electrons, transform-
ing into dehydro-L-ascorbic acid, which contains an aromatic
ring. This substance can be reduced back to ascorbate, but if
further oxidized, the ring irreversibly opens, forming dike-
togulonic acid, and the vitamin C solution is rendered perma-
nently inactive.131 Therefore, airtight containers with UV
protection are necessary and the product must be formulated
at a low pH to encourage absorption. One exception to this
rule is the ascorbyl phosphate form of vitamin C, which can
penetrate into the skin when not at a low pH. Vitamin C
products that contain ascorbyl acid at a low pH will sting the
skin in susceptible individuals (sensitive skin types that have
the stinging subtype). Ascorbic acid is the most important
antioxidant to use for antiaging because of its stimulatory
effects on collagen production; however, only a few compa-
nies have successfully developed stable vitamin C formula-
tions that are efficacious. Some forms of vitamin C have
inhibitory activity on tyrosinase, making it a useful treatment
for pigmentation disorders.
Vitamin E
Vitamin E, or tocopherol, found in various vegetables such as
asparagus and spinach, as well as seeds, nuts, and olives, is
the universal term for eight related tocopherols and tocotri-
enols. Vitamin E forms are referred to as either “tocopherol”
or “tocopheryl” followed by the name of what is attached to
it, as in “tocopheryl acetate”. Tocopherol exhibits better
absorption, while tocopheryl displays a slightly longer shelf-
life. The vitamin E forms used in cosmetics, usually alpha-
tocopheryl acetate and alpha-tocopheryl linoleate, are less
likely to cause contact dermatitis than D-alpha-tocopheryl and
are more stable at room temperature. Vitamin E has emollient
as well as antioxidant properties. It can extend the shelf-life
of skincare products and enhance the antioxidant abilities of
ascorbic acid. The topical application of alpha-tocopherol has
36
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
part of an antiaging skincare regimen for wrinkle-prone skin
types.
Role of noninvasive procedures
Prescription medical facials
Facials have been performed for years by aestheticians to
improve the skin’s appearance; these treatments are often
performed in spas and salons as well as medical practices. A
prescription medical facial is differentiated from these facials
by the fact that they are performed only under medical super-
vision and incorporate the use of prescription medications.
For example, imiquimod, a toll-like receptor 7 agonist, has
been shown to improve the appearance of aged skin.151 Pre-
scription retinoids such as tretinoin, adapalene, and tazarotene
can be used in combination with other ingredients to activate
retinoic acid receptors. Rosacea, melasma, and acne medica-
tions can be used in the regimens. These ingredients may be
combined with the use of lasers, lights, radiofrequency, ultra-
sound, needling, cryotherapy, and chemical peels. The exact
protocols for prescription medical facials, which depend on
the patient’s Baumann Skin Type, are beyond the scope of this
chapter, but the point is that physicians have a large prescrip-
tion drug armamentarium that can be used in an off-label way
to improve the appearance of the skin.
Microdermabrasion
Microdermabrasion is a painless resurfacing modality that
requires no anesthesia or recuperation time and causes no side
effects. This procedure provides the immediate benefit of
improving skin texture by removing the most superficial
layers of the stratum corneum.152 The microdermabrasion
machine propels sterile micronized aluminum oxide crystals
at the skin while applying vacuum suction to remove these
particles along with the desquamated skin. The depth of the
treatment depends on the force at which the particles are
propelled and the speed at which the device is passed over
the skin. The goal of microdermabrasion is to remove the
outer layer of the epidermis, promoting natural exfoliation.153
It may facilitate transdermal delivery of topically applied
ingredients.154,155
Microdermabrasion devices are classified as cosmetic
rather than medical, and are therefore not regulated by the
FDA. This has allowed the marketing claims of the manufac-
turers of these devices to go unchallenged or unproven.
Typical indications include acne, acne scarring, skin pigmen-
tation, striae distensae, and photoaging.154 In 2013, micro-
dermabrasion was the fifth most popular type of minimally
invasive aesthetic procedure performed.156
Miscellaneous procedures
There is a plethora of in-office procedures that can be used in
conjunction with cosmeceuticals, prescription medications,
prescription medical facials, and cosmetic procedures. For
example, blue light (400-420 nm) has been shown to improve
acne by eradicating P. acnes bacteria.157 Red light decreases
skin inflammation. Radiofrequency, ultrasound, and other
heat sources are used to tighten the skin on the body and the
face. These treatments work by delivering heat in the
facial moisturizers, supplements, and sunscreens; however,
its use poses some challenges. Resveratrol has poor bioavail-
ability when taken orally because it is metabolized very
rapidly by the liver and intestine.144 For this reason, topical
formulations are preferred. Various formulations to increase
stability and cutaneous penetration have been developed;
however, resveratrol is affected by pH and temperature and
may react with other ingredients in the skincare regimen
causing a loss of efficacy.145
Green tea
Green tea, extracted from the Camellia sinensis plant, is one
of the most studied antioxidants, with myriad in vitro and in
vivo studies investigating its effects.146 The polyphenolic cat-
echins of green tea, which include (−)epicatechin-3-O-gallate
(ECG), (−)gallocatechin-3-O-gallate (GCG), (−)epigallocate-
chin (EGC), and (−)epigallocatechin-3-O-gallate (EGCG), have
been shown to modulate the biochemical pathways important
in cell proliferation, inflammatory responses, and responses
of tumor promoters.147 EGCG seems to be the most potent of
these compounds and is the preferred form in topical skincare
products.
In human skin, these polyphenols from topically applied
green tea have been shown to confer photoprotection, dose-
dependently decreasing UV-induced erythema, the number of
sunburn cells, and DNA damage while protecting epidermal
Langerhans cells.148 In addition, there is evidence from work
with mice that the EGCG-induced increase of IL-12 results in
augmented production of enzymes that repair UV-induced
DNA damage.149 EGCG also thwarts collagen degradation,
which leads to photodamage by downregulating UV-induced
expression of AP-1 and NF-κB and inhibiting metalloprotein-
ases in murine skin.150 In a 2004 study, hairless SKH-1 mice
were exposed to multiple doses of UVB after oral administra-
tion of green tea polyphenols, which were found to have
inhibited UVB-induced protein oxidation and expression of
matrix-degrading MMPs.150 This finding, coupled with the
same result seen in vitro in human skin fibroblast HS68 cells,
demonstrates the antiaging potency of green tea polyphenols.
For this reason, oral and topical green tea represent good
choices as an antioxidant for the skin. Most products that list
“green tea” on the label do not contain enough of the EGCG
fraction of green tea. EGCG levels are not typically listed on
product labels. Notably, though, a large volume of green tea
may turn a skincare product brown, which is one indicator of
the amount of green tea extract in the product.
Summary of antioxidants
There are no conclusive studies showing that antioxidants
prevent cutaneous aging because long-term trials would be
very difficult to perform. It is important to remember that
there are also no long-term trials proving that sunscreen
prevents skin aging. It is very challenging to prove prevention
of aging. However, basic science studies reveal that antioxi-
dants play a role in preventing many of the causes of skin
aging such as glycation, DNA damage, mitochondrial damage,
and oxidation of lipids. For this reason, it is prudent to recom-
mend antioxidants as well as sunscreens as a daily preventive
measure. Multiple studies demonstrate that retinoids improve
the appearance of aged skin; therefore, retinoids are a critical
37
Conclusion
dermatitis, inflammation, acne, and postinflammatory hyper-
pigmentation. For example, patients who are identified as
having a dry skin type have an impaired skin barrier. They
are more likely to suffer from adhesive allergies or react to
irritants such as soap or antibacterial washes used prior to
and during surgery.159 Use of a barrier repair moisturizer for
four days prior to surgery can decrease the incidence of der-
matitis by strengthening the skin’s barrier. Patients undergo-
ing laser resurfacing often develop acne during the healing
phase from the occlusive ointments. Identification of an acne-
sensitive skin type would alert the physician to use silver
textile pillowcases or garments to decrease P. acnes bacteria
counts and lower the risk of post-procedure acne. Retinoids,
zinc, and ascorbic acid may improve wound healing. One
study showed that dermabrasion patients who were pre-
treated with tretinoin healed four days faster and had fewer
milia and less postinflammatory hyperpigmentation than
those who received placebo.160 Several other studies have
shown similar healing improvement on topical retinoids.161
Using a retinoid prior to wounding speeds healing but using
a retinoid after wounding will slow down healing. Pre- and
postsurgical skincare is as important as a consistent daily
skincare regimen to maximize patients’ skin health and
improve surgical outcomes.
temperature range of 55–75°C, which causes the hydrogen
bonds in collagen that stabilize the triple-helical structure to
break. When this occurs, the collagen molecule unfolds irre-
versibly from its native state, resulting in collagen shrinkage
and skin tightening.158 These skin-tightening procedures
should be combined with topical retinoids and ascorbic acid
to increase collagen production during the treatment cycle.
Chemical peels utilize various resurfacing, exfoliating, light-
ening, and anti-inflammatory ingredients. Lasers and intense
pulsed light can be used to decrease melanin patches and
accumulations of hemoglobin. These procedures are often
used in combination to enhance results. Regardless of what
procedure is chosen, consistent daily use of skincare targeted
to the patient’s Baumann Skin Type will improve outcomes.
Conclusion
The first step in the patient consultation is identifying the
patient’s Baumann Skin Type. Even if a patient presents for
surgery and the surgery to be performed is not on the face,
the skin’s health will affect the healing process and influence
scarring. Diagnosis of skin type allows the physician to iden-
tify patients at risk for developing contact dermatitis, irritant
1. Baumann L. The Skin Type Solution. New York: Bantam Dell;
2006. The Skin Type Solution represents a significant advance in
classifying skin and assisting practitioners and patients in selecting the
most suitable skincare products. The Baumann Skin Typing System,
described comprehensively in this book, simultaneously considers skin
type according to four different parameters that yield 16 distinct skin
type permutations.
16. Aburjai T, Natsheh FM. Plants used in cosmetics. Phytother Res.
2003;17:987–1000.
17. Baumann L. Oils. In: Cosmeceuticals and Cosmetic Ingredients. New
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55. Baumann LS. Less-known botanical cosmeceuticals. Dermatol Ther.
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103. Uitto J. Understanding premature skin aging. N Engl J Med.
1997;337:1463–1465.
105. Gilchrest BA, Eller MS, Yaar M. Telomere-mediated effects on
melanogenesis and skin aging. J Investig Dermatol Symp Proc.
2009;14:25–31.
107. Boukamp P. Skin aging: a role for telomerase and telomere
dynamics? Curr Mol Med. 2005;5:171–177. Over the last 15 years, the
roles of telomeres and telomerase have emerged as integral in unraveling
the mechanisms of intrinsic or cellular aging. Noting that the epidermis
is one of the few regenerative tissues to express telomerase, Boukamp
considers the provocative question of whether epidermal telomerase can
play a role in retarding or preventing cutaneous aging.
108. Krunic D, et al. Tissue context-activated telomerase in human
epidermis correlates with little age-dependent telomere loss.
Biochim Biophys Acta. 2009;1792:297–308.
114. Fisher GJ, Datta SC, Talwar HS, et al. Molecular basis of sun-
induced premature skin ageing and retinoid antagonism. Nature.
1996;379:335–339. It is well established that chronic sun exposure leads
to the manifestation of premature or extrinsic skin aging. Fisher et al.
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37.e1
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37.e4
SECTION I
CHAPTER 4 • Skincare and nonsurgical skin rejuvenation
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SECTION I • Aesthetic Surgery of the Face
5.1
Injectables and resurfacing techniques:
Introduction
J. Peter Rubin
This section provides a comprehensive overview of the tools
and techniques for effecting non-surgical aesthetic improve-
ments. An unparalleled panel of experts has contributed to
this section. The section begins with a chapter of soft-tissue
fillers, elegantly presented by Dr. Trevor Born and colleagues.
This chapter highlights characteristics of the filler agents,
technique, strategic placement for maximal benefit, and man-
agement of complications. The next chapter covers the topic
of botulinum toxin. Most certainly, botulinum toxin has
evolved as a revolutionary, safe, and widely used powerful
approach to enhancing facial aesthetics. Dr. Kane is a true
master in the use of botulinum toxin, a pioneer in this field,
and an exceptional educator. He highlights the versatility of
botulinum toxin and the proper techniques for achieving the
desired effect. Laser resurfacing is addressed in the next
chapter, expertly presented by Dr. Steven Cohen and col-
leagues. The indications, proper technique, and management
and prevention of complications is clearly discussed in this
text. The final chapter in this section is about chemical peels.
Dr. Suzan Obagi, an internationally recognized expert in
chemical skin resurfacing, presents a wonderful perspective
on this technology. With an emphasis on patient selection, and
adapting technique to achieve the best results while minimiz-
ing complications, the proper use of chemical peels is thor-
oughly discussed in this chapter.
The material covered in this section provides an in-depth
toolbox for the plastic surgeon to complement his or her surgi-
cal facial rejuvenation practice with adjunctive non-surgical
methods. Importantly, the techniques covered in this section
are highly complementary with each other, and a thorough
understanding of these techniques, along with fundamentals
of patient selection and managing complications, provides a
powerful armamentarium for the aesthetic plastic surgeon.