The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

its lack of reversibility and potential for respiratory depression, it is unclear whether
its use should expand to office-based settings without the assistance of an anesthesi-
ologist. By far the most common combination, and the one used exclusively at our in-
stitution is midazolam and fentanyl.
Midazolam is a benzodiazepine agonist with a rapid onset and recovery and causes
very few cardiopulmonary effects. It is water soluble, resulting in very little venous
irritation, and intravenous injection is painless. In addition, midazolam administra-
tion causes retrograde amnesia in a dose-responsive fashion, thereby limiting patient
recall. Midazolam is also reversible; in the event of an overdose, flumazenil can be
administered to reverse the benzodiazepine effects. However, benzodiazepines affect
respiration much less than narcotics do, and the dose response is very graded, so re-
versibility has in practice never been required in our experience. Midazolam has been
used successfully for CS in continuous and bolus dose fashion. The only absolute
contraindication for the use of midazolam is in patients with benzodiazepine hyper-
sensitivity or acute angle-closure glaucoma. Relative contraindications include preg-
nancy and the presence of significant cardiac and pulmonary diseases.
Fentanyl is a synthetic mu opioid receptor agonist. It is one of the strongest opioids
available, with a potency 80-fold greater than morphine and 100-fold greater than
heroin. It has a rapid onset and recovery, an acceptable side effect profile, and is re-
versible, making it the ideal analgesic for CS. There are many fentanyl analogs on
the market today, including alfentanil (ultra–short acting: 5 to 10 minutes), sufen-
tanil (5 to 10 times more potent than fentanyl), and remifentanil (shortest acting),
but because of their very short action and their potency, they have not found wide
usage in aesthetic surgery. Common side effects with all narcotics include constipa-
tion, somnolence, dizziness, anxiety, cardiopulmonary depression, and nausea and
vomiting. These side effects can be reduced by limiting the total administered nar-
cotic dose. Respiratory depression is the major side effect in practice, and it is im-
portant to note that benzodiazepines potentiate this effect. The peak onset is 6 to
12 minutes, so it is critically important to space the dosing with small increments to
avoid overshoot in clinical effect. In the event of an overdose, naloxone can be admin-
istered, but in the cumulative clinical experience at Northwestern University, nalox-
one reversal has been necessary in less than 1 in 1000 cases. With increased attention
to limiting the dose (usually 25 to 50 g for local anesthetic injection, with cumula -
tive doses for an entire procedure not to exceed 250 g), and the short effective clin-
ical half-life, the potential need for a reversing agent is reduced even more. The half-
life of naloxone is much shorter than that of fentanyl. If a patient has received a
significant dose of fentanyl, it may be necessary to readminister naloxone.
It cannot be overemphasized that the key to the CS technique and maintenance of
the CS state is through the use of the described medications in small, incremental
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Part I  Fundamentals

doses that are properly spaced (every 5 minutes for benzodiazepines; slightly longer
for fentanyl, depending on patient alertness and the level of sedation/analgesia). This
allows appropriate titration of medications to limit or reduce the risk of side effects
and maximize efficacy of sedation and patient comfort. Titration of medications is
guided by close observation of the patient’s vital signs, including respiratory rate,
oxygen saturation, and overall state of alertness. An example of this technique is dis-
cussed next.
The Conscious Sedation Technique
After obtaining informed consent, and before the operation begins, patients receive
three premedications: an antibiotic, an antiemetic, and an anxiolytic. As with most
aesthetic surgery cases, patients receive an antistaphylococcal antibiotic as prophy-
laxis. At our institution we typically use 1 or 2 g of cefazolin in penicillin-sensitive
patients and 900 mg of clindamycin in penicillin-allergic patients. Administration
of an antibiotic is followed by an antiemetic; at our institution we administer 4 mg
of ondansetron (Zofran) intravenously. Finally, patients are given intravenous di-
azepam (Valium) for anxiolysis. Diazepam is generally injected in incremental doses
of 5 to 10 mg until adequate preoperative subjective relaxation is achieved. The ap-
propriate state of preoperative relaxation is confirmed by slurred speech, a tendency
to speak softly, and nystagmus. The observation of even slight nystagmus allows the
physician to objectively monitor when an effective sedating dose of diazepam has
been achieved. The most common dosing of diazepam is between 10 and 50 mg, but
in patients with a history of diazepam usage or other neuroleptic drug use, much
higher doses are occasionally used. The major problem with higher dose diazepam
administration is the potential for prolonged postoperative drowsiness, which may
extend the time to discharge. Most patients also receive between 0.1 and 0.2 mg of
clonidine. Clonidine has been shown to improve sedation, stabilize vital signs, and de-
crease the amount of narcotic analgesic required as a result of its intrinsic analgesic
and anxiolytic properties.
Once the patient is in the operating room, cardiac monitors, a pulse oximeter, and
blood pressure cuffs are applied. One nurse or assistant is responsible for continu-
ously monitoring patient status through these methods. This individual must have
appropriate experience and background in continuous patient monitoring. In many
cases this is a CRNA trained in airway management. The patient’s status is reported
to the surgeon in 5-minute increments. Any change among the measured parame-
ters (vital signs, oxygen saturation, level of alertness, or blood pressure) is commu-
nicated to the surgeon. On the basis of these parameters, the patient receives 0.5 to
3 mg of incremental bolus midazolam for sedation and/or fentanyl in increments of
12.5 to 25 g.
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Chapter 3  Sedation and Anesthesia for Aesthetic Surgery

Accurate record-keeping of the medications administered and their timing is para-
mount to avoid overdose or too-frequent administration. We use a large, easy-to-
read dry-erase board for record-keeping.
After adequate infiltration of local anesthetic, fentanyl is infrequently administered,
especially near the end of the procedure. The total dose of fentanyl should be mon-
itored and should not exceed 250 g, even in longer procedures. The potential for
unexpected respiratory depression and risk of postoperative nausea and vomiting
increases greatly with additional incremental doses. In our experience over the past
5 years, effective administration of local anesthesia has cut our average cumulative
fentanyl dose over the course of a procedure by 30% to 50%. By limiting the amount
of medication toward the end of the procedure, the patient is allowed to slowly re-
turn to a normal state of arousal and awareness.
The major risk factor associated with the use of midazolam and fentanyl is respira-
tory depression, with the effects of the two potentiating each other. With effective
therapeutic doses of benzodiazepines sufficient to truly relieve anxiety and achieve
a high degree of amnesia, fentanyl can be administered judiciously with less postop-
erative nausea and truly mild respiratory depression. In this instance, the mild re -
spiratory depression can easily be managed by verbal commands or patient stimu-
lation. A jaw thrust is sometimes necessary to assist airway protection in patients
who have drifted into a deeper state of sedation. In older patients with lower base-
line oxygenation, supplemental oxygen is occasionally beneficial. It is imperative
that the surgeon and nurse administering the sedation be competent in identifying
and treating patients who briefly enter a deeper state of sedation and could benefit
from stimulation, jaw thrust, or in truly exceptional cases, naloxone reversal of the
narcotic.
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Part I  Fundamentals

Local Anesthesia: A Critical Component
of Sedation Anesthesia
As a result of the increasing number of office-based procedures and the subsequent
increase in the use of sedation anesthesia, local anesthesia has become a critical ad-
junct to office-based surgical practice. We think that effective sedation and anesthe-
sia in aesthetic surgery begins and ends with adequate local anesthesia. Thus we will
discuss local anesthesia techniques in detail.
77
Chapter 3  Sedation and Anesthesia for Aesthetic Surgery
Plastic surgeons are extremely familiar with the available local anesthetics and ba-
sic infiltration techniques. The most commonly used compounds include the esters
procaine, tetracaine, and chloroprocaine and the amides lidocaine, mepivacaine,
bupivacaine, etidocaine, and prilocaine. A thorough knowledge of the pharmacoki-
netics of the commonly used agents is imperative to optimize anesthesia, analgesia,
and patient comfort, while minimizing the risks associated with these agents.
Allergic reactions are rare and are more likely to occur with an ester compound.
Toxicity usually results from an overdose. Systemic manifestations can include
headaches, tinnitus, perioral paresthesias, restlessness, seizures, apnea, and cardiac
depression. Surgeons should follow recommended guidelines regarding safe maxi-
mum dosages to reduce the risk of toxicity. The maximum dosage can often be ex-
tended by adding epinephrine to the anesthetic agent.
Commonly Used Local Anesthetic Agents
Duration of
Recommended Dosage
Maximum Total
Agent
Class
Action (min)
Guidelines (mg/kg)
Dosage (mg)
Procaine
Ester
15-60
7.0
350-600
(Novocain)
Lidocaine
Amide
30-60
Without epinephrine: 4.5
300
(Xylocaine)
120-360
With epinephrine: 7.0
Mepivacaine
Amide
45-90
7.0
400
(Carbocaine)
Bupivacaine
Amide
120-240
Without epinephrine: 2.5
175
(Marcaine)
180-420
With epinephrine: 2.5-4.0
225-400

In 1987 Klein first described the tumescent technique, which involved infiltration of
large volumes of dilute lidocaine with epinephrine into the local subcutaneous tis-
sues to assist with suction lipectomy. During his seminal work, he discovered an im-
portant concept—the maximum dosage of lidocaine with epinephrine that could be
safely injected extended well beyond the recommended guidelines of 7 mg/kg. In
fact, he had safely used doses as high as 35 mg/kg without reaching toxic plasma
levels. Since that report, a similar study by Ostad et al found that doses as high as
55 mg/kg can be used. Over the next several years it became increasingly clear that
the tumescent technique offered significant perioperative advantages, including a re-
duction in surgical time, less potential for postoperative edema and hematoma, and
improved postoperative pain control; furthermore, it eliminated the need for gen-
eral anesthesia when paired with CS techniques.
This concept gained significant popularity over the following decade and has revo-
lutionized local anesthesia technique. At this point the cumulative experience is in
the millions of patients. In our practice we routinely approach the 35 mg/kg level of
lidocaine, and in thousands of cases we have never encountered a hint of toxicity.
One very useful safety feature of this CS protocol is that the antidote for early lido-
caine toxicity (which is first manifested neurologically) is the administration of ben-
zodiazepines, which have already been administered.
We employ the tumescent technique (or more accurately, flooding of the tissues with
dilute local anesthetic, whether in the face, nose, breast, abdomen, or fat) in most of
our aesthetic surgery cases using sedation anesthesia. Our goal is not to achieve
turgidity of the tissues, but rather to achieve vasoconstriction, providing a bloodless
field and truly effective local anesthesia.
Our dilute local anesthetic solution consists of lidocaine with epinephrine mixed in
normal saline solution, which is sufficient to achieve anesthesia of fat. In our expe-
rience, 0.3% lidocaine is a sufficient concentration to achieve anesthesia for skin in-
cisions, and approximately 0.1% lidocaine is sufficient to achieve anesthesia of breast
tissue or muscle in sufficient volumes. Therefore our standard mix for skin incisions
of the breast, abdomen, or face is 100 ml of 1% lidocaine, 1:100,000 epinephrine
in 250 ml of normal saline solution, with 0.05% lidocaine for infiltration along ab-
dominal fascia or in fat for liposuction. For breast reduction procedures under con-
scious sedation, 0.1% lidocaine is sufficient; however, to avoid skin complications,
we limit the epinephrine concentration to 1:2,000,000. Depending on the specific
procedure and anatomic location, an appropriate volume of solution is injected along
the incision lines and into the regional soft tissues.
78
Part I  Fundamentals

For example, during a breast augmentation procedure, after all incision lines have
been adequately infiltrated, approximately 30 ml of dilute local solution is infiltrated
directly into the subpectoral plane in the axillary portion of the breast to achieve ef-
fective regional breast anesthesia.
The table of injection techniques gives dilute anesthetic solutions for various aes-
thetic procedures.
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Chapter 3  Sedation and Anesthesia for Aesthetic Surgery
Local Anesthetic Injection Techniques for Various
Plastic Surgery Procedures
Procedure
Dilute Local Injection Technique
Face lift/brow lift
100 ml per side, along incision lines; 50-150 ml for submental region
Breast augmentation
100-150 ml for each breast, with dedicated 30 ml injected into
subpectoral plane in axillary tail region
Mastopexy
250-500 ml for each breast, depending on breast size
Abdominoplasty
75-100 ml along all incision lines; 50-100 ml for abdominal fascia;
remainder of solution for liposuction assistance where necessary

Outcomes and Safety
Our ability to provide less-invasive anesthesia and optimize patient comfort has ad-
vanced rapidly over the past 20 years. Despite these advances, we must maintain
good clinical judgment and uphold superior standards in technical skills, surgical
facilities, and patient safety. Office-based surgery can be performed safely and of-
fers patients the highest degree of privacy and convenience, but surgeons must real-
ize that the risk of serious injury or death exists. In fact, some published reports in-
dicate that the risk of serious injury or death is tenfold higher for office-based
procedures.
There is no doubt that the appeal of enhanced privacy, convenience, and comfort
has substantially contributed to the number of patients seeking aesthetic surgery in
the office setting. As with the truest of economic fundamentals, with this increase in
demand, we have seen an unparalleled rise in the number of office-based procedures
that are performed yearly.
To deliver optimal results in the safest environment, it is imperative that aesthetic
surgeons adhere to strict guidelines set forth by governing bodies. For instance, the
ASPS has published a series of guidelines to advise surgeons on appropriate safety
measures for office-based practices. In addition to these specific guidelines, basic
principles of ethical patient care should become the foundation of every aesthetic
surgeon’s practice. These include (1) performing office-based procedures in an ac-
credited facility in accordance with policies set forth by the appropriate governing
bodies, (2) only performing procedures for which one has been trained and is qual-
ified to perform, (3) maintaining up-to-date, functioning equipment and appropri-
ate facilities, and (4) applying the protocols necessary to create an environment in
which the foremost concern is patient safety. All staff and personnel should be trained
and certified to perform advanced cardiac life support (ACLS), efficiently manage
emergencies, effectively stabilize patients, and appropriately transfer patients when
necessary.
We have seen firsthand in our own practice the rising demand for sedation-based
anesthesia and aesthetic surgery over the years. The well-publicized deaths from pul-
monary embolus and respiratory complications have increased public awareness of
the risks of general anesthesia. Over the past 15 years we have performed more than
4000 procedures employing the sedation and anesthesia techniques described in this
chapter. The techniques have been widely used in our resident aesthetic clinic and
by other plastic surgeons at Northwestern University.
As with all aspects of aesthetic surgery, achieving the optimal patient outcome and
experience requires appropriate patient selection, operative planning, and realistic
expectations. The delivery of appropriate sedation coupled with effective local anes-
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Part I  Fundamentals

81
Chapter 3  Sedation and Anesthesia for Aesthetic Surgery
thesia is a learned skill that requires the ability to pay significant attention to the
level of sedation, stable vital signs, and oxygenation while focusing on the opera-
tion at hand. In practice, this means being alerted to changes in the patient’s status
by the monitoring nurse through 5-minute reports and maintaining a steady state
of sedation by continued small increments of benzodiazepine administration.
We have used CS anesthesia for a wide range of aesthetic procedures, including suc-
tion lipectomy, abdominoplasty, breast surgery, rhytidectomy, blepharoplasty, and
rhinoplasty. We have never had a patient develop deep venous thrombosis or a pul-
monary embolism as a result of these techniques. Additionally, the risk of develop-
ing postoperative nausea and vomiting has nearly been eliminated with an effective
balance of sedation, narcotic, and antiemetic prophylaxis. As a result, the incidence
of unplanned hospital admission is extremely rare.
Key Observations
During our experience with CS, we have made several key observations that are im-
portant for surgeons employing CS techniques.
Patient Selection
1. The use of CS should be avoided in patients who are extremely anxious and have
an absolute desire to be “out,” with a stated very low pain tolerance. These pa-
tients may require large amounts of sedation, which prolongs the recovery and
increases the risk for nausea and vomiting. However, with experience, and for
easier procedures (such as rhinoplasty), some of these patients can still do very
well with sedation.
2. For patients with any significant history of coronary artery disease, arrhythmias,
or significant pulmonary problems, their procedure should performed under MAC
or DS with the assistance of an anesthesiologist to optimize patient safety.
3. Patients with a significant history of depression, bipolar disorder, or other men-
tal illness may have unpredictable responses to sedation and should be consid-
ered for MAC.
4. Patients who take several neuroleptic drugs may be difficult to sedate, and caution
should be used.
Procedural Considerations
1. Essentially any aesthetic procedure is applicable (including harvesting costal car-
tilage) if good local anesthesia can be achieved.
2. Patients can get restless after 4 hours; therefore we avoid using CS in procedures
that last longer than 41⁄2 to 5 hours.
3. For long procedures with significant fluid infiltration, insertion of a Foley catheter
after the patient is sedated can be very useful.
4. Local infiltration, for liposuction for instance, with very dilute (0.05% xylocaine)
can take 15 to 30 minutes for maximal effect.

5. Planning a procedure to minimize the number of separate times that local anes-
thetic is infiltrated eases the procedure. For instance, when doing a combination
breast augmentation and abdominoplasty, we infiltrate both surgical fields com-
pletely at the beginning of the procedure when the patient is usually most deeply
sedated. This enables the local anesthetic sufficient time to take full effect in both
fields, while subjecting the patient to only one period of injections, significantly
easing the procedure, and speeding it up.
Concluding Thoughts
As the number of office-based procedures and the demand for more convenient and
safer anesthesia continue to rise exponentially, plastic surgeons must become comfort-
able with the techniques of sedation anesthesia to stay competitive with their col-
leagues. Sedation techniques can be applied for the majority of aesthetic procedures,
so long as these procedures are performed in an accredited facility, with strict ad-
herence to the appropriate standards and guidelines, with a particular focus on main-
taining maximal patient safety.
Clinical Caveats
 Sedation anesthesia results in less risk for deep venous thrombosis, pulmonary
embolism, and postoperative nausea and vomiting.
 The major distinction between deep sedation and conscious sedation is the pa-
tient’s ability to respond to external stimuli.
 Sedation anesthesia should be performed in accredited facilities by surgeons and
personnel who are trained in medication administration and able to provide air-
way assistance if necessary.
 The conscious sedation state can be maintained by careful titration of medica-
tions and administration in small, incremental bolus doses.
 Appropriate local anesthesia is paramount to effective conscious sedation.
 Office-based surgery can be performed safely, so long as surgeons adhere to the
standards and guidelines set forth by appropriate governing bodies, with the pri-
mary focus on patient safety.
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Part I  Fundamentals

Annotated Bibliography
American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-
Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiolo-
gists. Anesthesiology 4:1004-1017, 2002.
Useful guidelines prepared by the ASA for administration of sedation by nonanesthesi-
ologists.
Hasen KV, Samartzis D, Casas LA, Mustoe TA. An outcome study comparing intravenous
sedation with midazolam/fentanyl (conscious sedation) versus propofol infusion (deep
sedation) for aesthetic surgery. Plast Reconstr Surg 112:1683-1689; discussion 1690-
1691, 2003.
Beautiful description of conscious sedation technique and comparison to deeper, propo-
fol-based sedation techniques.
Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based
surgery setting. Plast Reconstr Surg 110:1337-1342; discussion 1343-1346, 2002.
First of three ASPS Task Force guidelines on office-based surgical safety.
Iverson RE, Lynch DJ. Patient safety in office-based surgery facilities: II. Patient selection.
Plast Reconstr Surg 110:1785-1790; discussion 1791-1792, 2002.
Second of three ASPS Task Force guidelines on office-based surgical safety.
Iverson RE, Lynch DJ; American Society of Plastic Surgeons Committee on Patient Safety.
Practice advisory on liposuction. Plast Reconstr Surg 113:1478-1490; discussion 1491-
1495, 2004.
Final article in the series of three ASPS Task Force guidelines on office-based surgical
safety.
Klein JA. The tumescent technique for liposuction surgery. Am J Cosmetic Surg 4:263-267,
1987.
Seminal article describing the tumescent technique for local anesthesia.
Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg.
J Dermatol Oncol 16:248-263, 1990.
Seminal article challenging the prior recommendations for the maximum dosage of li-
docaine with epinephrine that can be safely injected.
Marcus JR, Tyrone JW, Few JW, Fine NA, Mustoe TA. Optimization of conscious sedation
in plastic surgery. Plast Reconstr Surg 104:1338-1345, 1999.
Follow-up with useful guidelines for optimizing conscious sedation in plastic surgery.
Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with lidocaine dose of 55 mg/kg is
safe for liposuction. Dermatol Surg 22:921-927, 1996.
A follow-up to Klein’s article, further substantiating the safety of dilute lidocaine with
epinephrine and further pushing the envelope with regard to the maximum safe dosage.
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Chapter 3  Sedation and Anesthesia for Aesthetic Surgery

Suggested Readings
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nique for conscious sedation in plastic surgery. Br J Plast Surg 56:272-275, 2003.
Beer GM, Spicher I, Seifert B, et al. Oral premedication for operations on the face under
local anesthesia: a placebo-controlled double-blind trial. Plast Reconstr Surg 108:637-643,
2001.
Blake DR. Office-based anesthesia: dispelling common myths. Aesthet Surg J 28:564-570;
discussion 570-571, 2008.
Buck DW, Mustoe TM, Kim JYS. Postoperative nausea and vomiting in plastic surgery. Semin
Plast Surg 20:249-255, 2006.
Byrd HS, Barton FE, Orenstein HH, et al. Safety and efficacy in an accredited outpatient
plastic surgery facility: a review of 5316 consecutive cases. Plast Reconstr Surg 112:636-
641; discussion 642-646, 2003.
Christian M, Yeung L, Williams R, et al. Conscious sedation in dermatologic surgery. Der-
matol Surg 26:923-928, 2000.
Cinnella G, Meola S, Portincasa A, et al. Sedation during office-based plastic surgery proce-
dures: comparison of two opioid regimens. Plast Reconstr Surg 119:2263-2270, 2007.
Clayman MA, Clayman SM, Steele MH, et al. Promoting a culture of patient safety: a re-
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Hausman LM. Advances in office-based anesthesia. Curr Opin Anaesthesiol 16:421-427,
2003.
Hijawii J, Fine NA, Mustoe TA. Anesthesia techniques in plastic surgery. In McCarthy J,
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Kryger ZB, Fine NA, Mustoe TA. The outcome of abdominoplasty performed under con-
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Facial Aesthetic Surgery
in Skin of Color

JULIUS W. FEW
CHAPTER 4

A
ccording to 2008 statistics from the American Society for Aesthetic Plastic Sur-
gery (ASAPS), persons of color represent the fastest-growing group of con-
sumers in elective aesthetic medicine. With the increasing availability of information
and awareness of the latest innovations, patients’ expectations are high, and the need
is clear for interventions that are individualized to the specific needs of ethnic patients.
Skin of color has more advantages than disadvantages when it comes to the aging
process because of its inherent protection against actinic damage and its sebaceous na-
ture and suppleness. Thus the types of interventions requested and the specific indi-
cations differ from those of patients with lighter skin. In addition, patients of color
tend to present later in life than those with light skin.
In general, darker-pigmented skin has an increased epidermal melanin content and
large, singly dispersed melanosomes within melanocytes. Melanosomes are distrib-
uted throughout the epidermis in darker skin, whereas in lighter skin they are lim-
ited to the basal and lower malpighian layer of the epidermis. Black/brown skin is
thicker and the dermis more compact than white skin. Fibroblasts are large and nu-
merous, and thus there is a significant turnover of collagen in dark skin. These find-
ings may help to explain why skin of color is at an increased risk of adverse scarring
with epidermal or dermal trauma.
Treatment Considerations for Skin of Color
The primary focus in treating skin of color relies on several major considerations.
When treating the skin of ethnic patients, the surgeon must consider the presence
and/or prevention of postinflammatory hyperpigmentation and hypertrophic/keloid
scar tendencies. In general, there are a variety of surgical and nonsurgical options to
help avoid these unwanted events. Excess tension, inflammation, and a genetic pre-
disposition appear to play the major part in hypertrophic or keloid scar formation.
As with any approach, surgical or nonsurgical, it is vital to neutralize all possible
variables in an effort to avoid complications.
In some instances, the very nature of the treatment is keloidogenic. Face lifts and
skin resurfacing are by their very nature keloid promoting in at-risk patients because
of skin tension and inflammation, respectively. I have found that nonabsorbable su-
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Part I  Fundamentals

ture material is less reactive in at-risk skin types, thereby limiting local tissue inflam -
mation. Nonabsorbable suture material can be removed subsequently, eliminating
the potential offending agent. The surgeon must understand the fine balance between
allowing the suture to control tension and the need to limit a reactive substrate.
If hyperpigmentation exists in an area in which cosmetic enhancement is planned,
one should consider treating this before a procedure is performed. This is particu-
larly applicable preceding injections of fillers or botulinum toxin. Regardless of skin
tone, sunscreen protection is vital, especially with preexisting postinflammatory hy-
perpigmentation. For existing hyperpigmentation, I typically begin with a solution
of 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone, which the patient
applies nightly for 2 to 6 weeks before a planned surgery. Skin-bleaching therapy is
resumed 1 week after the procedure. As with all forms of medicine, prevention is the
key to a successful outcome.
INDICATIONS AND TREATMENT MODALITIES
The following discussion provides a general framework for the treatment of patients
of color but is by no means an exhaustive list of treatment options for these patients.
Periorbital Rejuvenation
Most of the literature on facial aesthetics reflects white ideals, which runs the risk,
if taken too literally, of conflicting with the desires of patients with other cultural
ideals. However, there are goals that remain consistent, regardless of the patient’s
race, ethnicity, or sex.
The surgeon must strive for an approach that will restore and enhance appearance
in the most natural way possible, without distortion of function. Most elective pa-
tients are not trying to assume the appearance of another person, but rather to feel
that their outward aspect conveys a message consistent with their inner feelings. The
most common comments heard in consultation for eyelid rejuvenation are a desire to
“not look tired,” or “not look sad.” The endpoint sought by most patients is: “I want
to look refreshed.”
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Part I  Fundamentals
Pertinent Anatomy
According to our study published in 2006, approximately 40% of African Ameri-
can women fear losing their ethnic identity if they undergo blepharoplasty, which
emphasizes the importance of sensitivity to this issue. In studying the faces of pa-
tients of African descent, I have found a strong association with Asian features, es-
pecially with regard to the lateral canthus of the eye. When questioned, patients of
color felt their eyes shared canthal and upper eyelid characteristics with those of
Asian ancestry, although they clearly did not want to change their own ethnic char-
acter. In general, when questioned, patients in this group are not pursuing a younger
look, or a change in ethnic characteristics, but rather a less-tired look.
The split-face image above demonstrates the composite nature of facial aging in an
African American woman: the left side shows the patient 17 years before and the
right side just before rejuvenation surgery. As Flowers and others taught us, the peri-
orbital aging process begins at the forehead/brow region. The process begins with
forehead redundancy and flattening of the brow apex. Crowding of the lateral and
central upper eyelid occurs as the brow migrates inferiorly. The upper lid often loses
its septal support, leading to brow prolapse and an exacerbation of upper eyelid full-
ness and congestion. The lateral canthal complex then migrates inferiorly, loosening
the lower eyelid sling. The lower lid then takes on an elongated appearance, and tear
troughs and nasojugal sulci develop. This is followed by ptosis of the midface and
deepening of the nasolabial sulcus. Finally, jowls form. Reviewing the patient’s more
youthful photos is vital in planning periorbital surgery.
Preoperative Planning
A successful outcome depends on a successful surgical plan. When selecting the over-
all approach, surgeons must realize that patients of color are looking for significant
improvement but fear overcorrection more than white patients do, according to our
research. Past photos are reviewed primarily to assess normal canthal and perior-
bital landmarks for surgical planning. In general, I prefer to perform canthopexy lib-
erally to restore canthal tilt, preserve the majority of the upper eyelid orbicularis as

an autologous graft, and place the upper blepharoplasty closer to the ciliary margin
than in a typical white eyelid (taking care to measure the exact height of the tarsal
cartilage). If supratarsal malposition is found in the upper eyelid, the surgeon and
patient discuss ptosis correction versus three-point fixation of the supratarsal crease.
Ptosis surgery is recommended in patients adversely affected by the condition and/or
those desiring restoration to a more youthful appearance. Regardless of race or eth-
nicity, it is vital to beware of patients with dry-eye syndrome, because ptosis correc-
tion will exacerbate these symptoms.
For patients of African heritage, I find that canthal ptosis with aging occurs at a
faster rate than in white patients. This finding is based on controlled photo files an-
alyzed with high-resolution photography and computer evaluation of the canthal an-
gle in more than 500 subjects. Although the lateral canthus starts higher than the me-
dial canthus in a youthful patient of color, the drop over time is relatively dramatic.
The surgeon may be deceived to find the medial and lateral canthal points equal, a
common finding in the white population, and mistakenly leave this malposition un-
treated while other periorbital concerns are addressed. This omission leaves the pa-
tient with an incomplete correction and subjective dissatisfaction.
Brow ptosis in persons of color occurs to a lesser extent and at a much later age than
in white patients. Despite great advances with light-based treatments, laser therapy
to the lower eyelid in skin of color remains a challenge. Given the rare finding of ex-
cessive lower eyelid skin after treatment of redundant deeper tissue, immediate sub-
ciliary skin-pinch excision is preferred. The removal of skin in this location is very
effective and safe, typically leaving no signs of surgical intervention.
I have found that 6-0 Prolene suture in skin of color leaves no identifiable marks.
This approach has even been used in patients with a known history of keloid for-
mation in other parts of the body.
Once the surgical plan has been defined, there are techniques that are common to
patients of all ethnic backgrounds. In particular, this involves (1) supporting the
brow-forehead aesthetic unit to provide the scaffold for successful periorbital reju-
venation and (2) assessing risk factors in the rejuvenation plan.
There are considerations unique to patients of color, and these require a modified
approach to achieve the desired outcome. Because most of these patients do not have
significant signs of aging in the forehead region until much later in life, the focus is
typically set on balancing the brow position and providing support for the planned
eyelid repositioning. I have found that internal browpexy is ideal for these patients,
limiting the scar to the supratarsal area. The upper eyelid becomes deflated over time,
making preservation and restoration the most important variables. Fat excision is
often limited to the nasal upper eyelid fat compartment. One must be very conser-
vative with fat excision in the more lateral compartments. The upper eyelid is an ideal
access point for lateral retinacular release and lateral canthopexy.
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Part I  Fundamentals
Given the unique challenges of pigmented skin and visible scarring, I have found it
ideal to attempt to keep visible scars within the confines of the lateral canthal point.
For this reason, I developed the transconjunctival deep plane midface lift. This is a
technique that provides primary access to the lower lid and midface through the
transconjunctival approach and eliminates the need for traditional skin muscle flap
surgery and the accompanying scar. In addition, the approach leaves the orbicularis
muscle undisturbed, minimizing the risk of eyelid malposition from muscle con-
tracture or paralysis. With the orbitomalar ligament divided, the midface is readily
available and amenable to suture fixation after elevation. This technique can often
replace or eliminate the need for more traditional face-lift approaches.
Because there are often few rhytids visible on the skin of patients of color, deep au-
tologous fat injection and/or grafting is ideal for malar restoration and tear-trough
augmentation. I prefer the lateral ala and oral commissure as access points for fat
injection. The ideal fat graft for skin of color is the dermal or septal fat graft for tear-
trough and direct malar augmentation. Patients are advised that the implanted au-
tologous tissue will initially feel hard to the touch and undergo maturation and soft-
ening over 6 to 12 weeks. Although a patient of African descent may wish to preserve
a natural appearance, it is important to slightly overcorrect, anticipating the post-
operative relapse and “settling” of the surgical manipulation. I always use nonab-
sorbable suture to limit the risk of hyperpigmentation and/or the suture reaction seen
with absorbable material. The sutures are removed at 4 to 7 days, thus limiting the
potential for a suture reaction.
It is not possible to cover every nuance of periorbital rejuvenation in patients of color,
but I will provide some illustrative examples of technical approaches to the area.
I will describe the treatment approach and rationale in two African American women
to demonstrate the algorithm for both primary and secondary rejuvenation.
Incision 7 mm
from black line
Orbicularis oculi muscle
Inferior oblique muscle
Inferior fornix
of conjunctiva
Orbital septum
Inferior tarsus

This woman presented in her late fifties wanting to look “less tired.” The split im-
age emphasizes the changes that have occurred; the appropriate location for her lat-
eral canthus relative to the medial canthus can be seen. It is important to recognize
her asymmetry before the procedure. In particular, her right brow is lower and flat-
ter than the contralateral side, creating a more hooded appearance to the right up-
per eyelid. She has forehead rhytids, but they are largely reactive and dynamic, in-
voluntarily responding to brow and eyelid ptosis. With transpalpebral brow correction,
the forehead assumes a more aesthetic position, making direct forehead rhytidec-
tomy unnecessary. With these findings, I prefer to approach this indication with peri -
orbital access only.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color
Preoperative
Long-term postoperative result

In addition, I address upper eyelid excess while preserving the underlying orbicularis
and conservative resection of the nasal fat pad. Because her lower lid distraction is
less than 6 mm, a canthopexy is planned with a lateral retinacular release. Because the
patient has significant tear-trough deformity, septal fat prolapse, and submalar de-
pression exacerbating midface ptosis, a transconjunctival deep plane midface lift will
be done. A tear-trough fat graft will soften the sulcus. The procedure can be done un-
der monitored anesthesia care (MAC) or general anesthesia, depending on surgeon
and patient preference.
Markings
The supratarsal crease is marked with the patient awake and in the upright position.
The desired apex of the brow is marked at the level of the lateral limbus of the iris,
marking preoperative asymmetry. The redundant skin of the upper eyelid is marked,
with the brow in the desired corrected position. Care is taken to not take the cephalic
limb of the upper lid excision beyond the midpoint of the area between the
supratarsal crease and inferior edge of the natural brow.
Operative Technique
The procedure begins with the patient supine. After the appropriate marks have been
made, tetracaine ophthalmic drops are placed, followed by lubrication and protec-
tive, evaginated corneal shields. A solution of 1% lidocaine with epinephrine
1:100,000 is injected in the field, regardless of the level of anesthesia. The surgical
incision begins with an upper blepharoplasty; excess upper eyelid skin is removed
while preserving the underlying muscle.
The muscle is then divided at the level of the supratarsal crease, preserving the un-
derlying septal extension. The muscle is elevated in a cephalad direction, using
insulated needle tip cautery. Care is taken to identify and preserve the supraorbital
neurovascular bundle. Dissection on the supraorbital rim is done deep to the subor-
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Part I  Fundamentals
Levator aponeurosis
Levator muscle
Medial horn of levator
Tarsus
Inferior retractors
(capsulopalpebral fascia)
Whitnall’s ligament
Muscle aponeurotic
junction
Release
lateral canthus
Lateral horn

bicularis fat pad but superficial to the periosteum. The lateral brow retaining liga-
ments are separated, allowing release of the caudal 3 cm of the forehead from the
brow. The surgeon then conservatively resects nasal fat excess using the needle tip
cautery. Release of the lateral retinaculum, as described by Jelks (see p. 94), is done
through the upper lateral eyelid exposure. The lateral 1.5 to 2 cm of periorbital or-
bicularis is elevated off the periosteum, allowing exposure of the lateral retinaculum
and upper and lower lateral septal fat compartments. Selective release of the reti-
naculum without lysing the canthal tendon can be done through this approach un-
der direct vision.
The surgeon then turns to the transconjunctival approach (see p. 92). A conjuncti-
val 5-0 silk traction suture is placed 8 to 10 mm from the inferior ciliary margin. The
transconjunctival incision is made above the traction suture and a preseptal expo-
sure is developed deep to the orbicularis muscle. The arcus marginalis and orbito-
malar ligament are identified and preserved. The orbital malar ligament is divided
with needle tip cautery, preserving the arcus marginalis and periosteum. A preperi -
osteal dissection is carried down to the desired level of correction, keeping all fat and
soft tissue off the periosteum. One can readily reach the level of the ala while care-
fully identifying and protecting the infraorbital neurovascular bundle. Using the deep
orbicularis to arcus marginalis, one- or two-point fixation can be performed through
the transconjunctival exposure with a 4-0 Vicryl or PDS suture on a small tapered
needle. Care must be taken to avoid incorporating capsulopalpebral fascia or con-
junctiva in the closure, since this could lead to lid malposition. One- or two-point
suture fixation, deep orbicularis to periosteum, is performed through the lateral as-
pect of the upper blepharoplasty exposure.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color
After securing the lateral aspect of the midface while taking care to preserve the zy-
gomaticofacial nerve located at the malar eminence, the surgeon performs the lat-
eral canthopexy. I prefer 4-0 Mersilene or braided ophthalmic nylon, double-armed,
to plicate the lateral canthal tendon to the interior aspect of the superolateral peri -
osteum. The knot is carefully buried. Attention is then turned to the browpexy.
Suture fixation of the lateral canthus to the
interior of the lateral orbit periosteum

96
Part I  Fundamentals
The apex is identified and the inferiormost aspect of the brow margin is transposed
to the deep surface of the orbicularis. The deep orbicularis is then anchored to the
periosteum of the frontal process, typically 1.5 to 2 cm above the supraorbital rim
using a 5-0 Vicryl suture. The surgeon must be careful not to overcorrect, because
the brow tends to migrate superiorly over time with thorough brow release.
Finally, the upper blepharoplasty incision is closed with a running 6-0 Prolene su-
ture. Any redundant lower eyelid skin can be removed using a skin-pinch excision,
preserving the underlying orbicularis.
Postoperative Care
A Steri-Strip bolster dressing is placed to support and reinforce the superolateral lift
of the midface-cheek unit. The conjunctival incision is not closed. Ophthalmic lu-
brication is not instilled for the first 48 hours after surgery to avoid a granuloma-
tous reaction. The patient can place cool compresses over the eyes for the first 36 to
48 hours and liberal applications of an ophthalmic steroidal agent if significant
chemosis appears (a rare finding).
Levator aponeurosis
Müller’s muscle
Preaponeurotic fat
Frontal bone
SOOF
Frontalis
Orbicularis muscle
Orbital septum
Septal extension
Posterior
orbicularis fascia
Tarsus
Middle
lamella
Septal
extension
Orbicularis
oculi muscle
Septal fat
Levator
aponeurosis
Superior
tarsus
Sagittal view: Layers of the upper eyelid
Layers of the upper eyelid to gain access to the
brow for internal browpexy

This patient illustrates the importance of having a well-laid plan and understanding
what the patient really desires. This woman had undergone a four-lid blepharoplasty
at another clinic more than a year earlier and was not pleased with her result, which
she felt made her look “tired” and “unhappy.” She had objective signs of uncorrected
canthal ptosis and lower lateral eyelid retraction, creating a gapping at the lateral
aspect of the eye and increased scleral show. Had the previous surgeon looked at her
more youthful photos, he or she would have appreciated the significance of her can-
thal ptosis and subsequent loosening of the lower eyelid mechanism. The inferior
lateral cant of the eye makes her look angry. Given these findings, I felt that revision
upper and lower blepharoplasties would be appropriate, with a transconjunctival
deep plane midface lift. The midface lift is intended to recruit skin and soft tissue to
the correct lower lid retraction and preserve an appropriate correction to the lateral
canthus. In addition, the patient required a lateral retinacular release with canthopexy,
as previously described, to achieve harmony in the periorbital region. As the 3-year
follow-up images show, this patient was able to achieve significant, persistent cor-
rection. Note the paucity of visible scar formation despite the revisionary nature of
the intervention.
Patients of color are particularly well suited for autologous fat injection to the mid-
face and tear trough, primarily because of the robust nature of the overlying skin and
soft tissue. There are a variety of techniques for preparing and injecting the fat, but
I have found tumescent aspiration with concentrated injection to work well. I do not
advocate centrifugation; I simply use a sterile nonstick gauze pad or simple gravity
filtration. The fat is then injected through concealed injection ports, such as the oral
commissure or nasal ala. Slight overcorrection is done to offset the average take of
75%. I do not place sutures at the injection sites for closure because of the increased
risk of prolonged or chronic suture tract marks.
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Results
Preoperative
3 years postoperatively

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Part I  Fundamentals
Nonsurgical Periorbital Rejuvenation
In previous publications I have shown the safety and efficacy of using hyaluronic
acid filler in facial soft tissue and skin restoration in skin of color. There has been no
reported difference in adverse effects or complications with such synthetic fillers.
I find that it is better to inject the filler in the deeper dermis, with as few points of
injection trauma as possible. In addition, neurotoxin injection enhances the benefit.
With injection of a neurotoxin initially, one can simulate a brow lift and correction
of lateral brow hooding and crow’s-feet. In patients with prolapse of the lower eye-
lid septal fat and a prominent tear trough, hyaluronic acid can be injected to correct
the defect and deemphasize the prominence of the prolapsed fat. In addition, sig-
nificant harmony can be achieved in the lid-cheek junction. The overlying skin tends
to be thicker and is more forgiving of contour irregularities. I prefer to inject the
glabella and forehead, preserving the caudal 1.5 cm of the frontalis overlying the
brow apex, and injecting the crow’s-feet area 1 cm away from the orbit. The exact
dose varies, but I often supplement the above with 2 to 3 units injected directly into
the superior border of the brow apex.
In a secondary procedure, the brow and tear trough can be injected with hyaluronic
acid filler; this is an off-label indication. There are a variety of hyaluronic products
that can achieve similar results, and it is ultimately up to the user to find the most
appropriate option. I recommend using serial injection, placing the product on the
periosteum laterally. As one progresses medially on the tear trough, the injections be-
come more superficial while remaining submuscular. The nasojugal fold is the most
superficial and requires great caution to prevent hematoma and/or a Tyndall effect.
Care must be exercised so that the product is not deposited in the septum or the
malar fat pad, because this can cause prolonged edema and will be counterproduc-
tive. A useful strategy is to inject 2 to 3 mm below the obvious tear trough and mas-
sage the area to mold the end result, thus almost guaranteeing that the product is
not placed into or under the orbital septum. Linear threading is placed more nasally
to avoid visible lumps and bumps.
Care is taken to not overcorrect. Patients are made aware of the option to do a sec-
ondary injection 2 weeks later, if needed. This is much better than having to use
hyaluronidase to break down too much product. Secondarily, hyaluronic acid filler
can be injected to restore and lift the lateral brow and reinforce the brow apex. This
injection technique requires deep injection and care to avoid the supraorbital neu-
rovascular junction. Typically, I do not exceed 0.2 to 0.3 ml of product. I have found
that filler in this area will consistently last more than 12 or more months, and I have
seen patients with persistence beyond 24 months. This provides a great “trial run”

for a patient who is uncertain about the degree of correction desired or who wishes
to avoid surgery at all costs. These options can also be used in a patient wanting only
segmental correction, such as limiting the correction to just the brow and upper eye-
lids and using filler and botulinum toxin for the lower eyelid and cheek. Fillers pro-
vide an amazing option for correction in patients of color, providing a great deal of
forgiveness and user friendliness for the surgeon.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color
Although the result is not surgical, one can see this patient’s enhanced appearance
following hyaluronic acid injection to the tear trough. The longevity of this filler is
typically more than 12 months and in some cases more than 2 years because of the
relative lack of tissue movement in the tear trough and brow. In addition, the injec-
tions involve minimal downtime.
Avoiding Problems
There are several advantages to treating the skin of patients of color. The overlying
skin is often more robust and shows fewer rhytids over time. This means that surgi-
cal intervention will focus on deeper tissue changes, in particular restoration of ptotic
tissue and lost soft tissue volume. As already noted, a common and avoidable omis-
sion is failure to use past patient photos, which can provide a roadmap to success.
Youthful photos also aid in appropriate planning for positioning of the lateral can-
thal mechanism. Failure to reposition the lateral canthus will not only result in a
poor cosmetic outcome, but will also place the patient at increased risk for lid mal-
position. It is important to plan the use of soft tissue fillers in these patients, either
nonpermanent products or autologous fat.

The transconjunctival deep plane midface lift allows preservation of the orbicularis
function while providing direct access to the ptotic cheek tissue and a mechanism
for restoration of a visible tear trough. To avoid difficulty with this procedure, I rec-
ommend using an insulated surgical system made up of insulated retractors and an in-
sulated needle tip cautery. In addition, the use of a fine, double-armed skin hook fa-
cilitates holding the deep midfacial tissue for suture placement. I recommend working
from medial/nasal to lateral for suture fixation. The canthopexy should follow the
midfacial suspension, but the canthopexy should not be expected to support the mid-
face alone. Conservative skin removal is recommended to avoid widened scars or vis-
ible extensions.
Perception is reality. This is extremely important in aesthetic surgery, but it is espe-
cially so in patients of African heritage, given their culturally specific ideals of beauty.
I prefer to meet with the patient at least twice; the focus of our discussion is on the
patient’s desired outcome. I make the patient aware that I will undercorrect rather
than overcorrect, allowing for later modification as needed. This places the patient
in the copilot seat and limits the potential for a later perception of failure. When
there is doubt about the patient’s long-range outcome goals, a temporary option
such as fillers and neurotoxins may be used.
Rhinoplasty
Nasal aesthetic surgery in people of color is very clinically and culturally specific.
Despite past attempts to compare the noses of white patients and patients of color,
the aesthetic goals are very different for each. In addition, the underlying structures
differ from those of white patients. Defining points such as alar width, tip fullness,
and radix height are inherently distinct in different racial/ethnic groups. If one looks
at individuals who personify beauty in the African, Latin, or Asian cultures, the
norms for whites do not fit. Adding to the complexity, there is no one universal
African, Latin, or Asian nose; there are multiple ideals within ethnic groups and mul-
tiple cultures. There have been unfortunate examples in the popular media demon-
strating how inappropriate attempts at changing one’s ethnic character to another
can be; the results are always obvious and unnatural.
Although much can be gleaned from past teachings, there are limitations and pitfalls
to the unswerving use of past approaches. In particular, I am not trying to “correct”
or “gentrify” a patient’s nose, but rather to enhance the appearance and bring it
closer to a given ethnic/familial definition of beauty and balance. The following dis-
cussion represents my personal approach to ethnic rhinoplasty and will focus on use-
ful concepts that can be molded to an individual practice.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color
Preoperative Planning
In general, I use the patient’s family photos as a useful guide to the individual’s aes-
thetic goals. This is extremely useful in patient consultation and in defining the de-
sired end result. Unfortunately, present-day virtual simulation is not accurate enough
to predict an ethnic patient’s end result because of the intrinsic variability of defin-
ing points. Of the patients referred to my practice who have undergone surgery else-
where, more than 50% of the cases involved the use of morphing software that the
patients perceived as an implied guarantee. Occasionally I see patients who wish to
completely change their ethnic identity—to assume the characteristics of another
racial identity. I advise surgeons to employ extreme caution in this very small and
dangerous subset of patients, because ultimately they will be extremely difficult to
satisfy.
Although I prefer to produce a slightly undercorrected result, at the time of surgery
the result must look slightly overdone to make up for the tendency of the skin enve-
lope to swell significantly and the loss of tip support during the recovery period. This
woman presented with severe lack of nasal tip support, to the point of complete col-
lapse when she smiled. She did not want a drastic change, but to have a nose that
looked more like her mother’s.
Preoperative
1 week postoperatively
2 years postoperatively

102
Part I  Fundamentals
An open-tip primary rhinoplasty was planned, beginning with a cephalic trim leav-
ing 7 mm of lower lateral cartilage. The dorsal hump was reduced under direct vi-
sion, with a formal septoplasty for correction of an obstructing septal deviation to
the left and harvest of donor cartilage. The nasal tip was then augmented with a col-
umellar strut and placement of dome sutures. The alar flaring was managed with an
internal diamond excision, as shown. Finally, the proximal nasal base was narrowed
with a low-to-low nasal sidewall fracture. The progressive change in the preopera-
tive and postoperative photos is shown on p. 101.
2
1
3
5
1
4
2
6

I prefer autologous tissue to alloplastic material in every case, but there are instances
in which the donor supply is limited and/or the patient does not accept the risk of
donor harvest. In these cases, it is vital to get complete soft tissue, beyond skin alone,
to allow for long-term tissue integration and limitation of extrusion. Unfortunately,
septal donor material is often limited if an extensive augmentation is planned. In gen-
eral, I prefer to use auricular and costal cartilage, respectively, if available. If a pa-
tient is keloid prone, I will preferentially use alloplastic material rather than risk the
development of ear or chest keloids. In patients with poorly controlled acne, I defer
alloplastic implantation until the acne is under control and appropriate prophylac-
tic treatment has been done.
In a patient of color who is uncertain about the idea of surgery or the end result,
hyaluronic acid filler injection, used with caution as an off-label indication, can be
a powerful tool. This is useful not only for demonstration purposes but also offers
a reasonably long-term solution, typically more than 12 months, and favors the
thicker skin envelope found in patients of color. This is an advanced application that
requires significant understanding of the vascular anatomy to avoid inadvertent in-
travascular injection. A prime advantage is the ability to use hyaluronidase injection
in patients who wish to remove the enhancement, typically providing complete res-
olution in 24 hours or less.
Before surgery, patients are made aware of the typical use of steroid injections dur-
ing postoperative recovery. Patients are typically considered for their first injection
of triamcinolone at 6 weeks after surgery. The injection is always placed deep to the
dermis with a microdroplet injection technique in the tip. A 27-gauge or smaller nee-
dle is used and a concentration of 40 mg/ml is used so that the medication can be
diluted 50%, with 1% lidocaine. A typical injection for my African American pa-
tients is 5 to 10 mg; I do not defat the dermis at the time of surgery. I then consider
an additional injection of a steroidal agent at 3, 6, and 12 months after surgery.
At all costs, I avoid visible scar placement. The use of Weir alar excisions can typi-
cally be avoided by using the internal alar excision, completely hiding the future scar,
as demonstrated on p. 101. Most primary cases are done via an open approach, us-
ing the natural recess located in the slightly hyperpigmented area at the columellar-
labial angle. This scar is very forgiving, and I have used it with good results in pa-
tients with a history of keloids.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color

The most common approach performed for a primary African, Asian, or Latin rhino-
plasty patient consists of an open tip with use of a septal strut, lower lateral cephalic
trim, and removal of the fibrofat pad collection at the crural dome. Lateral nasal in-
fracture is used to blend the width between the tip and radix. Typically, the dorsum
is left at its native height or is augmented with a cartilage or dermal fat graft onlay,
depending on the patient’s desired aesthetic endpoint.
Face Lift and Soft Tissue Restoration
With Autologous Fat Grafting
Darker-skinned individuals have a tendency to age prematurely in some areas and
late in others as a result of adipose tissue atrophy, bone remodeling, and gravita-
tional soft tissue changes. Individuals of African heritage tend to manifest signs of
aging in the deeper muscular layers of the face, with sagging of the malar fat pads
toward the nasolabial folds. The folds become prominent and cheek ptosis is noted.
Given the thicker dermis and subcutaneous tissue of some darker racial/ethnic groups,
combined with infraorbital hypoplasia, midface aging can occur at an earlier age.
For all the reasons mentioned earlier, rhytidectomy in skin of color can often be de-
ferred or even avoided, given the availability of minimally invasive technology. How-
ever, there are appropriate indications for soft tissue repositioning and correction of
facial rhytids in darker skin. The challenge I face is the nature of the procedure and
the increased risk for adverse events. In particular, I know that hypertrophic and/or
keloid scar formation may be exacerbated by increased skin closure tension, foreign
body reactions or inflammation, and the patient’s genetic factors. Therefore a simple
skin-tightening procedure can be the start of disfiguring scars, as you can see on p. 105.
I have found that the use of progressive-tension sutures in this patient group helps
to diffuse the ultimate resting tension on the periauricular skin closure. In addition,
focusing on deep tissue repositioning helps to decrease the reliance on “tight” skin clo-
sure. In addition, I prefer to use nonabsorbable suture for the middermal to super-
ficial dermal closure, which I remove within the first 7 to 10 days. Finally, I remove
significantly less redundant skin than in a white patient to minimize skin tension.
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Part I  Fundamentals
1
4-1 African American
rhinoplasty

This woman illustrates the result of a “lunchtime” skin lift. One can see how skin
tension can lead to devastating complications. She is seen less than a month after
surgery.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color
The patient is shown 6 months after a secondary face lift using a SMAS plication
with conservative skin excision and internal progressive skin tension sutures. It is im-
portant to note the limited skin undermining, exposing only the lateral aspect of the
midface–malar fat for suture plication.
My preferred facial rejuvenation procedure is the SMASectomy or SMAS plication
procedure, especially in skin of color, allowing composite preservation and reposi-
tioning of soft tissue, but a variety of other approaches can achieve good results
as well. The key is to reduce the provoking factors for poor scar in skin of color—
primarily unrestricted tension. If I am ever in doubt or the patient has a question-
able history of keloid formation, especially on the earlobe, I will either defer a face
lift or consider an isolated postauricular approach, because the scar is easier to cam-
ouflage and/or treat with an intralesional steroid injection.

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Part I  Fundamentals
This second face-lift example is a woman who presented more than 2 years after a
SMASectomy face lift, with autologous fat injection to the nasolabial folds and mar-
ionette grooves. The patient has a natural, well-maintained result that avoids the scar
issues seen in the patient on p.105. This case illustrates the importance of not plac-
ing the skin under excessive tension.
Fat Grafting
Autologous fat grafting can be performed alone or in combination with other pro-
cedures, using a variety of anesthesia options, including a local anesthetic only. I pre-
fer to use the lower abdomen or flank as the primary donor site. Injection of tumes-
cent local anesthesia, 60 ml 1% lidocaine with epinephrine 1:100,000 diluted into
250 ml normal saline solution plus 10% bicarbonate. Accordingly, the recipient site

is anesthetized using 1% lidocaine with epinephrine. Fat is aspirated using the
Byron instrumentation (Byron Medical, Tucson, AZ), which offers graded cannulas.
The harvest is then concentrated using a Telfa pad, strainer, or centrifuge, depend-
ing on the setting. Typically, 25% more volume than needed is injected. Care is taken
to avoid bolus injection, and a microdroplet technique is used. The fat is injected into
the subcutaneous layer accordingly. The puncture sites on the skin are not sewn but
rather closed with Steri-Strips or a simple gauze covering to prevent suture marks
that could hyperpigment during the healing process.
It is vital to use some form of silicone sheeting and/or scar massage during the acute
healing phase, usually for the first 4 to 6 weeks or more. I typically see these patients
two or three times during the first 6 weeks to assess for any evidence of scar hyper-
trophy or keloid formation. If there is evidence of such a scar process, intralesional
steroid injections are very effective.
Adjunctive Nonsurgical Procedures
Laser
Skin resurfacing in skin of color can be very challenging, but the delayed nature of
aging makes some of the light-based technologies an attractive option. In addition, the
use of less-invasive technology can be coupled with minimally invasive surgical and
nonsurgical technologies to provide the best of all worlds for this specific patient
group. Although traditional ablative technologies such as CO2 laser resurfacing may
pose challenges to the treatment of darker skin, the newer wave of fractional and
nonablative modalities offers significant benefits. Skin of color features the unique
paradox of offering inherent protection from actinic damage, dense sebaceous sup-
port to lubricate the skin, and relative thickness, making it very nice to work with
in all forms of handling. Yet it is much more prone to postinflammatory hyperpig-
mentation and adverse scar formation with resurfacing.
The primary indications for laser therapy in skin of color include hair reduction and
treatment of dyschromia, texture irregularities, and scars. There are several critical
considerations when considering laser treatment in these patients. The basics must
be followed, such as shaving hair before laser hair reduction to avoid excessive en-
ergy uptake in surface hairs that can cause severe burns. In addition, many cases bene -
fit from a patch test treatment before undertaking the definitive first treatment. Derm -
abrasion is really the benchmark for skin resurfacing in skin of color; it has been
used for more than a century.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color

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Part I  Fundamentals
This patient is seen before and after two sessions of dermabrasion to treat severe
forehead dyschromias. The technique is relatively low technology and offers the tech-
nician depth control and accuracy in uneven pigmentation cases, as this case demon-
strates. I often use dermabrasion for treatment of active or chronic acne. This tech-
nique can be employed as a pretreatment before laser resurfacing or hair removal.
Before any resurfacing, it is vital to have patients use strict sunscreen protection of
at least SPF 20 for 2 to 4 weeks before the treatment. In addition, although hydro-
quinone and retinoic acid use is beneficial for preparation of the skin and control of
pigmentation after the treatment, patients typically defer retinoic and hydroquinone
treatments for 1 week before and after resurfacing. During the treatment, two-phase
cooling is vital to prevent thermal postinflammatory hyperpigmentation. To prevent
complications, it is vital to respond quickly to a patient complaint of pain; a dis-
proportionate complaint of pain is an automatic indication to halt treatment and
reconsider the approach. Before the procedure, the need for realistic expectations is
discussed with patients so they will understand that the treatment process will likely
require a full year or more to achieve the greatest level of correction or enhancement.
The concept of selective photothermolysis is a concept developed in 1983 by An-
derson and Parrish. The concept is vital to the understanding of skin of color. Frac-
tional laser technology and nonablative capabilities are very attractive, given the ten-
dency for energy to focus on melanin. With the gridlike effect seen with fractional
laser treatment, there is less absolute injury and areas that are spared to aid in der-
mal recovery.

This woman with Fitzpatrick type IV skin requested treatment of active acne and
related scars. Her acne scars were initially treated with three rounds of dermabra-
sion. Once the acne was brought under control, a combination of nonablative and
ablative laser resurfacing was performed with the use of the Palomar fractional er-
bium laser system. The wavelengths used were 1540 nm for nonablative treatment,
two sessions, and 2940 nm for ablative treatment, one session. The 6-month post-
operative results are shown. Her regimen following skin resurfacing consisted of ap-
plications of silver sulfadiazine during the 5 days of reepithelialization, sunscreen
protection at all times, and generalized cleansing of the skin. After 2 weeks, the pa-
tient used skin bleach (fluocinolone/hydroquinone/tretinoin [Tri-Luma] was pre-
ferred) for 4 to 6 weeks.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color

Fillers
The use of fillers in skin of color has many advantages and enjoys the same safety
and efficacy profile seen in white patients. Because of the increased thickness of pa-
tients’ skin and the darker pigment, the injection of product into the dermis tends
to blend very well. In addition, longevity of effect appears to be at least the same if
not greater in skin of color.
Based on my research with Dr. Grimes, I have found that several points should be
considered regarding injectable fillers. In particular, the primary goal of any injec-
tion in skin of color is to minimize the number of needle perforations to the epider-
mis to reduce the risk of postinflammatory hyperpigmentation. In addition, it is im-
portant to inject the material into the deeper dermis to minimize the risk of
dermal-epidermal separation, which can lead to epidermolysis and postinflamma-
tory hyperpigmentation. Therefore our preferred technique, when possible, is linear
threading with a 1- or 1.5-inch needle. To our knowledge, and based on a review of
the current literature, there have been no reported cases of keloid or hypertrophic
scar formation after the injection of hyaluronic, hydroxyapatite, or collagen fillers.
Synthetic fillers are extremely advantageous in individuals of color who do not want
to undergo surgical intervention. In particular, volume restoration to the midface
can be readily achieved with a combination of deep injection to the submalar and
tear-trough regions. In addition, the nasolabial folds and marionette grooves are fur-
ther filled and corrected. Finally, with mild jowl formation, the prejowl sulcus can
be filled, giving an appearance of a “liquid face lift.”
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Part I  Fundamentals
In patients with few rhytids, significant results can be achieved by injecting hyaluronic
acid into the nasolabial folds, prejowls, and marionette grooves.

Concluding Thoughts
The use of expanded techniques in persons of color can lead to very safe, predictable
outcomes. The material presented can form a framework for both clinical applica-
tion and scientific investigation.
Clinical Caveats
Rhinoplasty
 The surgeon reviews family photos when possible as a guide in planning intervention.
 Overprojection and overrotation of the nasal tip should be avoided.
 Postoperative deep tissue steroid injections should be planned.
 An open incision is placed at the nasal–upper labial junction, in the natural shadow.
 The use of morphing software to demonstrate potential results may lead the pa-
tient to have false expectations of what is possible, leading to patient dissatisfaction.
Autologous Fat Grafting
 Excessive skin resection and/or tight skin closure must be avoided.
 Absorbable suture closure on superficial skin should be minimized.
 Soft tissue restoration should be seen as a primary tool; face lifting is secondary
in skin of color.
Adjunctive Nonsurgical Procedures
 A pretreatment patch test for laser patients is advisable.
 Laser settings should be conservative.
 Dermabrasion is the benchmark procedure for skin resurfacing.
 Filler is injected into the deep dermis.
 Fillers can serve as a supplement or substitute in facial rejuvenation.
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Chapter 4  Facial Aesthetic Surgery in Skin of Color

Annotated Bibliography
Baker DC. Lateral SMASectomy, plication, and short scar facelift: indications and techniques.
Clin Plast Surg 35:533-550, 2008.
This review of less-invasive face-lift techniques is outlined by a single surgeon. The fo-
cus is on significant results with less scar burden, a concept that is particularly appeal-
ing to persons of color.
Few J. Rejuvenation of the African American periorbital area: dynamic considerations. Semin
Plast Surg 23:198-206, 2009.
A comprehensive review of African American periorbital considerations is presented.
Few JW, Lorente O. Transconjunctival deep plane midface rejuvenation. In de Castro C,
Boehm K, Codner, MA, eds. Midface Surgery. Techniques in Aesthetic Plastic Surgery
Series. Philadelphia: WB Saunders, 2009.
The authors discuss how to minimize potential complications in midfacial rejuvenation.
There is a focus on minimizing visible scar by using a transconjunctival approach to the
lower eyelid and midface.
Grimes PE, Few JW. Injectable fillers in skin of color. In Carruthers J, Carruthers A. Proce-
dures in Cosmetic Dermatology: Soft Tissue Augmentation, 2nd ed. Philadelphia: WB
Saunders, 2008.
The authors discuss the growing use of injectable fillers and toxins in skin of color. There
is an emphasis on technique in darker skin and avoiding known complications in this
subgroup of patients.
Hoefflin SM. Ethnic Rhinoplasty. New York: Springer-Verlag, 1997.
Ethnic rhinoplasty is reviewed in persons of Latin, African, and Asian descent. A vari-
ety of principles are outlined in a very concise fashion.
Odunze M, Cohn A, Few JW. Restylane and people of color. Plast Reconstr Surg 720:2011-
2016, 2007.
A formal prospective review of Restylane injection in persons of color. The safety and
efficacy of this filler is outlined, with long-term follow-up. Methods of avoiding com-
plications are reviewed.
Odunze M, Reid RR, Yu M, Few JW. Periorbital rejuvenation and the African American pa-
tient: a survey approach. Plast Reconstr Surg 118:1011-1018, 2006.
Perceptions of eyelid beauty in African American women is outlined using a survey ap-
proach. This article discusses the basis for surgical treatment around the eye in women
of color from a patient perspective and sets the stage for the rejuvenation of the lateral
canthus.
Odunze M, Rosenberg DS, Few JW. Periorbital aging and ethnic considerations: a focus on
the lateral canthal complex. Plast Reconstr Surg 121:1002-1008, 2008.
A large series of photographs is reviewed to evaluate the rate of descent of the lateral
canthus with aging in various racial and ethnic groups. The authors point out the im-
portance of repositioning the lateral canthus in rejuvenation surgery and how a failure
to do so leads to incomplete correction of the aging process.
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113
Chapter 4  Facial Aesthetic Surgery in Skin of Color
Suggested Readings
Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective ab-
sorption of pulsed radiation. Science 220:524-527, 1983.
Brissett A, Chike-Obi C, Cole P. Keloids: pathogenesis, clinical features, and management.
Semin Plast Surg 23:178-184, 2009.
Bullocks J, McKnight A, Momoh A. Socioeconomic impact of ethnic cosmetic surgery: trends
and the potential financial impact the African American, Asian American, Latin Amer-
ican, and Middle Eastern communities have on cosmetic surgery. Semin Plast Surg
23:163-167, 2009.
Bullocks J, Cole P, Hatef D, et al. Skin care in ethnic populations. Semin Plast Surg 23:168-
172, 2009.
Chan H. Ablative and nonablative resurfacing in darker skin. In Grimes PE, ed. Aesthetics
and Cosmetic Surgery for Darker Skin Types. Philadelphia: Wolters Kluwer, 2008.
Cole P, Hatef D, Kaufman Y, et al. Laser therapy in ethnic populations. Semin Plast Surg
23:173-177, 2009.
Draelos Z. Cosmeceuticals in ethnic skin. In Alam M, ed. Cosmetic Dermatology for Skin
of Color. New York: McGraw-Hill, 2009.
Flowers RS. The open approach to forehead and brow lifting. Aesthet Surg J 18:463-464,
1998.
Grimes PE. Beauty: an historical and societal perspective. In Grimes P, ed. Aesthetics and
Cosmetic Surgery for Darker Skin Types. Philadelphia: Wolters Kluwer, 2008.
Grimes PE, Sherrod Q. Structural and physiologic differences in the skin of darker racial eth-
nic groups. In Grimes PE, ed. Aesthetics and Cosmetic Surgery for Darker Skin Types.
Philadelphia: Wolters Kluwer, 2008.
Jelks GW, Glat PM, Jelks EB, et al. The inferior retinacular lateral canthoplasty: a new tech-
nique. Plast Reconstr Surg 100:1262-1270, 1997.
Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharo-
plasty. Plast Reconstr Surg 97:1334-1342, 1996.
Rendon M. Skin-lightening agents. In Grimes PE, ed. Aesthetics and Cosmetic Surgery for
Darker Skin Types. Philadelphia: Wolters Kluwer, 2008.

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Photographic Essentials
in Aesthetic Surgery

FARZAD R. NAHAI, WILLIAM Y. HOFFMAN
CHAPTER 5

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Part I  Fundamentals
P
hotography and plastic surgery are inextricably intertwined, both in history
and in today’s practice. The development and popularization of photography
in the 1800s gave people a new medium by which to measure, perceive, and evalu-
ate themselves. Even for people of modest means, a photographic portrait was a spe-
cial event, taken by itinerant photographers who carried their equipment with them.
Most small towns had a photographic studio offering portraiture at a moderate cost.
Certainly, popular photography had and still has a role in the general public’s per-
ception of themselves and can arguably be linked to the development of plastic sur-
gery. Images of youth, beauty, and health pervade our daily lives. Often these pho-
tographic images are brought to the plastic surgeon as a representation of a patient’s
aesthetic goal.
Our patients are keenly aware of our reliance on photography as a diagnostic, doc-
umentary, and assistive tool. Photographs serve as records and legal documents. Be-
cause so much of plastic surgery is visually driven and amenable to photographic
documentation, it is critical that we have a formal understanding of photographic
techniques and strive for standardization of methods. We must apply these standard
methods when producing photographic documentation in plastic surgery so that we
have the means to accurately and adequately record patient outcomes and to com-
pare preoperative and postoperative results. The recent advent of digital photogra-
phy and its revolutionary effect on image creation has had a significant impact on
the field of plastic surgery. This new technology has expanded our capabilities for
photographic documentation, storage of and access to photographs, and even pa-
tient consultation.
History
In 1839, the process of making photographs, first named the daguerreotype after
Louis Daguerre, was introduced; the remarkably clear images were called “mirrors
with a memory.” It was in that same year that Sir John Herschel coined the term
photography, which is derived from the Greek words for “light” and “writing.” The
popularity of photography grew, and soon physicians of that era were using this new
medium to record clinical conditions. In 1845, Gordon Buck, a New York surgeon,
was the first to create a clinical photograph, a daguerreotype of a leg fracture. How-
ever, the original daguerreotype was only capable of producing a single photograph—
in a sense an original piece of art that could not be duplicated. The wet-plate tech-
nique, introduced by Frederick Scott Archer in 1851, made photographic prints
possible. With this new capability, Dr. Buck was able to take multiple photographs
of his cases, including cleft lip repairs.

The next big step forward was the development of the dry-plate technique and cel-
luloid film. George Eastman pioneered the mass production of film that could be
stored in a roll. In 1881 he founded his company in Rochester, New York, which
later became Eastman-Kodak. The first roll camera, the Kodak, was then introduced
by Eastman in 1888 with the slogan “You push the button—we do the rest,” repre-
senting the birth of snapshot photography.
Photography Basics
Before addressing the issue of photography in plastic surgery, surgeons must have a
basic understanding of how photographs are made and what equipment is needed
to produce high quality images. These basics are applicable to both 35 mm film pho-
tography and digital photography. Today most plastic surgeons have adopted digital
photography. In this introduction we will discuss the camera, the digital sensor, lens,
and flash. A discussion of film is included as a historical reference and as a founda-
tion to understanding the common terminology still used in digital photography.
The Camera and Optics
Capturing an image involves exposing the medium onto which the image is recorded
(that is, a digital sensor chip or silver-based film) to an appropriate amount of light.
The camera or lens contains a shutter that controls the amount of time that light is
allowed to strike the medium. Within the lens is a diaphragm that acts much like the
iris of the eye; it controls the exposure, or amount of light, that enters the film cham-
ber (or the chip, in a digital camera). The shutter and diaphragm act in concert to
control the exposure of the subject onto the recording medium.
Single-lens reflex (SLR) cameras contain a mirror in front of the shutter that pro jects
the exact image seen by the lens to the photographer through a viewfinder. In “point-
and-shoot” cameras, separate optics permits the photographer to see what the cam-
era is “seeing.” In today’s digital point-and-shoot cameras, images gathered through
the lens are also seen on liquid-crystal display (LCD) monitors.
The characteristics of the lighting environment dictate how much light is exposed to
the recording medium (chip or film) and the duration of exposure. A built-in light
meter in the camera calculates the best-fit exposure to record that scene. Exposure
is controlled by shutter speed and aperture. Shutter speed is generally measured in
fractions of a second (1⁄250 sec, 1⁄500 sec, 1⁄1000 sec) and refers to the amount of time
that the shutter within the camera is open. Aperture refers to the diameter of the
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Chapter 5  Photographic Essentials in Aesthetic Surgery

opening of the diaphragm and is commonly referred to as the f-stop or f-number.
The f-stop is typically described in terms of f/4, f/5.6, f/8, f/11, and so forth. It is an
inverse relationship: the larger the f-number, the smaller the aperture, and therefore
the less light that is allowed in. With the many available shutter speeds and f-stops,
there are numerous metering combinations that result in the same exposure. This is
an important concept to comprehend in understanding how optics and camera set-
tings can affect photographs.
The concept of depth of field is critical in clinical photography. It refers to the dis-
tance in front of and behind the focal plane, or the subject in focus in the photo-
graph, that remains in focus. A shallow depth of field means there is a small distance
about the focal plane that is in focus; as the depth of field increases, so does the area
in front of and beyond the focal plane that is in focus. Three factors control depth
of field: the aperture, subject distance, and focal length of the lens. Assuming a fixed
focal length and subject distance, the aperture may be manipulated to minimize or
maximize the depth of field. A large aperture (f/3) has a shallow depth of field, thus
making anything beyond or in front of the subject blurry. As the aperture increases
(for example, to f/8), the depth of field lengthens and more objects within a certain
range of the focal point will appear in focus.
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Part I  Fundamentals
The three photographs above are good examples of the aperture-setting effect on
depth of field. The first photograph was taken at f/4.5, the second at f/8, and the
third at f/16. These chess pieces were set 24 inches from the camera and 1 inch from
each other. Notice how much more of the photograph is in focus with the larger
aperture setting on the right.
f/4.5
f/8
f/16

This is a clinical example of the same phenomenon. The photograph on the left was
taken at f/2 and the one on the right at f/8. Notice how in both photographs the tip
of the nose is in focus, but only in the larger-aperture photograph are the eyes and
forehead also in focus. This effect, which is based on aperture setting, must be con-
sidered when selecting camera settings in a clinical situation. In general, clinical pho-
tographs should be taken with a larger aperture number (f/8 or f/11) (smaller actual
aperture size) to ensure crisp focus throughout.
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Chapter 5  Photographic Essentials in Aesthetic Surgery
Barrel distortion is a lens effect that causes images to be spherized at their center.
This type of distortion typically occurs with wide-angle lenses and at the wide end of
zoom lenses. The photographs above show an example of barrel distortion with a
wide-angle setting. The photo on the left is taken with an 80 mm lens and the one
on the right with an 18 mm lens. One can notice the robust effect a change in focal
length alone can have on an image. In the clinical setting, subjects can appear rounded
and centrally full or projective when, in fact, they are not.
f/8
f/2

The three-dimensional opposite of barrel distortion, pincushion distortion, is a lens
effect that causes images to be pinched in their center. This is associated with the
telephoto end of zoom lenses or with the addition of a telephoto adaptor. Because
of these types of distortion, wide-angle and zoom lenses are not recommended for
clinical use.
Lenses
Lenses are made up of multiple elements, usually individual concave and convex
glass lenses, the combination of which gives a lens its operating characteristics. Lenses
come in many different sizes, called focal lengths, based on the distance in millime-
ters from the posterior element to a point at which parallel rays of light are focused.
The characteristics of a lens are largely based on its focal length.
A “standard” lens (one that does not magnify or diminish the size of an image) for
any film or sensor size can be calculated based on the diagonal of the film. For ex-
ample, the calculated standard lens size for 35 mm film is 35 by 24 mm, making its
diagonal 43 mm. (Despite this calculation, 50 mm is the accepted standard.) This is
an important concept to understand when using interchangeable lenses on digital SLR
cameras, which for the most part have sensor chips that are smaller than the dimen-
sions of 35 mm film. As a result, the standard lens on a digital SLR camera would, in
fact, be a shorter focal length. Conversely, the same lens on a digital SLR will be the
equivalent of a longer focal length 35 mm lens; for a digital sensor that is two thirds
the size of 35 mm film, a 60 mm lens would behave like a 90 mm lens on a digital
camera. As digital sensors are developed that increase in dimension and match the
size of 35 mm film, this discrepancy will no longer be an issue, and lenses can be freely
interchanged without concern for converting focal length (at present such sensors are
available but are prohibitively expensive). For point-and-shoot cameras, the range of
a lens is usually expressed in “35 mm equivalent” to make comparisons easier.
Lenses less than 50 mm in focal length are considered wide angle, and lenses greater
than 50 mm in focal length are considered telephoto. Zoom lenses can traverse a
range of focal lengths. Wide-angle lenses are good for panoramic/wide views, and
telephoto lenses are good for viewing objects that are far away. Later in this chapter
we will discuss how shutter speed, aperture, and lens optics affect the taking of pho-
tographs and how these apply to the plastic surgery setting.
Flash
The flash plays an integral role in photography in the plastic surgery setting. Clini-
cal photographs are taken indoors in variable lighting conditions. Therefore it is im-
portant to have a reliable light source, comprehend how it works, and understand
how flash photography can affect the images produced. The intensity of the flash de-
termines the f-stop that can be used; the f-stop (as discussed earlier) determines the
depth of field. Proper use of the flash enables small apertures and more depth of field.
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Part I  Fundamentals

Too much flash and improper aperture settings can result in washed-out photographs
that lack definition and exhibit poor color quality.
Flashes on point-and-shoot cameras are typically mounted on one side of the cam-
era at a relatively short distance from the lens. SLR cameras have a mount for the
flash, usually above the lens, in addition to connectivity capabilities to operate mul-
tiple flashes at a distance from the lens. This is important because multiple flashes
eliminate shadows. The “red eye” effect of point-and-shoot flash photography is a
symptom of the flash being positioned too close to the lens. Some cameras have fea-
tures that correct for this problem.
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Chapter 5  Photographic Essentials in Aesthetic Surgery
In addition, attention must be paid to flash position relative to the lens because of
the shadows that are cast. As demonstrated by these photographs, the shadows pro-
jected on the backdrop can have a significant deleterious effect on the composition
of the photos, most notably on lateral and oblique views. A projected shadow should
not be viewable in clinical photography. A simple rule of thumb is that the flash
should be positioned on the same side as the anteriormost part of the patient, plac-
ing the shadow behind the patient, as in the figures on the far right.

Ideally, multiple flashes should be used to eliminate shadows. Twin flashes are avail-
able that mount on the camera and eliminate the problem of sidedness with single-
source flashes. Otherwise, a dedicated space with flashes set up on either side of the
subject, or a committed studio, is needed. The setup of a committed studio will be ad-
dressed later. Ring flashes, flashes that mount at the end of the lens, are used for macro-
photography. These can decrease shadows; however, they tend to make contours dif-
ficult to distinguish so they are used principally for intraoral and dental photography.
Film
Although digital photography is the current norm and some major camera compa-
nies no longer make film-based cameras (Canon stopped in 2006), film has some ad-
vantages over digital images: 35 mm film has excellent resolution, comparable to dig-
ital cameras with 6- to 10-megapixel sensors. Having said this, today’s digital cameras
with resolutions as low as 3 or 4 megapixels offer adequate resolution for clinical
use. Film also represents a stable record that cannot be altered or modified, as digi-
tal images can; when stored properly, it cannot be lost or erased. Photographs made
on quality film (such as Kodak Kodachrome) can last up to 30 years when stored
properly.
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Part I  Fundamentals
Equipment for Clinical Photography
Camera
 With current trends, a digital SLR camera is the optimal choice for clinical photography.
 The camera should have manual controls for aperture and shutter speed to maximize
versatility and control.
 The camera should have manual and autofocus modes and accept interchangeable
lenses.
 A digital camera should have a minimum of 3 to 4 megapixels; 6 megapixels is pre-
ferred for publishing and enlarging photos.
 Although a digital SLR camera is best for a studio setting, the point-and-shoot digital
cameras with a rotating LCD screen offer an advantage for intraoperative photo taking
and awkward camera positions.
Lens and Flash
 Quality fixed focal length lenses should be used: a 50 to 60 mm lens for the body and
a 90 to 100 mm lens for the face.
 The lens should be marked with reproduction ratios.
 At least a top-mounted flash with through-the-lens metering should be used, but
optimally a studio setup with multiple flash units to eliminate shadows is preferred.
 A lens with macro capabilities should be used for closeup photographs.