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

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I
t is unfortunate that during the lengthy process of postgraduate surgical educa-
tion, the vast majority of candidates for certification by the American Board of
Plastic Surgery, as well as candidates in otolaryngology, oculoplastics, and derma-
tology, fail to fully grasp the relationship between aesthetic surgery and psychiatry.
Virtually all such candidates emerge into the clinical world filled with knowledge of
the latest cutting edge techniques in their specialty, but with only the vaguest sense of
the critical importance of appropriate patient selection criteria in elective surgery,
the sine qua non of building a successful career.
The problem is further compounded by several factors. The first is the love affair be-
tween the media and the universe of beauty surgery. The barrage of publicity sur-
rounding new techniques and procedures is inevitably accompanied by promises of
improvements as dramatic as they are trouble free. The second issue is the unfortu-
nate decision by the U.S. Federal Trade Commission, which in the late 1980s enforced
an end to the traditional prohibition of advertising by physicians. This, added to the
fact that aesthetic surgery presents to many practitioners the promise of hassle-free
additional income, further confuses the definition of adequate surgical training quali -
fications and quickly adds a carnival atmosphere to the practice of aesthetic surgery.
Mental health professionals and aesthetic surgeons agree that patients who exhibit
signs that suggest a variety of psychiatric diagnoses are very poor candidates for any
elective surgery. But some disorders, such as body dysmorphic disorder (BDD), come
in many shades of gray. This compounds the difficulty for a surgeon who is not fa-
miliar with warning signs that may seem reasonably obvious to a psychologist.
To confuse matters even more, experienced plastic surgeons can recall patients in
their practices whose minimal to moderate deformities caused disproportionate pa-
tient concern, yet after a well-executed correction, they experienced positive per-
sonality and life changes.
So what should the surgeon’s appropriate response be when faced with a patient
who seems to have an excessive preoccupation with a very slight or imagined de-
formity? Learning to say “No” may sound easy, but it is far more complicated than
it appears (see Chapter 1). Referral to a psychiatrist or psychologist almost always
results in an angry patient who walks out and will, sooner or later, have the proce-
dure done anyway (and will reap the consequences). The only reasonable course left
to the surgeon is to learn as early in his or her career as possible to select among
those shades of gray and where uncertainty exists and to rely on the counsel of more
experienced plastic surgeons or psychiatric colleagues, regardless of the consequences.
Failure to do so produces problems for the surgeon far beyond the value of any sur-
gical fee. In its ultimate (but thankfully rare) form, ignoring the “red flag” warnings
has cost at least five surgeons their lives in the past two decades: all were shot to
death by disturbed patients dissatisfied with their results.

To those whose primary responsibility is the maintenance of the highest quality
in surgical competence and to the risk managers in the professional liability world,
all the continuous dramatic changes in surgical technology have added an ever-
growing challenge and an increasingly heavy burden. However, none of these tech-
nologic advances should change the essential criteria for appropriate patient selec-
tion. In observing these criteria it is impossible to avoid occasional incursions into
the domain of mental health professionals.
Of all medical specialists, the plastic surgeon’s exposure to professional liability is
unique in several respects:
1. The plastic surgeon who performs elective aesthetic surgery is not assuming
the care of a sick or injured patient to make him or her well; rather, it is a
matter of taking a well patient to make him or her better.
2. The patient judges the results of treatment according to standards that are
entirely subjective, and often colored by the patient’s self-image. The actual
result may be good, but if it does not meet the patient’s expectations, it may
be judged a failure.
After years of practicing, teaching, and evaluating claims against plastic surgeons,
I have concluded that the four most critical elements for successful plastic surgery
are these:
1. Competence
2. Appropriate patient selection criteria
3. Documented disclosure
4. True informed consent
The remainder of this section will describe the plastic surgeon’s obligation to the pa-
tient and review in some detail the medicolegal parameters that apply. My primary
purpose is to provide an overview of the significant interface between elective aes-
thetic surgery and the specter of medical liability.
Legal Principles Applied to Plastic Surgery
Standard of Care
Malpractice generally means treatment that is contrary to accepted medical stan-
dards and that produces injurious results in the patient. Most medical malpractice
actions are based on laws governing negligence. Thus the cause of action is usually the
failure of the defendant/physician to exercise that reasonable degree of skill, learn-
ing, and care ordinarily possessed by others of the same profession in the commu-
nity. Whereas in the past the term community was accepted geographically, it is now
based on the supposition that all physicians keep up with the latest developments in
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their field. Thus community is now generally interpreted as a specialty community;
the standards are those of the specialty as a whole without regard to geographic lo-
cation. This series of norms is commonly referred to as the standard of care.
Warranty
The law holds that by merely engaging to render treatment, a physician warrants
that he or she possesses the learning and skill of the average member of that spe-
cialty and will apply that learning and skill with ordinary and reasonable care. This
warranty is one of due care. It is legally implied; it need not be mentioned by the
physician or the patient. However, the warranty is one of service, not of cure. Thus
the physician does not imply that the operation will be a success, or that results will
be favorable, or that he or she will not commit any medical errors not caused by lack
of skill or care.
Disclosure
While attempting to define the yardstick of disclosure, the courts divide medical and
surgical procedures into two categories:
1. Common procedures that carry minor or very remote serious risk (including
death or serious bodily harm); for example, the administration of antibiotics
2. Procedures involving serious risks for which the physician has an affirmative
duty to disclose the potential of death or serious harm and is obligated to ex-
plain in detail the complications that could possibly occur
Affirmative duty means that the physician must disclose risks on his or her own,
without waiting for the patient to ask. The courts have long held that it is the pa-
tient, not the physician, who has the prerogative of determining what is in his or her
best interests. Thus the surgeon is legally obligated to discuss with the patient ther-
apeutic alternatives and their particular hazards to provide sufficient information to
allow the patient to determine what is in his or her own best interest.
How much explanation and in what detail are dictated by a balance between the
surgeon’s feelings about the patient and the applicable legal requirements. It is sim-
ply not possible to tell patients everything without unnecessarily dissuading them
from appropriate treatment. Rather, the law holds that patients must be told the
most probable of known dangers and the percentage of likelihood of an adverse re-
sult. More-remote risks may be disclosed in general terms, but at the same time com-
paring their likelihood of occurring with everyday, unexpected events with unpleas-
ant outcomes. Do patients have the legal right to make bad judgments because they
fear a possible complication? Increasingly, the courts answer affirmatively. Once the
information has been fully disclosed, that aspect of the physician’s obligation has
been fulfilled. The weighing of risks is usually not a medical judgment but is instead
reserved for the patient.
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Obviously, the most common complications should be volunteered frankly and
openly, and their probability, based on the surgeon’s personal experience, should
also be discussed. Finally, any or all of this information is wasted unless it is docu-
mented in the patient’s record. For legal purposes, if it is not in the record, it never
happened!
Informing Your Patients Before They Consent
“Prudent Patient” Test
In many states the most important element in claims involving disputes over informed
consent is the prudent patient test. The judge will inform the jury that there is no li-
ability on the physician’s part if a prudent person in the patient’s position would
have accepted the treatment had he or she been adequately informed of all signifi-
cant perils. Although this concept is subject to reevaluation in hindsight, the prudent
patient test becomes most meaningful where treatment is lifesaving or urgent.
The concept may also apply to simple procedures in which the danger is commonly
thought to be remote. In such cases disclosure need not be extensive, and the pru-
dent patient test will usually prevail.
Refusals
As part of medical counseling, many state laws mandate that physicians warn pa-
tients of the consequences of failing to heed medical advice by refusing treatment or
diagnostic tests. Obviously, patients have a right to refuse. In such circumstances it
is essential that such refusals and their consequences be carefully documented and
that the surgeon verify and document that the patient understood the consequences.
Documentation is particularly important in cases involving malignancy, where re-
jection of tests may impair diagnosis and refusal of treatment may lead to the pa-
tient’s death. It is important to date all such entries in the patient record.
If the information you present includes percentages or other specific figures that al-
low the patient to compare risks, be certain that your figures conform to the latest
reliable data.
Consent-in-Fact and Implied Consent
What is the distinction between ordinary consent to treatment (consent-in-fact) and
informed consent? Simply stated, informed consent verifies that the patient is aware
of anticipated benefits as well as risks and alternatives to a given procedure, treat-
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ment, or test. On the other hand, proceeding with treatment of any kind without ac-
tually obtaining consent is “unlawful touching” and may therefore be considered
battery.
When the patient is unable to communicate rationally, as in many emergency cases,
there may be a legally implied consent to treat. The implied consent in an emergency
is assumed only for the duration of that emergency.
Treating Minors
Except in urgent situations, treating minors without consent from a parent, legal
guardian, appropriate government agency, or court carries a high risk of legal or
even criminal charges. There are statutory exceptions, such as for an emancipated
adolescent or a married minor. If you regularly treat young people, you should famil-
iarize yourself with the existing statutory provisions in your state and keep up to date.
Religious and Other Obstacles to Treatment
Occasionally you may be placed in the difficult position of being refused permission
to treat or conduct diagnostic tests on the basis of a patient’s religious beliefs or per-
sonal convictions. Although grave consequences may ensue, there is little you can do
in most states, beyond making an intense effort to convince the patient to undergo
the tests or treatment. In some states, court intervention may be obtained. Here too,
knowing the law of the state in which you practice is advisable. In all cases the in-
formed refusal must be carefully documented.
If a patient is either a minor or incompetent (and the parent or guardian refuses treat-
ment for the patient) and you know serious medical consequences will ensue if ap-
propriate tests and/or treatment are not undertaken, your legal and moral obli gations
change. You must then resort to a court order or another appropriate governmental
process in an attempt to secure surrogate consent. The participation of personal or
hospital legal counsel is advisable to ensure that the legal requirements applicable in
your locale are met.
The Six Elements of Informed Consent
In situations in which treatment is urgent (for example, in a patient with severe
trauma), it may be needless and cruel to engage in extensive disclosure that could
add to existing anxieties. However, you should inform the patient (or the closest rel-
ative or guardian) fully and completely of the treatment’s risks and consequences
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and document such discussions. The following six elements of a valid informed con-
sent fulfill what the law requires:
1. The diagnosis or suspected diagnosis
2. The nature and purpose of the proposed treatment or procedure and its an-
ticipated benefits
3. The risks, complications, or side effects
4. The probability of success, based on the patient’s condition
5. Reasonable available alternatives
6. The possible consequences if advice is not followed
In situations in which the nature of the tests or treatment is purely elective, as with
cosmetic surgery, the disclosure of risks and consequences may need to be expanded.
Literature available in the surgeon’s office can provide additional details about the
procedure. In addition, an expanded discussion should take place regarding the fore-
seeable risks, possible untoward consequences, or unpleasant side effects associated
with the procedure. This expansion is particularly necessary if the procedure is new,
experimental, especially hazardous, capable of altering sexual capacity or fertility,
or purely for cosmetic purposes.
Documentation
Written verification of consent to diagnostic or therapeutic procedures is crucial.
A simple entry of several lines might suffice, such as: “Have discussed in detail ob-
jectives, technique, and potential complications of procedure. Have also discussed
location and possible appearance of scars and sources of dissatisfaction. All ques-
tions answered. Patient understands and accepts.”
Also remember, however, that in an increasing number of circumstances laws now
require the completion of specifically designed consent forms. Studies indicate that
physicians sometimes actually underestimate the patient’s ability to understand. If
your records disclose no discussion or consent, the burden will be on you to demon-
strate legally sufficient reasons for such an absence. It is a test of your good judg-
ment of what to say to your patient and of how to say it to obtain meaningful con-
sent without frightening the patient. No permit or form will absolve you from
responsibility if there is negligence, nor can a form guarantee that you will not be
sued. Permits may vary from simple to incomprehensibly detailed. Most medicole-
gal authorities agree that a middle ground exists.
A well-drafted informed consent document is proof that you tried to give the patient
sufficient information on which to base an intelligent decision. Such a document,
supported by a handwritten note and entered in the patient’s medical record, is of-
ten the key to a successful malpractice defense when the issue of consent to treat-
ment arises.
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The Therapeutic Alliance
Obtaining informed consent need not be an impersonal legal requirement. When
properly conducted, the process of obtaining informed consent can help establish a
“therapeutic alliance” and launch or reinforce a positive physician-patient relation-
ship. If an unfavorable outcome occurs, that relationship can be crucial to main-
taining patient trust.
A patient’s usual psychological defense mechanism against uncertainty is to endow
his or her physician with omniscience in the science of medicine—an aura of om-
nipotence. By weighing how you say something more heavily than what you say, you
can turn an anxiety-ridden ritual into an effective claims-prevention mechanism. Psy-
chology literature refers to this as the sharing of uncertainty. Rather than shattering
a patient’s inherent trust in you by presenting an insensitive approach, your dialog
should be empathetic to the patient’s particular concerns or tensions and should
project believable reactions to an anxious and difficult situation.
Consider, for example, the different effects that the following two statements would
have:
 “Here is a list of complications that could occur during your treatment [op-
eration]. Please read the list and sign it.”
 “I wish I could guarantee you that there will be no problems during your treat-
ment [operation], but that wouldn’t be realistic. Sometimes there are problems
that cannot be foreseen, and I want you to know about them. Please read about
the possible problems, and let’s talk about them.”
By using the second statement, you can reduce the patient’s image of you as om-
nipotent to that of a more realistic and imperfect human being, who is facing, and
thus sharing, the same uncertainty. The implication is clear: “We—you and I—are
going to cooperate in doing something to your body that we hope will make you
better, but you must assume some of the responsibility.”
To allay anxiety, you may seek to reassure your patients. However, in so doing, be
wary of creating unwarranted expectations or implying a guarantee. Consider the
different implications of these two statements:
1. “Don’t worry about a thing. I’ve taken care of hundreds of cases like yours.
You’ll do just fine.”
2. “Barring any unforeseen problems, I see no reason why you shouldn’t do very
well. I’ll certainly do everything I can to help you.”
If you use the first statement and the patient does not “do fine,” he or she is likely
to be angry with you. The second statement gently deflates the patient’s fantasies to
realistic proportions. This statement simultaneously reassures the patient and helps
him or her to accept reality.
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The therapeutic objective of informed consent should be to replace some of the pa-
tient’s anxiety with a sense of his or her participation with you in the procedure.
Such a sense of participation strengthens the therapeutic alliance between you and
your patients. Instead of seeing each other as potential adversaries if an unfavorable
or less than perfect outcome results, you and your patients are drawn closer by shar-
ing acceptance and understanding of the uncertainty of clinical practice.
Patient Selection Criteria
Contemporary plastic surgeons practicing in the United States will find it virtually
impossible to end their careers unblemished by a claim of malpractice. However, well
over half of these instances are preventable. Most are based either on failures of com-
munication or patient selection criteria, not on technical faults.
Patient selection is the ultimate inexact science. It is a mixture of surgical judgment,
gut feelings, personality interactions, the surgeon’s ego strength, and regrettably, eco-
nomic considerations. Regardless of technical ability, a surgeon who appears cold,
arrogant, or insensitive is more likely to be sued than one who relates at a personal
level. Obviously, a person who is warm, sensitive, naturally caring, and has a well-
developed sense of humor and cordial attitude is less likely to be the target of a mal-
practice claim. The ability to communicate clearly is probably the most outstanding
characteristic of the claims-free surgeon. Communication is the sine qua non of build-
ing a physician-patient relationship. Unfortunately, the ability to communicate well
is a personality characteristic that cannot be readily learned in adulthood. It is an
integral part of the surgeon’s personality. There are, however, a number of helpful
guidelines.
GREAT EXPECTATIONS
There are certain patients who have an unrealistic and ide-
alized yet vague conception of what elective aesthetic surgery is going to achieve for
them. They anticipate a major change in lifestyle, with immediate recognition of their
newly acquired attractiveness. These patients may have an unrealistic concept of
where their surgical journey is taking them and have great difficulty in accepting the
fact that any major surgical procedure carries inherent risk.
THE EXCESSIVELY DEMANDING PATIENT
In general, the patient who brings pho-
tographs, drawings, and exact “architectural” specifications should be managed with
great caution. Such a patient may have little comprehension that the surgeon cannot
sculpt human flesh and blood as one would clay or marble. The patient must be
brought to understand the realities of surgery, the vagaries of the healing process,
and the margin of error that is a natural part of any elective procedure. Such patients
show very little flexibility in accepting any failure on the part of the surgeon to deliver
what was anticipated.
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THE INDECISIVE PATIENT
To the question, “Doctor, do you think I ought to have
this done?” the prudent surgeon should respond, “That is a decision I cannot make
for you. It is one you have to make yourself. I can tell you what I think we can
achieve, but if you have any doubt whatsoever, I recommend strongly that you think
about it carefully before deciding whether or not to accept the risks which I have
discussed with you.” The more the decision to undergo surgery is motivated from
within and not “sold,” the less likely that recriminations will follow an unfavorable
result.
THE IMMATURE PATIENT
An experienced surgeon should assess not only the phys-
ical maturity but also the emotional maturity of the patient. A youthful or imma-
ture patient (age has no relationship to maturity) usually has highly unrealistic ex-
pectations of what the surgery will achieve. When confronted with a mirror
postoperatively, this type of patient is likely to react in disconcerting or even violent
fashion if the degree of change achieved does not coincide with their preconceived
notions.
THE SECRETIVE PATIENT
Certain patients want to convert their surgery into a “se-
cret” and request elaborate precautions to prevent anyone from knowing they are
having surgery. Aside from the fact that such arrangements for secrecy are difficult
to achieve, this tendency is a strong indication that the patient has a degree of guilt
about the procedure. Thus there is a higher likelihood of subsequent dissatisfaction.
FAMILIAL DISAPPROVAL
It is far more comfortable, although not essential, if the
immediate family approves of the surgery being sought, particularly in the case of a
minor. If there is disapproval, errors in communication or less than optimal results,
this produces an automatic “See, I told you so!” reaction, which deepens the pa-
tient’s guilt as well as dissatisfaction.
PATIENTS YOU DON’T LIKE (OR WHO DON’T LIKE YOU)
Regardless of the sur-
geon’s personality, in life there are people you simply don’t like or who don’t like
you. Most experienced surgeons know within minutes of entering the examining
room whether they will or will not be operating on that patient. Accepting a patient
whom you basically dislike is a serious mistake. A clash of personalities, for what-
ever reason, is bound to affect the outcome of the case, regardless of the actual qual-
ity of the postoperative result. No matter how “interesting” such a case may appear,
it is far better to decline the patient.
THE “SURGIHOLIC”
A patient who has had a variety of plastic surgery procedures
performed and who might be called a surgiholic often is attempting to compensate for
a poor self-image by undergoing repeated surgeries. In addition to the implications of
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such a personality pattern, the surgeon is also confronted with a more difficult
anatomic situation as a result of the previous surgeries. He or she also risks unfa-
vorable comparison with previous surgeons. Often the percentage of achievable im-
provement isn’t worth the risk of the procedure.
An experienced surgeon is generally aware that patients often try to conceal their
true motivation for surgery. This can be a minefield for the surgeon and can result
in far-reaching, unpleasant end results.
Generally speaking, there is a clear risk-benefit ratio to every surgical procedure. If
the risk-benefit ratio is favorable, the surgery should probably be encouraged and
has a high probability of success. If the risk-benefit ratio is unfavorable, the reverse
not only applies, but also the unintended consequences of the unfavorable outcome
may turn out to be disproportionate to the surgical result. The only way to avoid a de-
bacle is to learn how to distinguish those patients whose body image and personal-
ity characteristics make them unsuitable for the surgery that they seek.
The Wheel of Misfortune: Exposures Most Likely
to Generate Claims
It should come as no surprise that the overwhelming majority of malpractice claims
lodged against plastic surgeons are concentrated in a handful of aesthetic surgery
operations. Unlike other surgical specialists, the plastic surgeon attending a patient
who seeks aesthetic improvement is not trying to make a sick patient well, but rather
a well patient better. This not only places a much heavier burden of responsibility
on the operating surgeon, but also subjects him or her to a much broader range of
possible reasons for patient unhappiness. Sources of dissatisfaction can range from
a catastrophic result to something as unpredictable as a patient’s hidden emotional
agenda or a simple communications failure.
Competitive pressures in the last few years have also blurred strict criteria for pa-
tient selection. As a result, it is not surprising to see a steadily upward trend in the
frequency of claims against plastic surgeons. We have surveyed approximately 1000
plastic surgeons about the genesis of patient complaints across 15 years’ experience.
Losses from lawsuits against plastic surgeons are notable for their frequency rather
than their severity (a large number of claims alleging relatively minor damages). Al-
though severity has never characterized plastic surgery’s loss experience in the past,
the clear trend is toward ever-larger awards, particularly in cases in which an elec-
tive procedure has resulted in a patient’s death.
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A pie chart shows the distribution of aesthetic surgery claims in our practice in 2009.
Scarring
Most surgeons assume the patient understands that healing involves the formation
of scar. Unfortunately, this is seldom discussed in the preoperative consultation. In
plastic surgery, the appearance of the resulting scar can be the major source of dis-
satisfaction. It is imperative that the plastic surgeon obtain from the patient clear ev-
idence of his or her comprehension that without a scar, there is no correction and
no healing. The patient must be made to understand that his or her healing qualities
are as individual as hair texture or eye color; they are built into each person’s genetic
program. Documentation of such a conversation in the preoperative chart should go
a long way toward making any resulting claim more defensible.
Breast Reduction
The genesis of dissatisfaction most often involves:
 An unsatisfactory scar
 Loss of nipple or breast skin cover requiring revision
 Asymmetry or “disfigurement”
Breast Augmentation
Litigation involving breast augmentation is even more common than with breast re-
duction surgeries. Approximately 44% of all elective surgery claims involve aug-
mentation. Setting aside for the moment breast implants and autoimmune disease,
the most frequent causes of dissatisfaction are:
 Encapsulation with distortion and firmness
 Wrong size (too small, too large)
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Rhinoplasty
Data from TDC, Napa, CA: 2009.
Abdominoplasty
Lipoplasty
Facial
resurfacing
(laser)
Breast surgery
Blepharoplasty
Rhytidectomy

 Infection
 The need for repeat surgeries and their attendant costs
 Nerve damage with sensory loss
Face Lift and Blepharoplasty
Face lifts and blepharoplasties account for approximately 11% of all claims. The
most common allegations are:
 Excessive skin removal, resulting in a “starey” look
 Dry eyes or the inability to close the eyes
 Nerve damage, resulting in a distorted expression
 Skin slough, resulting in excessive scarring and the need for revision surgery
 Impaired vision
The most dreaded complication in blepharoplasty is permanent impairment of sight.
A few years ago, while reviewing a series of five such cases with no evident causa-
tion, we suddenly discovered a common thread: in all five patients the operation had
been conducted with a local anesthetic containing added epinephrine. All patients
had been sent home with less than 60 minutes of recovery time. All had done some-
thing after returning home that caused a sudden rise in blood pressure: a sneezing
fit, nausea, a constipated bowel movement. This was followed shortly thereafter by
orbital pain and massive ecchymosis requiring emergency evacuation of a periorbital
hematoma. These problems are difficult; some patients fully or partially regain vi-
sion. All require the attention of an ophthalmic surgeon.
Rhinoplasty and Septoplasty
Lawsuits associated with rhinoplasty and/or septoplasty procedures constitute ap-
proximately 15% of aesthetic claims. Among the most common allegations are:
 Unsatisfactory result: improper performance
 Continued breathing difficulties
 Asymmetry
Of all operations performed by plastic surgeons, rhinoplasty and septoplasty have
the highest degree of unpredictability. The problem is greatly exacerbated by inap-
propriate patient selection criteria. In these claims there is almost universally a gap be-
tween the patient’s expectations and the results obtained, even when the surgical
outcome appears excellent. The inappropriate use of imaging devices very often causes
patients to have unrealistic expectations, as does the showing of “brag books” con-
taining only excellent results. The clear implication is: “This is the kind of work that
I do, and this is what you can expect.” Unfortunately, in many cases the actual re-
sults fall short of the promise, and a cycle of dismay and disappointment is put into
motion.
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It is interesting to note that the incidence of dissatisfaction in rhinoplasty is more
than twice as common in men as it is in women.
Abdominoplasty
Abdominoplasty with or without suction-assisted lipectomy represents approximately
3% of claims. The most common allegations are:
 Skin loss with poor scars
 Nerve damage
 Inappropriate operation
 Infection with postoperative mismanagement
There is little question that the combination of suction-assisted lipoplasty before the
actual abdominoplasty has significantly increased the morbidity rate associated with
this operation and doubled the number of claims in this category. Clearly, a much
higher percentage of skin sloughs occur in procedures preceded by suction-assisted
lipectomy.
Suction-Assisted Lipectomy
Suction-assisted lipectomy procedures, whether conventional or ultrasonic, have now
become the single most requested elective aesthetic procedure in the United States.
However, the rising popularity of this procedure has brought with it a host of prob-
lems. To begin with, because this is not a surgical procedure in the traditional sense,
it is being performed by a wide variety of practitioners, some of them with no surgical
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WHEN SURGERY RESULTS FALL SHORT OF PROMISE
Surgeon
Patient
Surprise
Anger
Disappointment
Increased avoidance
Anger
Perceived arrogance
Rising hostility
Visit to the lawyer

background or clear understanding of the surgical anatomy involved. Additionally,
with the advent of “tumescent” techniques, an unseemly race has developed to see
who can suction out the most fat. The net result has been a dramatic rise in severe
morbidity and fatal outcomes from “high-volume” liposuction. What is high vol-
ume? It is generally agreed that anything above 5000 cc of extracted fat constitutes
high volume. The extraction of this amount of fat causes profound physiologic
changes, which in turn can lead to severe complications and/or fatal outcomes. Also,
the infusion of large amounts of fluid with even a weak concentration of lidocaine
has also resulted in a number of fatal outcomes as a result of anesthetic overdose.
To make matters worse, these procedures are often combined with other prolonged
operations. Our experience clearly indicates that when a patient has been under anes-
thesia for more than 6 hours, undergoing multiple procedures, the percentage of
complications and/or fatal outcomes rises dramatically.
The cavalier way in which this operation is sometimes performed requires rethink-
ing, particularly when the amounts of fat extracted are significant. In a number of
venues in the United States, the state medical regulatory authorities are beginning to
take notice, and unless there is a significant downturn in the morbidity associated
with this procedure, there will undoubtedly be some regulatory intervention.
Skin Resurfacing
Chemical peels and laser resurfacing constitute roughly 3% of lawsuits. The princi-
ple allegations are:
 Blistering/burns with significant scarring
 Infection/postoperative mismanagement
 Permanent discoloration postoperatively
Because individual healing characteristics are unpredictable, it is probably a good
idea to do a “test patch” in an area that can be hidden (for example, the back of the
neck). Certainly the printed information given to the patient preceding this opera-
tion should contain clear warnings that the quality of healing is linked to the indi-
vidual’s genetic makeup and cannot be predicted. The operator must make it clear
to the patient that final color and texture determination is not always in the hands
of the surgeon, and heavy makeup may be needed for an indeterminate period.
Miscellaneous Claims
Approximately 5% of all complaints against plastic surgeons have to do with mis-
cellaneous allegations, such as:
 Untoward reaction to medications or anesthesia
 Improper use of preoperative or postoperative photos
 Sexual misconduct (physician or employee)
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There are certain common issues among all procedures performed by plastic sur-
geons that are commonly not brought to the attention of the patient in preoperative
consultations, yet often are the triggering mechanism for a claim. They are:
 Unexpected scarring
 Lack of adequate disclosure (tailored to the patient’s level of understanding)
 General dissatisfaction: the patient’s expectations were not met
Psychological and Psychiatric Aspects
of Modifying Anatomy
The increasing popularity of elective aesthetic surgery makes it imperative to estab-
lish clear criteria for patient selection. Who is the “ideal” candidate for aesthetic sur-
gery? The surgeon must differentiate between healthy and unhealthy reasons for seek-
ing aesthetic improvement.
There are basically two categories that make the patient a poor candidate for elec-
tive aesthetic surgery. The first is anatomic unsuitability, but the second is equally
important, though more subtle: psychological inadequacy. The strength of a patient’s
motivation is critical: it has a startlingly close relationship with the patient’s satis-
faction postoperatively. Furthermore, a strongly motivated patient tends to have less
pain, a better postoperative course, and a significantly higher index of satisfaction.
Although these characteristics are impossible to predict with absolute accuracy, it is
possible to establish some objective criteria for patient selection. These are illustrated
in the graph above.
1
2
3
4
5
1
2
3
4
5
Patient’s deformity
(as assessed by the surgeon)
PATIENT SELECTION GUIDE
Patient’s degree of concern
(as perceived by the patient)

A patient’s objective deformity can be depicted along the horizontal axis (as judged
by the surgeon), while the degree of concern over that deformity (as perceived by
the patient) can be represented on the vertical axis. Two opposite extremes emerge:
1. A patient with a major deformity but minimal concern is represented in the
lower right-hand corner. This is a patient with an obvious major deformity
in whom it is clear that any degree of improvement will be regarded with
satisfaction.
2. A patient with a minor deformity but extreme concern is represented in the
upper left-hand corner. In contrast, this is a patient with a deformity that the
surgeon perceives to be minor, but who demonstrates an inordinate degree of
concern and emotional turmoil. Such patients are most likely to be dissatis-
fied with any outcome. The anxiety expressed over the “deformity” is merely
a manifestation of inner turmoil, which is better served by psychiatric care
than by a surgical procedure.
Most persons who seek aesthetic surgery fit somewhere between the two. The closer
the patient comes to the upper left-hand corner of the graph, the more likely that
surgery will result in an unfavorably perceived outcome, and possibly involvement
of a lawyer.
Effective Communication
Most litigation in plastic surgery has the common denominator of poor communi-
cation. This physician-patient relationship can be shattered by the surgeon’s arro-
gance, hostility, coldness (real or imagined), or simply by the fact that “he or she
didn’t care.” There are only two ways to avoid such a debacle: (1) make certain that
the patient has no reason to feel that way, and (2) avoid treating a patient who is go-
ing to feel that way no matter what is done.
Although the physician’s skill, reputation, and other intangible factors contribute to
a patient’s sense of confidence, rapport between the patient and physician is based
on forthright and accurate communication. This will normally prevent the vicious
cycle of disappointment, anger, and frustration by the patient, and reactive hostil-
ity, defensiveness, and arrogance from the physician, which deepens the patient’s
anger and ultimately may provoke a lawsuit.
Anger: A Root Cause of Malpractice Claims
Patients feel both anxious and bewildered when elective surgery does not go smoothly.
The borderline between anxiety and anger is tenuous, and the conversion factor is
uncertainty—fear of the unknown. A patient frightened by a postoperative compli-
cation or uncertain about the future may surmise: “If it is the doctor’s fault, then
the responsibility for correction falls on the doctor.”
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Chapter 8  Aesthetic Surgery and the Law

The patient’s perceptions may clash with the physician’s anxieties, insecurities, and
wounded pride. The patient blames the physician, who in turn becomes defensive.
At this delicate juncture, the physician’s reaction can set in motion a chain reaction—
or prevent one. The physician must put aside feelings of disappointment, anxiety, de-
fensiveness, and hostility to understand that he or she is probably dealing with a
frightened patient who is using anger to gain control of the situation.
The patient’s perception that the physician understands that uncertainty, and will
join with him or her to help to overcome it, may be the deciding factor in preserv-
ing the therapeutic relationship.
One of the worst errors in dealing with an angry or dissatisfied patient is to try to
avoid the patient. The surgeon must actively participate in the process rather than
attempting to avoid the issue.
Body Dysmorphic Disorder (BDD)
As the popularity of aesthetic surgery increases, one is reminded of the fairy tale in
which it is asked: “Mirror, mirror, on the wall, who’s the fairest of them all?” The
number of patients finding comfort and solace in multiple elective surgical proce-
dures is growing. Beyond the unrealistic expectations of aesthetic correction, many
patients seek surgery when the need for it is dubious at best. The physical change
sought through surgery is usually more a manifestation of the patient’s flawed body
image or preoccupation with a perceived flaw than of a measurable deviation from
physical normality. Beware of the patient showing a pathologic preoccupation about
a physical trait that may be within normal limits or so insignificant as to be barely
noticeable, but that to the patient has become a consuming obsession.
The trend toward vigorous advertising and marketing of cosmetic surgery contin-
ues to grow worldwide, and in such a climate there is a greater probability that in-
dividuals with BDD will eventually opt for the surgeon’s scalpel rather than a psy-
chiatrist’s consultation as an answer to their perceived problem. Increasingly, we see
traditional surgical judgment replaced either by financial considerations or plain ego
on the part of the surgeon.
Furthermore, it is easy for a well-meaning surgeon to be deceived about a patient’s
pathologic motivation. Because patients with BDD may not be identified as such in
initial consultation with the plastic surgeon, medical disputes about the surgical out-
come depend entirely on what was said versus what was understood. For this rea-
son accurate, detailed documentation is absolutely essential.
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Part II  Business Basics

In the best of all possible worlds, the prospective patient would project from the
mind onto a screen exactly the changes he or she conceives so the surgeon could de-
cide whether he or she can translate that image into reality. Lamentably, we have not
yet achieved such imaginary technology.
It is also conceivable that the physical deformity really is at the center of the patient’s
psychological fragility. There are many examples of beneficial change wrought
through successful aesthetic corrective surgery. Nonetheless, statistically the odds for
an unfavorable result and a claim are much greater when the comparison between
the objective deformity and the distress it creates in the patient is out of proportion.
The surgeon must assess for appropriate psychological balance in early interviews
with the patient and to lean strongly away from surgery in a patient for whom there
is doubt of such balance.
At a time of large-scale changes in health care delivery in the United States, certain
socioeconomic factors also come into play. With the rising number of practitioners
in many specialties, competitive pressures affect patient selection criteria. There is a
trend toward substitution of economic considerations for surgical judgment. Because
of recent constrictions on medical incomes, some practitioners seem to see elective
aesthetic surgery as the last area of practice unencumbered by either insurance or
governmental restrictions. This has attracted individuals with inadequate qualifica-
tions. Even within the ranks of board-certified plastic surgeons, the trend toward ag-
gressive marketing of services and the need to “sell” surgery has further blurred pa-
tient selection criteria.
Concluding Thoughts
It is possible to reduce the likelihood of all these unpleasant experiences by applica-
tion of simple principles: maintaining good communication and rapport with the
patient through good times and bad; restricting your practice to those procedures
with which you feel thoroughly comfortable; close and careful attention to docu-
mentation of your activities; and above all, the realization that a normal tempera-
ture and a valid credit card by themselves are very poor criteria for elective aesthetic
surgery.
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Chapter 8  Aesthetic Surgery and the Law

Clinical Caveats
 The four most critical elements for successful plastic surgery are competence,
appropriate patient selection criteria, documented disclosure, and true informed
consent.
 The surgeon should rely on the counsel of more experienced plastic surgeons or
psychiatric colleagues when uncertainty exists in patient selection.
 The plastic surgeon’s exposure to professional liability is unique in that he or she
is treating a well patient to make him or her better (not assuming the care of a sick
or injured patient to make him or her well), and the patient judges the results of
treatment according to subjective standards, often colored by the patient’s self-
image.
 By weighing how he says something more heavily than what he says, a surgeon
can reduce the patient’s image of him as omnipotent to that of a more realistic and
imperfect human being, who is facing, and thus sharing, the same uncertainty.
 The ability to communicate clearly is probably the most outstanding characteris-
tic of the claims-free surgeon; communication is the sine qua non of building a
physician-patient relationship.
 Anatomic unsuitability and psychological inadequacy make a patient a poor candi -
date for elective aesthetic surgery. A strongly motivated patient will tend to have less
pain, a better postoperative course, and a significantly higher index of satisfaction.
242
Part II  Business Basics
Suggested Readings
Castle DJ, Phillips VA. Disorders of Body Image. London: Wrightson Biomedical Publishers,
2002.
Goin M. Rhinoplasty: Changing the Body. Philadelphia: Williams & Wilkins, 1981.
Gorney M. Medical malpractice: the carrier’s point of view. In Goldwyn R, ed. Unfavorable
Results in Plastic Surgery. Philadelphia: Lippincott Williams & Wilkins, 2001.
Gorney M. Ten years’ experiences in aesthetic surgery malpractice claims. Aesthet Surg
J 21:569-571, 2001.
Gorney M. The wheel of misfortune: genesis of malpractice claims. Clin Plast Surg 26:15-
19, 1999.

NONSURGICAL
COSMETIC TREATMENTS
PART III

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Clinical Decision-Making for
Nonsurgical Cosmetic Treatments

FOAD NAHAI
CHAPTER 9

I
n today’s fast-paced life, our patients want to look their best yet may not have the
time to recover from open surgical procedures. Ubiquitous media and advertising
claims promise that they can undergo facial rejuvenation during their lunch hour, or
even invasive surgical procedures from which they can recover in only 48 hours. With
the emphasis on a youthful facial appearance and an appealing, slim figure, much
younger patients are consulting us about facial rejuvenation and body contouring.
We can choose from an array of nonsurgical treatments that for some patients come
close to fulfilling the requirement of minimal treatment time with almost immedi-
ate recovery. We refer to these procedures as cosmetic treatments. In fact, any pro-
cedure that can be offered without a skin incision falls into this category. We further
divide these procedures into those which are truly noninvasive (no skin penetration)
and those in which a needle or laser penetrates the skin. This is an important dis-
tinction, because in my opinion, truly noninvasive procedures such as facials, light
peels, and microdermabrasion can be safely performed by a trained aesthetician even
in a nonclinical setting. More-invasive procedures, such as injections of toxins and
fillers, and invasive laser treatments should be performed in a clinical setting, such
as a physician’s office or outpatient center, rather than at a spa or beauty salon. Some
patients may simply faint at the sight of a needle, and very rarely, there may be an
immediate allergic reaction to the material; these eventualities are easily dealt with
in a medical environment. Although injectable toxins are safe in the hands of trained
nurses and physician assistants, a physician should evaluate the patient, make deci-
sions concerning treatment, and be available on the premises when a nurse or physi-
cian assistant is injecting toxins or fillers.
These treatments may be the primary treatment or an adjunct to open surgical pro-
cedures. In general, they are the primary treatment for a younger patient with early
facial aging and an adjunct for an older patient who has already undergone facial
rejuvenation procedures.
These procedures are also “practice builders.” The young patient who today is un-
dergoing microdermabrasion, toxin treatments, and filler injections will be tomor-
row’s face-lift patient. Research has shown that patients who are satisfied with their
cosmetic treatments are likely to return to the same surgeon for surgical procedures
as the aging process continues. It is a rare aesthetic practice that does not offer the full
range of cosmetic treatments.
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Part III  Nonsurgical Cosmetic Treatments

Options for cosmetic treatments are constantly increasing. New and improved fillers
and new toxins are regularly being introduced. An array of nonsurgical transcuta-
neous skin-tightening devices is under development or in early trials. Lasers continue
to evolve, with noninvasive lasers that now can produce noticeable skin tightening.
This rapid growth and innovation will inevitably lead to significant improvements
in the materials and devices available today, and some of the devices and injectables
of today may well be obsolete tomorrow. The first filler that I had any experience
with was bovine collagen; it has been at least 10 or more years since I last injected it.
It is important that those of us who inject these materials and operate the devices
or supervise their use be familiar with the associated physics, mode of action, safety
limits, risks, and limitations.
Most of these treatments have proved safe and efficacious, yet we must guard against
excessive claims and clearly explain the limitations. Obviously, microdermabrasion
is not a substitute for laser ablation or dermabrasion in a patient who has deep fa-
cial rhytids. Transcutaneous skin tightening is not a substitute for a face lift. A com-
mon reason for patient dissatisfaction with these cosmetic treatments is that the ef-
fectiveness of the treatment falls well short of the patient’s expectations. Although
I refer to these treatments as practice builders, exaggerated claims of their effective-
ness, such as marketing them as a substitute for a face lift, will backfire and lead to
loss of the physician’s credibility.
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Chapter 9  Clinical Decision-Making for Nonsurgical Cosmetic Treatments
Cosmetic Treatments
Noninvasive
Minimally Invasive
Moderately Invasive
Spa treatments
Light-based treatments
Injectables
Facials
Microdermabrasion
Ablative lasers
External ultrasonography
Fruit acid peels
Peels: TCA, croton oil
Nonablative lasers
Dermabrasion
Sclerotherapy
Transcutaneous skin tightening

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Part III  Nonsurgical Cosmetic Treatments
In the first edition of this book, this section was entitled “Choosing the Right Op-
tion: The Needle or the Knife.” It is no longer a question of needle or knife; these
are not competing but complementary treatment methods. We now have enough ex-
perience with injectables to know which patients are best suited for them, whose
best interests would be served by the knife, and in which patients we can delay a
surgical procedure by offering injectables. Before choosing the appropriate nonsur-
gical or cosmetic option, the patient and surgeon should make the fundamental de-
cision together concerning surgical or nonsurgical treatment or a combination of
the two. I like to think of this as the option between the needle and the knife. Many
patients have already made their decision before the initial consultation, regardless
of the suitability of needle or knife. It’s not unusual for young people who are
nowhere near ready for a face lift to come in to discuss a face lift, while individuals
with advanced facial aging who are no longer candidates for cosmetic treatments
frequently ask for nonsurgical treatments. To most of the younger patients I recom-
mend skin care, light peels, toxin, and injectables, if needed, while strongly advising
patients to wait for the appropriate time to undergo a surgical procedure. To an
older patient who is a candidate for surgical rejuvenation but comes in to discuss
cosmetic treatments, I recommend surgical treatment as the first choice and discuss
cosmetic treatments as a less effective alternative and perhaps a better adjunct to a
surgical procedure rather than the primary treatment.
The choice between cosmetic treatments and open surgical procedures should be an
informed decision. The patient must clearly understand that the effects of most cos-
metic treatments are temporary and repeat procedures will be required. An excep-
tion is injection of autologous fat as a filler, which I consider a surgical procedure
requiring anesthesia and an operating room. There is also a limit to the degree of re-
juvenation offered by cosmetic treatments, and the patient must fully understand
that these treatments are not a substitute for surgical rejuvenation.
Choosing the Right Option:
The Needle and the Knife

This 55-year-old woman was a candidate for a full face and neck lift, blepharoplasty,
and resurfacing. She fully realized that this was her best option, but her lifestyle and
professional commitments would not allow her to put aside the time required to re-
cover from full facial aesthetic surgery. Instead, she opted for toxin injections to the
forehead and glabellar area and Restylane injections for the nasolabial folds and peri -
oral areas. Clearly, a face lift and resurfacing would have produced a much more
dramatic rejuvenation; however, the patient is satisfied with this suboptimal but
modest improvement, which fits into her lifestyle.
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Chapter 9  Clinical Decision-Making for Nonsurgical Cosmetic Treatments
This middle-aged woman realized that her best treatment option was surgical but
chose less-invasive procedures. She underwent autologous fat grafting to fill the na-
solabial folds, erbium:YAG laser resurfacing of the perioral area and lower lids, and
toxin injections to the forehead and glabella. Her brow asymmetry is less noticeable
following toxin injections.

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Part III  Nonsurgical Cosmetic Treatments
Face
Most women undergoing noninvasive facial cosmetic treatments are seeking im-
provement of facial rhytids. I evaluate their rhytids at rest and on animation, we grade
the rhytids by severity, depth, and extent of the problem, then we make recommen-
dations. In addition, some patients also want improvement of skin blemishes, tex-
ture, and color. More and more younger women are seeking preventive maintenance.
For them we recommend skin care, including tretinoin, and a general antiaging and
nutritional program. Once our aesthetician and I have evaluated the patient’s skin
and rhytids, we then classify the patient according to the rhytids, whether present
at rest or on animation, and the depth of the rhytids.
GRADE I: NO RHYTIDS AT REST OR ON ANIMATION
Grade I patients require only
preventive and maintenance skin care. I advise them that it is too early for any sur-
gical or invasive procedures and that their best interests would be served by preven-
tive measures, including tretinoins and glycolic acid peels, if needed, but most of all
we discuss skin health: avoiding environmental toxins, such as smoking and second-
hand smoke, and taking precautions about sun exposure. Patients are also advised
on general antiaging measures, including diet, exercise, and the use of antioxidants.
We encourage these patients to come in for biannual follow-up visits. Once their fa-
cial aging proceeds to the next grade, the treatment plan is adjusted accordingly. Pa-
tients should understand that these preventive measures will not eliminate the ag-
ing of their skin and at best will delay visible signs.
GRADE II: SUPERFICIAL RHYTIDS ONLY ON ANIMATION
For each successive grade,
I recommend most if not all of the treatments of the preceding grade plus specific treat-
ments for the current grade. Toxin injection is without question my first choice for this
grade. By eliminating muscle function, especially in the glabella, forehead, and crow’s-
feet, the lines are eliminated and the brow shape and position are improved. I would
not recommend toxin injections for perioral lines at this grade. Toxin injections com-
bined with the treatments outlined for grade I complete the recommendations.
Classification of Rhytids
Grade I
No rhytids at rest or on animation
Grade II
Superficial rhytids on animation only
Grade III
Deep rhytids on animation only
Grade IV
Superficial rhytids at rest, deep on animation
Grade V
Deep rhytids at rest, deeper on animation

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Chapter 9  Clinical Decision-Making for Nonsurgical Cosmetic Treatments
AT REST
ON ANIMATION
Grade I
Grade II
Grade III
Grade IV
Grade V

GRADE III: DEEP RHYTIDS ON ANIMATION
In grade III patients, for the glabella,
forehead, and crow’s-feet, toxins again are my first choice and by far the most effec-
tive treatment. However, toxin injections alone will not eliminate the rhytids but merely
soften them in this grade. With these patients I discuss one of these additional options:
 Deep peels such as trichloracetic acid (TCA) (30% and higher)
 Ablative lasers
 Dermabrasion
 Fillers of small molecular size, such as Restylane (Fine Lines)
For perioral lines and wrinkles, careful toxin injections may be considered in addi-
tion to the previously cited options.
I have found that most women will choose fillers rather than peels, lasers, or derm -
abrasion for their convenience, despite my caution that fillers are only a temporary
solution. Most women are accustomed to the routine of regular beauty salon ap-
pointments for haircuts or coloring, so they don’t necessarily find return visits to the
cosmetic surgeon for touch-ups (which is required for toxin injections) to be objec-
tionable. It further indicates that our patients would rather come back for repeat
filler treatments than face the 10 days to 3 weeks of down time following ablative
laser, peels, or dermabrasion.
GRADE IV: SUPERFICIAL RHYTIDS AT REST AND DEEP ON ANIMATION
The recom-
mendations for grade IV patients are essentially the same as those for grade III pa-
tients. However, any ablative procedures (lasers, peels, dermabrasion) will have to
penetrate the skin more deeply. Not only will a larger volume of filler be required,
but also injections will have to be performed at a deeper level.
GRADE V: DEEP RHYTIDS AT REST AND DEEPER ON ANIMATION
Grade V patients
are the best candidates for perioral administration of toxins, but as in grades III and
IV, toxins alone is not sufficient. At this grade I may recommend a brow lift and a
face lift if the rhytids extend beyond the perioral and periorbital areas, especially if
severe rhytids are associated with loss of skin elasticity and the shifting of subcuta-
neous components. I also warn grade V patients that they may require retreatment
of ablative laser therapy, dermabrasion, and peels within 6 months to 1 year of the
initial treatment.
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Part III  Nonsurgical Cosmetic Treatments

253
Chapter 9  Clinical Decision-Making for Nonsurgical Cosmetic Treatments
Deep
Deep
TREATMENT OPTIONS FOR RHYTIDS
RHYTIDS
AT REST
RHYTIDS ON
ANIMATION
Rhytids
No observable
rhytids
Superficial
Preventive
measures
Renova
Glycolic acid
Skin care
Nutritional and
Avoid sun
Avoid environ-
antiaging program  exposure
 mental toxins
Antioxidants  Diet  Exercise
Toxins
Renova
or
Microdermabrasion
Light peels
Toxins
or
Deep peels
Ablative laser
(erbium:YAG)
or
Fillers
TCA
Croton oil
Rhytids
No observable
rhytids
Superficial
Preventive
measures
Glycolic acid
Skin care
Nutritional and
Avoid sun
Avoid environ-
antiaging program  exposure
 mental toxins
Antioxidants  Diet  Exercise
Toxins
Tretinoin
or
Microdermabrasion
Light peels
Toxins
or
Fillers
Deep peels
or
Ablative lasers

Tretinoin

or
Dermabrasion

Nasolabial Folds and Marionette Grooves
A number of patients consider deep nasolabial folds to be a sign of aging and seek con-
sultation for improvement of their folds and grooves only. They feel that deep, over-
hanging folds make them appear to be frowning, angry, or unhappy. Although most
of these patients would be best served through a combination of rhytidectomy and
local treatments to improve on the folds, they often opt for local treatments only.
Unlike facial rhytids, which reflect the insertion of the muscles of facial expression
into the skin, nasolabial folds and marionette grooves reflect not only muscle inser-
tion and muscle pull but also adhesions of the dermis to the fascial layers of the face.
Established nasolabial folds and marionette grooves are resistant to superficial and
even deep ablative skin procedures. However, muscular manipulation with toxins
and superficial and deep injections of filler materials can be very effective in amelio-
rating these folds. The deeper the fold, the deeper the level of injection and the more
viscous the material. In addition to dermal and subdermal injections, filler materi-
als may also be placed within the subcutaneous tissues. Many surgical options are
also available, including various rhytidectomy procedures, as well as local excisions.
Recommendations are made based on the grading of the folds.
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Part III  Nonsurgical Cosmetic Treatments
Classification of Nasolabial Folds and Marionette Grooves
Grade I
Visible folds on animation
Grade II
Visible folds at rest
Grade III
Visible folds at rest and deepening of folds on animation
Grade IV
Deep folds at rest and deeper on animation
Grade V
Overhanging folds
GRADE I: VISIBLE FOLDS ON ANIMATION
The first line of treatment for these pa-
tients is the use of filler material, injected superficially in the dermis. The choices in-
clude Restylane (especially Restylane Fine Lines), Juvéderm Ultra, and porcine col-
lagen. Semipermanent fillers such as Radiesse are best avoided in the superficial plane.
GRADE II: VISIBLE FOLDS AT REST
For grade II patients, treatment is similar to that
for grade I patients, with injections in the superficial and deep levels. At this grade,
patients may also be candidates for toxin injections.

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Chapter 9  Clinical Decision-Making for Nonsurgical Cosmetic Treatments
AT REST
ON ANIMATION
Grade I
Grade II
Grade III
Grade IV
Grade V

GRADE III: VISIBLE FOLDS AT REST AND DEEPENING OF FOLDS ON ANIMATION
Grade III patients will require deep injection of filler material. The best filler in this
area is autologous fat. Recommended fillers include, in order of preference, autolo-
gous fat, Restylane, Radiesse, and Juvéderm Ultra Plus.
In addition to filler materials, toxins are effective in treating patients of this grade.
Toxin injections of the depressor anguli oris for the marionette grooves and the leva-
tor labii superioris and the levator labii superioris alaeque nasi for the nasolabial folds.
Although autologous fat is the best filler at this grade, most patients opt for the other
fillers rather than go through the more extensive procedure and recovery associated
with structural fat grafting. They opt for a less permanent result in favor of expediency.
GRADE IV: DEEP FOLDS AT REST AND DEEPER ON ANIMATION
The recommenda-
tions are essentially the same for grade IV as for grade III, plus the option of surgi-
cal intervention: specifically, a midface lift in addition to autologous fat injection.
GRADE V: OVERHANGING FOLDS
The recommendations of filler injections and
toxin remain the same for this grade. As far as surgical interventions, I add the op-
tion of direct excision as an alternative to a midface lift. Should the patient choose to
undergo a midface lift, the direct placement of autologous dermis fat graft or SMAS
fat graft is an alternative to autologous fat injections. Most individuals in grades IV
and V are more suitable candidates for rhytidectomy procedures, with injectable
fillers as an adjunct.
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Part III  Nonsurgical Cosmetic Treatments

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Chapter 9  Clinical Decision-Making for Nonsurgical Cosmetic Treatments
Toxins
Intradermal injections
of less viscous fillers
Deeper injection
of more viscous fillers
Deep injections of
viscous fillers
or
TREATMENT OPTIONS FOR NASOLABIAL FOLDS AND MARIONETTE GROOVES
GRADE I
Visible folds on
animation
GRADE II
Visible folds at rest
GRADE III
Visible folds at rest
Deepening of folds
on animation
GRADE IV
Deep visible folds
at rest
Deeper folds on
animation
GRADE V
Overhanging folds
1. Restylane Fine Lines
2. Juvéderm Ultra
1. Restylane
2. Juvéderm Ultra Plus
1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra Plus
Toxins
Marionette grooves
Depressor
anguli oris
Nasolabial folds
Levator labii
superioris
Levator labii
superioris
alaeque nasi
Deep injection of
viscous fillers, including
subcutaneous tissue
Deep injection of
viscous fillers, including
subcutaneous tissue
Toxins
Midface lift
Toxins
Midface lift
Direct excision
1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra
1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra Plus
Marionette grooves
Depressor
anguli oris
Nasolabial folds
Levator labii
superioris
Levator labii
superioris
alaeque nasi
Marionette grooves
Depressor
anguli oris
Nasolabial folds
Levator labii
superioris
Levator labii
superioris
alaeque nasi

Periorbital Region
Although toxins are established as the treatment of choice for crow’s-feet and peri-
orbital wrinkling, fillers are rapidly gaining in popularity for rejuvenation of the peri -
orbital area. The nonanimal synthetic hyaluronic acids (NASHAs) have an estab-
lished role in the treatment of tear troughs and are being popularized for additional
volume to the upper lid and brow. Some physicians think that fillers and fat are the
preferred treatment for volume restoration in the periorbital area, obviating the need
for extensive and complex surgical procedures. Care should be exercised when in-
jecting fillers into the tear-trough area. The tissues are thin, and superficial injection
may lead to the bluish discoloration referred to as the Tyndall effect.
Neck
Light- and medium-depth peels as well as judicious laser resurfacing play a role in
rejuvenation of the neck, not only as a primary treatment but also as an adjunct af-
ter face lifts and neck lifts. Toxin also has a role in the temporary amelioration of
platysma bands. In my practice I limit the treatment of the neck to light peels and
toxin injection, because these are effective and relatively risk free. Ablative lasers
and other more-invasive skin-rejuvenative procedures carry a great risk of scarring
and unfavorable results in the neck.
Body
A number of patients are evaluated for skin changes on the exposed areas of the
chest and upper extremity. These patients are candidates for skin rejuvenation. We
offer them body peels (light glycolic acid peels), bleaching agents, and intense pulsed
light (IPL) treatment of areas of dyschromia.
Skin-tightening devices have been advocated for the improvement of stretched, in-
elastic abdominal skin, and striae in particular. Improvements have been limited,
and this treatment would not be an alternative to skin excision.
Hands
Injection of autologous fat into the dorsum of the aging hand is now an established
and effective treatment. In addition, fillers have also been shown to rejuvenate the
aging hand. Sclerotherapy of prominent dorsal hand veins is also beneficial.
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Part III  Nonsurgical Cosmetic Treatments

Patient Example
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Chapter 9  Clinical Decision-Making for Nonsurgical Cosmetic Treatments
This patient demonstrates lateral brow ptosis, glabellar and transverse forehead lines
at rest, periorbital aging with tear-trough deformity, and deepening of her nasolabial
folds, marionette grooves, and early jowls. She has had toxin injections to the crow’s-
feet, glabella and forehead, and the depressor anguli oris and mentalis muscles.
NASHA fillers were injected into the lower eyelids, nasolabial folds, marionette
grooves, and along the jawline to minimize the jowls. Her only surgical procedure
was excision of the mole on the right side of her chin. The effectiveness of this non-
surgical treatment is clearly demonstrated on the split view.

Concluding Thoughts
Noninvasive treatments for facial rejuvenation have become the most popular of all
cosmetic procedures, with toxins being by far the most common cosmetic treatment
worldwide. Our choice of fillers has expanded so that we can pick and choose the
appropriate filler for a given area. The role of injectables has now gone beyond facial
rejuvenation and will continue to expand. Injectables have proved safe, effective,
and popular with surgeons and patients alike. The search continues for other modal-
ities of treatment that have the same attributes. Cosmetic treatments are not a sub-
stitute for surgical facial rejuvenation but are relatively effective stopgap measures
that will allow most patients to postpone full surgical rejuvenation until a face lift
is really needed or the patient has time to go through the recovery of a face lift. For
all cosmetic surgeons, this remains a growth area and an opportunity to attract to-
morrow’s face-lift patient today. It is also a way to offer patients a full range of op-
tions to better meet their needs.
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Skin Care and
Dermatologic Treatments

INJA BOGDAN ALLEMANN, DAVID J. GOLDBERG
CHAPTER 10

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S
kin care and dermatologic treatments comprise a range of measures that are appli-
cable to every person, regardless of his or her skin type, age, or underlying problem.
The seven basic goals of skin care are:
1. Cleansing
2. Protecting
3. Moisturizing
4. Preventing skin aging
5. Slowing the effects of aging
6. Reversing the effects of aging
7. Treating specific problems
Cleansing is a simple but important aspect of skin care. The skin must be cleansed
and protected from harmful exogenous factors and influences. Because the skin is
the outermost organ in direct contact with as well as a barrier against the environ-
ment, it is also the area in which the aging processes are most clearly seen. Conse-
quently, skin care should also focus on preventing and slowing, or ideally even re-
versing the visible aging processes of the skin. Finally, dermatologic skin care
treatments should address specific skin problems, such as erythema, pruritus, and
inflammation.
This chapter focuses on skin care for the healthy individual who seeks medical advice
for cosmetic and aesthetic problems. In addition to basic skin care, it will discuss
more specific skin care needs that physicians may encounter regularly when treat-
ing cosmetic patients.
It presents a logical approach to skin care with a specific focus on protection, pre-
vention, and reversal of cutaneous aging. There are three basic categories to con-
sider when defining a skin care regimen: primary prevention, secondary prevention,
and tertiary measures.
Approach to Antiaging Skin Care
Primary prevention
Measures undertaken before any signs of skin aging or aestheti-
cally bothersome skin changes have developed
Secondary prevention
Measures undertaken when signs of skin aging, such as fine
lines and pigment alterations, begin to develop and are visible
Tertiary measures
Measures undertaken to target already progressively aged skin,
with clear wrinkles and folds, volume loss, pigment irregulari-
ties, or obvious aesthetically disturbing skin changes

Patient Profiles
Following are examples of typical candidates for each category of care.
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Chapter 10  Skin Care and Dermatologic Treatments
PRIMARY PREVENTION
This 26-year-old patient
with no signs of skin aging is a candidate for pri-
mary prevention.
PRIMARY AND SECONDARY PREVENTION
This 37-
year-old patient has the beginning signs of skin ag-
ing, such as fine lines and slight pigment alterations.
She is a candidate for primary and secondary pre-
vention.
PRIMARY, SECONDARY, AND TERTIARY CARE
This
46-year-old patient has clear signs of skin aging,
with medium-depth wrinkles and folds and the be-
ginnings of volume loss and pigment irregularities.
She is a candidate for primary and secondary pre-
vention as well as tertiary measures.

Patients’ dermatologic characteristics and their needs and concerns are the central fac-
tors directly influencing what treatments should be suggested. Scientific and evidence-
based data provide a sound basis for skin care and therapeutic measures.
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Skin analysis, patients’ needs and concerns,
professional consultation
Scientific data, evidence-based data
Primary
prevention
Secondary
prevention
Tertiary
measures
Although the division of treatments into three categories is somewhat arbitrary, such
an approach helps to organize patient needs in a structured way. These approaches
should not be regarded as exhaustive and exclusive; they leave room for personal
interpretation. The table shows the approach we use.
Approach to Skin Care and Dermatologic Treatments
Primary Prevention
Secondary Prevention
Tertiary Measures
UV protection
Topical retinoids
Topical retinoids
Smoking cessation
Botulinum toxin
Botulinum toxin
Weight reduction
Fillers
Chemical peels
Healthy nutrition
Antioxidants
Fillers
Regular sports activities
Antiinflammatory agents
IPL laser
Minimal stress
Depigmenting agents
Fractional resurfacing
Topical retinoids
Nutritional supplements
Hair transplantation
Botulinum toxin
Vitamins
Blepharoplasty
Antioxidants
Coenzyme Q10
Face lift
Nutritional supplements
Minoxidil
Finasterid
IPL, Intense pulsed light; UV, ultraviolet.
As can be seen, many of the treatments are listed in more than one category. A good
example of this is the treatment of dynamic rhytids with injections of botulinum
toxin. Botulinum toxin ideally prevents the formation of dynamic wrinkles and
should thus theoretically be used before wrinkles even appear—hence as a primary
preventive measure. One could argue, however, that botulinum toxin treats already
formed dynamic wrinkles and should thus be employed as a secondary measure. In
our opinion, treatment with botulinum toxin belongs in all three categories.

Skin Aging
The visible aging process of the skin starts sometime between the twentieth and thir-
tieth year of life and progresses gradually. Consequently, while still young, individ-
uals need to focus on preserving the youthful qualities of their skin. The older the
patient, the more that skin care should focus on slowing down, preventing, or even
reversing the skin’s aging process. The aging process has some unique characteris-
tics for the skin that differ from those seen in other body organs.
Intrinsic and Extrinsic Skin Aging
There are two distinct processes of skin aging: intrinsic and extrinsic; these must be
differentiated. Intrinsic aging is the process determined by our genetic predisposi-
tion, by the naturally and constantly occurring oxidative metabolism within our
cells, and by cellular senescence, characterized by telomere shortening. Consequently,
intrinsic aging takes place on the entire skin, progresses chronologically with age,
and can probably not be prevented or influenced. In contrast, extrinsic aging is driven
by exogenous factors, primarily by exposure to ultraviolet (UV) light, but also by
such factors as nicotine use, air pollution, stress, and microorganisms. Thus extrin-
sic aging is not universal but takes place on exposed areas, such as the face, neck,
back of the hands, and forearms. Extrinsic aging progresses at an individual pace,
depending on the patient’s exposure to the various damaging factors, and is conse-
quently preventable to some degree, or at least influenceable. Historically, intrinsic and
extrinsic processes were regarded as separate entities. However, newer data show
that they share common molecular mechanisms. The two occur in parallel and lead
to cumulative changes to the structure of the skin, its function, and appearance.
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Chapter 10  Skin Care and Dermatologic Treatments
Causes of Intrinsic and Extrinsic Skin Aging
Intrinsic Aging
Extrinsic Aging
Genetic predisposition
UV light
Oxidative metabolism
Nicotine
Cellular senescence
Air pollution
Microorganisms
UV, Ultraviolet.
Features of Intrinsic and Extrinsic Skin Aging
Intrinsic Aging
Extrinsic Aging
Chronologic
Individual
Entire skin
Exposed skin
Most probably not influenceable
Influenceable
Physiologic
Pathologic

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Oxidative Stress and Reactive Oxygen Species
Oxidative stress, which skin is exposed to on a constant basis, plays a pivotal role
in intrinsic and extrinsic aging. Oxidative stress is delivered by the creation of reac-
tive oxygen species (ROS), also known as free radicals. Free radicals are formed nat-
urally through normal human mitochondrial oxidative metabolism as well as through
exogenous factors, such as UV exposure, air pollution, smoking, radiation, alcohol,
exercise, and inflammation. The free radical theory of aging, which was proposed
by Harman in 1956, is currently one of the most widely accepted theories to explain
the causes of aging.
Free radicals can damage vital structures, such as DNA, cytoskeletal elements, cel-
lular proteins, and cellular membranes. Recent data further suggest that free radi-
cals can induce various transcription factors, such as activator protein-1 (AP-1) and
NF-kappaB, and increase the expression of matrix metalloproteinases (MMPs), in
particular collagenase, which degrades skin collagen and plays a central role in the
skin’s aging process. Clinically, these processes lead to photoaging, wrinkling, in-
flammation, erythema, edema, preneoplastic lesions, and skin cancer. Fortunately,
the body also has defense mechanisms against such free radicals, called antioxidants
(superoxide dismutase, catalase, glutathione peroxidase, alpha-tocopherol, ascorbic
acid, glutathione, and ubiquinone).
ANTIOXIDANT
Defense
mechanism
ROS/
FREE RADICAL
Production
UV
UV
As part of the natural aging process, however, the body’s endogenous defense mech-
anisms decrease while the production of ROS increases, resulting in an imbalance and
an increased number of unchecked radicals. Furthermore, antioxidant defense mech-
anisms can be inhibited by UV and visible light, whereas UV light exposure is known
to increase the formation of free radicals, which only further tips the balance. These
data provide the scientific background for the use of antioxidants, which have re-
cently become very popular. (These are discussed in further detail on pp. 286-287.)

Anatomy of the Skin
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Chapter 10  Skin Care and Dermatologic Treatments
Stratum basale
Basement membrane
Papillary dermis
Stratum corneum
Stratum granulosum
Stratum spinosum
Epidermis
Dermis
Subcutaneous
tissue
Histologic section through normal skin
The skin is composed of three layers: epidermis, dermis, and subcutaneous tissue,
each with its specific function and characteristics.
Epidermis
The epidermis is the outermost layer of the skin and thus is vulnerable to exogenous
assault. It is composed of various layers: the deepest is the basal layer, followed by the
spinous layer, the granular layer, and ultimately the outermost layer, the stratum
corneum, with its desquamating cells. The stratum corneum is the skin barrier to the
environment and thus is important in protecting the skin from exogenous influences.
The stratum corneum is important from a cosmetic standpoint because it is respon-
sible for the texture, smoothness, and glow of the skin, the moisture level of the un-
derlying epidermis, and the skin’s pigmentation. The main cells that compose the
epidermis are the keratinocytes, also called corneocytes. As they mature, these cells
migrate upward to become the various layers of the epidermis, until they are desqua-
mated on top of the stratum corneum. This keratinization process or cell cycle of
the keratinocytes takes approximately 26 to 42 days. Retinoids can accelerate this
cell cycle, resulting in younger keratinocytes in the stratum corneum and a smoother
skin appearance. In between the keratinocytes is an intercellular lipid bilayer. This
entire structure can be thought of as “bricks” (keratinocytes) surrounded by “mor-
tar” (lipids), yielding the “brick-and-mortar” structural organization of the epider-
mis. The lipids are composed of fatty acids, cholesterol, and ceramides that help re-
duce transepidermal water loss. A disrupted skin barrier leads to increased
transepidermal water loss and dry skin with a rough surface.

Melanocytes with their melanosomes are also located in the epidermis. These deter-
mine a person’s physiologic skin color (skin phototype defined by Fitzpatrick; see
p. 271). The number of melanocytes is relatively constant from one person to another
and from one skin color to another. Differences in skin color are thus determined by
the number and size of the melanosomes produced and distributed by the melanocytes.
Pigmentary disorders can lead to an increased number of melanocytes or melanosomes
in the basal layer of the epidermis and the upper layers of the dermis.
Dermis
Below the epidermis lies the dermis, which is composed mainly of fibroblasts, fibro-
cytes, collagen, and elastin, which together are embedded in an extracellular matrix.
The dermis also contains nerves, blood vessels, and a variety of skin appendages.
The extracellular matrix is composed mainly of glycosaminoglycans, which can bind
their weight in water 1000-fold. This matrix plays a key role in an individual’s cos-
metic appearance, since it is responsible for the elasticity, flexibility, and volume of the
skin. With aging, the extracellular matrix and its thickness decrease, and the arrange-
ment of various dermal components, especially the collagen and elastin, change dra-
matically. Collagen I is the most important and abundant collagen type in the der-
mis, followed by collagen type III.
With age, collagen becomes increasingly degraded, reducing the skin’s durability and
resilience. The amount of elastin decreases and aggregates in chunks, producing the
typical histologic solar elastosis of intrinsically aged skin (see the section, right, on
p. 269). The most cosmetically important glycosaminoglycan is hyaluronic acid.
Hyaluronic acid’s function is to bind water and help hold the moisturizing level of the
skin. Glycosaminoglycans and hyaluronic acid show an age-related decline, leading
to dry, saggy skin. Collagen, elastin, and glycosaminoglycans make up the three-
dimensional structure of the dermis. As all of these decline and become rearranged,
the clinical result is volume loss, reduced elasticity, and decreased suppleness of the
skin. Unfortunately, most topical cosmetic treatments do not penetrate into the der-
mis; thus it is difficult for them to reverse these changes.
Subcutaneous Tissue
The subcutaneous tissue is located below the dermis and is composed of adipocytes,
surrounded by fibrous tissue and blood vessels. The subcutaneous tissue’s distribu-
tion throughout the body depends at least in part on sex and age; redistribution oc-
curs as the individual ages.
Not only do the changes of intrinsic and extrinsic skin aging differ in terms of their
cause, they also differ in clinical and histologic presentation.
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Part III  Nonsurgical Cosmetic Treatments

Clinical Features of Intrinsically
and Extrinsically Aged Skin
Intrinsically aged skin, seen on sun-protected areas of the body such as the back,
buttocks, and abdomen, is dry, thin, and lax. It shows fine wrinkling and regular pig-
mentation. Extrinsically aged skin, which we can see on sun-exposed areas such as
the face, neck, chest, the back of the hands, and forearms, is thickened, shows deep
folds and wrinkles, and has irregular pigmentation.
Histologic Changes of Intrinsically and Extrinsically
Aged Skin
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Chapter 10  Skin Care and Dermatologic Treatments
Intrinsically aged skin shows atrophy and thinning of the epidermis, with flattening
of the dermoepidermal junction. The dermis also becomes thinner and the amount of
collagen fibers, elastin, and extracellular matrix are all reduced.
Extrinsically aged skin shows an increased thickness of epidermis and dermis as a
result of cellular hyperproliferation, with qualitatively and quantitatively changed
dermal matrix proteins. Impaired fibrous structure is seen, with accumulation of
fragmented elastic fibers, mucin, and glycosaminoglycans, leading to the character-
istic histologic findings of solar elastosis. Increased melanin production leads to clin-
ically obvious hyperpigmentation.
Histologic section through intrinsically aged skin
Histologic section through extrinsically aged skin

Functions of the Skin
The skin has numerous functions:
 Barrier against the external environment
 Regulation of moisture
 Production of sweat
 Production of sebum
 Immune defense
 DNA repair
 Wound healing
 Thermoregulation
 Cell growth
 Vitamin D production
 Vascular reactivity
If any of these functions are impaired, as often is the case in aging skin, the prob-
lems listed below can occur.
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Problems With Impaired Skin Function
 Impaired barrier function →dry skin, pruritus
 Impaired vascular reactivity →disturbed moisture control and thermoregulation →
pruritus and abnormal temperature sensation
 Reduced sweat glands →reduced sweat production →disturbed thermoregulation
 Reduced sebaceous glands →reduced sebum production →dry skin
 Reduced number of Langerhans cells →reduced immune control →increased cuta-
neous dermatoses and infections
 Impaired DNA repair →benign →and malignant neoplasia
 Impaired wound healing →prolonged wound healing and ulceration
 Impaired vascular reactivity →increased telangiectasis

Skin Types
Before recommending any skin care regimen to a patient, the physician must know
what skin type the patient has. When considering skin types, one must differentiate
between the skin phototype, developed by Harvard dermatologist T.B. Fitzpatrick in
1975, and the “cosmetic” skin type. As the name implies, Fitzpatrick’s skin phototype
scale classifies the skin by an individual’s response to exposure to UV radiation. Thus
the phototype is determined by the individual’s constitutional skin color and ethnic-
ity, the amount of melanin pigment in the skin, and the reaction to sun exposure.
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Chapter 10  Skin Care and Dermatologic Treatments
Assessment of a patient’s Fitzpatrick skin phototype is important and has implica-
tions for two issues of cosmetic relevance: the tendency to develop rhytids and the
predisposition to develop postinflammatory hyperpigmentation or postinflamma-
tory pigment alterations. Because individuals with Fitzpatrick skin types I to III have
fewer melanin granules in their skin, they are naturally less protected from UV
radiation. Hence they develop rhytids at an earlier age and to a greater extent. Fitz-
patrick skin types IV to VI wrinkle less; however, in general, they show a higher ten-
dency for postinflammatory pigment alterations (hyperpigmentation and hypopig-
mentation) after inflammatory dermatosis or minimally invasive procedures, such
as peels and various laser treatments.
Fitzpatrick’s Classification of Skin Types
Skin Type
Typical Features
Reaction to Sun Exposure
I
White
Always burns, never tans
II
White
Usually burns, tans with difficulty
III
White
Sometimes burns, tans average
IV
Moderate brown
Rarely burns, tans with ease
V
Dark brown
Very rarely burns, tans very easily
VI
Black
Does not burn, tans very easily

The cosmetic skin types patients refer to are the designations used by the majority
of manufacturers in the cosmetic industry: normal, oily, dry, combination (oily in
the T-zone), and sensitive.
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Part III  Nonsurgical Cosmetic Treatments
Obviously, the cutaneous problems and requirements that cosmetic patients can pre -
sent with are far more complex than can be reflected within these five categories.
We think the most comprehensive approach for categorizing cosmetic skin types was
developed and published by Baumann in 2003 (the Baumann skin typing system).
Its classification is based on four main skin parameters:
1. Oily versus dry
2. Sensitive versus resistant
3. Pigmented versus nonpigmented
4. Wrinkled versus tight (unwrinkled)
To assess one’s individual skin type, Baumann’s book contains a questionnaire with
separate questions for each parameter, with a score assigned to each parameter. The
various combinations yield 16 potential skin type permutations. The book also pro-
vides comprehensive product recommendations and useful tips for physicians as well
as consumers.
Cosmetic Skin Types
Normal
Balanced skin, neither oily nor dry. It has a translucent, soft, smooth texture and
a healthy glow.
Oily
Skin that has an oily shine as a result of overactive sebaceous glands with excess
oil production. Often associated with enlarged pores and an irregular, coarse skin
surface. Tendency to develop comedones and acne (“blackheads” and “pimples”).
Dry
Skin that does not shine, is dull, and frequently flakes. Skin feels dry and tight,
especially after washing.
Combination
Oily shine in the so-called T-zone (forehead, nose, chin) and dry skin in the
surrounding skin. This is the most common skin type.
Sensitive
Skin that often shows redness, flakiness, and irritation; may itch, burn, or sting.
Skin that frequently reacts to various factors, such as weather and topical products.
Baumann’s Sixteen Potential Skin Type Permutations
Oily,
Oily,
Dry,
Dry,
Pigmented
Nonpigmented
Pigmented
Nonpigmented
Sensitive
OSPW
OSNW
DSPW
DSNW
Wrinkled
Sensitive
OSPT
OSNT
DSPT
DSNT
Tight
Resistant
ORPW
ORNW
DRPW
DRNW
Wrinkled
Resistant
ORPT
ORNT
DRPT
DRNT
Tight
D, Dry; O, oily; P, pigmented; R, resistant; S, sensitive; T, tight; W, wrinkled.