The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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15 Botulinum Toxin Injection for Facial Rejuvenation
Sean Michael Devitt and Steven Fagien
Abstract
Nonsurgical procedures are the most common treatment
modality used for facial rejuvenation, with neurotoxin injection
being the most common of these procedure performed. In this
chapter, we discuss the history and development of botulinum
toxin, its role in the nonsurgical management of facial aging,
its advantages and disadvantages, and its clinical applications
for patients undergoing aesthetic surgery. Case examples and
specific injection techniques for each target muscle are provided.
Keywords
neurotoxin, botulinum toxin, Botox, Xeomin, Dysport, -euveau,
nonsurgical, facial rejuvenation, safety, rhytids, aging
15.1 Introduction
For a brand name to become a part of the common vernacular,
it often requires being first in a new and unique application,
time-proven benefits, and widespread use that translates to a
strong association with a certain type of product. Use of such
names as Band-Aid (-ohnson and -ohnson, 1ew Brunswick, 1-)
for adhesive bandages in general, Xerox (Xerox Corporation, Palo
Alto, CA) as a verb for ´the making of a photocopy,µ and Google
(Alphabet Inc., Mountain View, CA) as a verb for ´searching the
Internetµ are examples of this brand recognition. Brand associ-
ation has emerged in the world of aesthetic treatments as well.
Since its FDA approval in 2002 for the temporary treatment of
glabellar rhytids, Botox (onabotulinumtoxinA; Allergan, Irvine,
CA) Cosmetic has transformed aesthetic medicine, and ´Botoxµ
has become the household name despite the later introduction
of many competitive neurotoxins. 1aturally, the popularity
and effectiveness of Botox has led to the development and FDA
approval of four additional botulinum toxin type A derivatives
for the temporary treatment of glabellar lines. Dysport (abobot-
ulinumtoxinA; Galaderma Laboratories, Fort :orth, TX), which
was approved in 2009, and Xeomin (incobotulinumtoxinA; Merz
Pharmaceuticals, Raleigh, 1C), which was approved in 2011,
and now -euveau (prabotulinumtoxinA-xvfs), with approval in
2019, are widely commercially available. The American Society
for Aesthetic Plastic Surgery (ASAPS) reported that botulinum
toxin type A injections were performed 6.5 times more than
the top five cosmetic surgical procedures combined, and more
than the top four nonsurgical minimally invasive cosmetic pro-
cedures combined. It is crucial for the physician to understand
the similarities and more importantly the differences in these
products to treat patients appropriately. For aesthetic purposes,
botulinum toxin is primarily used in the face and neck, although
unique uses continue to expand for both aesthetic and nonaes-
thetic indications.
Facial rejuvenation requires an understanding of the natural
aging process and how it is related to a patient’s underlying anatomy.
:ithout this knowledge, it is impossible to manipulate a patient’s
tissue to restore a more youthful appearance. :hile patients’ over-
all appearance and aesthetics are their focus, a physician must see
deeper and understand how each region of the face ages differently
in order to provide the best guidance and treatment plan. There
are many surgical and nonsurgical methods available to rejuvenate
the face; deciding which method for each specific patient is part
of the art of medicine. Surgical procedures are inherently more
invasive, with longer downtime, but they are often able to make
greater changes and are in general used to restore the effects of soft
tissue laxity and ptosis. Greater does not necessarily mean better,
however, as a patient often seeks subtle changes or just wishes to
slow down the aging process. 1onsurgical procedures address skin
quality, soft tissue volume, and the hyperdynamic movements of
underlying muscles that lead to both dynamic and static rhytids. A
physician must know the benefits and drawbacks of both surgical
and nonsurgical methods, regardless of the age of the patient, in
order to provide the patient with multiple options for treatment
and to manage patient expectations. Only then can a patient truly
give informed consent and partner with the physician to develop
a rejuvenation plan.
15.2 Nonsurgical Skin Rejuvenation
After seeing a patient in consultation, a physician must decide
whether the patient would benefit more from a surgical or from a
nonsurgical treatment. These are not mutually exclusive, as many
patients benefit from a combination of treatments. Office-based
nonsurgical skin rejuvenation for addressing facial rhytids, and
more broadly facial aging, is performed using one of these three
methods, depending on the nature and location of the concern.
1. Lasers, intense pulsed light (IPL), photo rejuvenation, chemical
peels, and dermabrasion are used for softening static lines and
improving appearance and quality of skin. These resurfacing
techniques have their greatest benefit in leveling the epidermis
and improving collagen in the dermis. Unlike botulinum toxin
treatment, these resurfacing methods require varying lengths of
recovery as the dermis and epidermis heal. Fractional lasers or
subdermal techniques allow for a quicker recovery time.
2. Botulinum toxin is used for the chemodenervation of underlying
muscles to prevent or attenuate dynamic wrinkles in the over-
lying skin. Repetitive motion of the skin during facial expression
leads to dermal atrophy and rhytids. Paralysis of the underly-
ing muscle by botulinum toxin prevents or reduces continued
movement and stress on the skin, improving the appearance
of dynamic lines. In the absence of movement, static lines can
also be improved as dermal repair occurs. Botulinum toxin can
also contribute to facial shaping by decreasing muscle bulk or
altering the dynamic balance between elevator and depressor
muscles.

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III Nonsurgical Cosmetic Treatments
3. Tissue fillers are used to replace missing dermal components
or subcutaneous volume. These injectable materials augment
areas of dermal atrophy by supporting or promoting regener-
ation of the dermal matrix or by enhancing volume. There are
many products to choose from, all with varying properties used
to shape and influence the native soft tissue along a spectrum.
They have been traditionally used in the treatment of volume
loss and the correction or improvement of soft tissue contours
and static lines. More recently, however, it has become clear that
with a greater understanding of the unique properties of par-
ticular agents, a variety of soft tissue fillers placed with preci-
sion can influence the excursion of soft tissue with animation
to restore balance of the (dynamic discord) muscles’ dominance
over the failing soft tissue integrity with age. Furthermore, the
effects of soft tissue agents in residence on the retaining liga-
ments and positive distal muscular effects (myomodulation) are
areas of great interest and exploration.
1onsurgical and surgical procedures are often used in conjunc-
tion to give the best result. As with most things in medicine, a
patient-specific combination of treatments is better than a one-
size-fits-all approach. 1onsurgical treatments can complement
and enhance surgical results and are used by many patients to
delay surgical intervention. Patients are hesitant go ´under the
knifeµ and are more comfortable with office-based procedures.
However, nonsurgical procedures, in general, should not be
considered to be, and rarely are, a satisfactory replacement for
surgical rejuvenation procedures.
:hen evaluating a patient for nonsurgical or surgical proce-
dures, the provider must not overlook the quality of skin. Patients
are often surprised at how much a good skin care regimen can
affect their overall appearance. A multimodal plan to improve all
aspects of aging from the outside in leads to facial harmony and a
youthful appearance.
Of the three broad categories of treatment for nonsurgical
facial rejuvenation just discussed, denervation, or more broadly,
neuromodulation with botulinum toxin type A injection still
enjoys the honor of being the most commonly requested proce-
dure among the spectrum of options because of its predictability
and dependability, ease of application, minimal downtime, and
repeatablility. In this chapter we discuss the history and develop-
ment of botulinum toxin, its role in the nonsurgical management
of facial aging, its advantages and disadvantages, and its clinical
applications for patients undergoing aesthetic surgery. It is crucial
that injectors understand the similarities and differences among
Botox, Dysport, Xeomin, and -euveau, so we will discuss recon-
stitution, dosing, and storage guidelines, injection techniques,
posttreatment protocols, and potential complications.
A fifth botulinum toxin, Myobloc (rimabotulinumtoxinB;
Solstice 1eurosciences, San Francisco, CA), is on the market and
is FDA-approved for the treatment of cervical dystonia. Unlike the
three previously mentioned products, which are derived from
botulinum toxin serotype A, Myobloc is derived from botulinum
toxin type B, and its use for aesthetic indications is off label. It is
widely available and is included in our discussion.
Finally, another botulinum toxin type A, DAXI (daxibotulinum-
toxinA; Revance Therapeutics, Inc., 1ewark, CA), is expected to get
FDA approval in 2020.
Due to the lack of or limited experience postmarket with
-euveau and DAXI, discussion and comparatives with these two
specific products will be limited.
15.3 History
A toxin produced by the anaerobic bacterium Clostridium botuli-
num was identified in 1897 as the causative agent in descending
muscle paralysis from food poisoning. The toxin was responsible
for devastating the canning industry in the 1930s, until reliable
methods for killing the bacterium’s spores were developed,
and was later purified by the United States Army for biological
warfare research. Some 40 years later, pediatric ophthalmologist
Dr. Alan Scott collaborated with Dr. Edward -. Schantz in the
preparation of a batch of crystalline toxin to determine its effec-
tiveness as an injectable agent for producing transient weakness
of extraocular muscles and permanent changes in ocular
alignment in a primate model. In 1980, Scott was the first to use
the toxin in humans to treat strabismus. Since that time, the
clinical use of botulinum toxin has been expanded and applied
to a wide range of conditions for which the principal therapeutic
aim is to reduce undesired or excessive contraction of muscles.
The transition of botulinum toxin’ s use from ophthalmologic to
aesthetic indications is credited to Carruthers and Carruthers in
1992, who serendipitously noted a reduction in glabellar rhytids
when injecting the corrugator supercilii muscles for benign
essential blepharospasm. Table 15.1 provides a brief timeline of
Clostridium botulinum toxin in clinical medicine and highlights
the FDA approval dates for its aesthetic uses to date.
15.4 Nonaesthetic Uses
Once feared as one of the most deadly toxins in the world, botuli-
num toxin is now one of the most widely used medicines, and its
applications are continuously expanding. It has been successfully
used to treat conditions from head (headache, cervical dystonia,
blepharospasm, facial rhytids) to toe (poststroke spasticity) and
everywhere in between. Table 15.2 includes just some of its
clinical uses and is by no means all-encompassing.
15.5 Available Neurotoxins/
Fundamentals
15.5.1 Product Preparation
Botulinum neurotoxin type A (Botox, Dysport, and Xeomin) is
one of seven serologically distinct and species-specific toxins
produced by C. botulinum, a gram-positive, spore-forming, obli-
gate anaerobe that is found naturally in the soil. It is produced by
fermentation of the Hall strain of C. botulinum type A in a culture
medium.
To prepare onabotulinumtoxinA (Botox Cosmetic), the culture
solution is purified by a series of acid precipitations to a crystalline
complex containing the toxin and other proteins. This complex
is then dissolved in sterile sodium chloride solution containing
human albumin and is then sterile-filtered before filling and

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vacuum drying. Botox Cosmetic is commercially available as a
sterile, lyophilized powder without preservatives. Each single-use
vial of Botox Cosmetic contains 100 units (10 variation) of botu-
linum type A neurotoxin complex, 0.5 mg of human albumin, and
0.9 mg of sodium chloride. A 50-unit vial is also available.
AbobotulinumtoxinA (Dysport) is prepared by purification
of the bacterial culture supernatant by a series of precipitation,
dialysis, and column chromatography. The neurotoxin complex is
composed of neurotoxin, hemagglutinin proteins, and nontoxin,
nonhemagglutinin proteins. It is commercially available as a ster-
ile, lyophilized powder. Each vial of Dysport contains 300 units
of botulinum toxin type A complex, 125 mcg of human serum
albumin, 2.5 mg of lactose, and trace amounts of cow’s milk pro-
teins. A 500-unit vial is also available for the treatment of cervical
dystonia.
IncobotulinumtoxinA (Xeomin) is also prepared by the puri-
fication of the bacterial culture supernatant. The neurotoxin is
then separated from the accessory proteins (hemagglutinins and
nonhemagglutinins) to yield a purified active neurotoxin. It is a
commercially available as a white to off-white lyophilized powder.
Each 100-unit vial of Xeomin contains 100 units of botulinum
toxin type A, 1 mg of human albumin, and 4.7 mg of sucrose. A
50-unit vial is also available.
RimabotulinimtoxinB (Myobloc), as previously mentioned, is
subtype B. It currently has FDA approval for the treatment of cer-
vical dystonia, but any aesthetic use is considered off-label, so it is
far less used for cosmetic purposes than the preceding three. It is
produced by the fermentation of the Bean strain of C. botulinum
type B, purified by a series of precipitation and chromatography
steps, and packaged as a clear to light yellow injectable solution
Table 15.1 Chronology of Clostridium botulinum toxin in clinical medicine
Date
(YenW
Author
1897
C. botulinum neurotoxin isolated
E. Ermengem
1920
Purification attempts
H. Sommer
1946
Crystallized type A purified
E. J. Schantz
1950
Therapy of hyperfunctional muscles
V. Brooks
1973
Pharmacologic weakening of extraocular muscles in monkeys
A.B. Scott
1979
Crystalline botulinum toxin A; batch 79–11
E. J. Schantz
1980
Botulinum toxin for treatment of strabismus in humans
A. B. Scott
1985
Botulinum A exotoxin used to treat blepharospasm
A. B. Scott
1985
Botulinum toxin used to treat spasmodic torticollis
J. K. Tsui
1989
FDA approves Botox for treatment of strabismus, benign essential blepharospasm, and hemifacial spasm
1990
Botulinum toxin used to treat dystonias
J. Jankovic
1992
Botulinum A exotoxin used to treat glabellar frown lines
J. D. Carruthers, A. Carruthers
1993
Botulinum toxin used to treat hyperfunction of facial expression
A. Blitzer, M. E Brin
1997
New lot of Botox reformulated and produced from bulk toxin
2000
Myobloc (botulinum toxin type B) approved for treatment of cervical dystonia
2002
FDA approves Botox Cosmetic for treatment of glabellar lines
2004
FDA approves botulinum toxin for treatment of primary axillary hyperhidrosis
2007
Botulinum toxin injections are the most common aesthetic procedure in the United States,
as reported by the American Society for Aesthetic Plastic Surgery (ASAPS)
2009
FDA approves Dysport for treatment of cervical dystonia and glabellar lines
2011
FDA approves Xeomin for treatment of glabellar lines
2013
FDA approves Botox Cosmetic for treatment of crow’s feet
2017
FDA approves Botox Cosmetic for treatment of forehead lines
2019
FDA approves Jeuveau for treatment of glabellar and forehead rhytids
Table 15.2 Partial list of the uses of botulinum toxin in medical therapy
Achalasia
Anal fissure
Back pain
Benign prostatic hypertrophy
Blepharospasm
Breast reconstruction and
augmentation
Cerebral palsy
Cervical dystonia
Dental procedures
Esophageal stricture
Essential tremor
Facial nerve disorders
Facial spasms
Gustatory sweating (Frey’s
syndrome)
Headaches
Hyperhidrosis
Inner ear disorders
Masseteric muscle hypertrophy
Mohs Micrographic Surgery repair
Neck pain
Overactive bladder
Parotid fistulas
Poststroke limb spasticity
Pressure ulcers
Reduced appetite
Spinal cord injury
Strabismus
Temporomandibular joint
dysfunction
Teeth grinding
Tourette’s syndrome
Vasospastic disorders
Vocal cord disorders
Wound healing

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III Nonsurgical Cosmetic Treatments
that does not require reconstitution. Each vial of Myobloc contains
5,000 units of botulinum toxin type B in 1 mL of a solution con-
taining 0.05 human serum albumin, 0.01 M sodium succinate,
and 0.1 M sodium chloride at a pH of 5.6. It is also available in
2,500 units (0.5 mL) and 10,000 units (2 mL).
It cannot be stressed enough that the unit dosings among the
four botulinum toxin products are not equivalent.
15.5.2 Mechanism of Action
Both Botox Cosmetic and Dysport are composed of botulinum
toxin type A, each with a unique toxin/protein complex that
results in different dosing between the two products. Once
injected, the botulinum toxin core quickly dissociates from the
complex due to the change in pH. Xeomin is a purified toxin
Type A that is not complexed to any proteins. For all three for-
mulations, the core neurotoxin single-chain protein has a mass
of approximately 150 kDa and is made up of two polypeptide
fragments (a 100-kDa heavy chain, Hc, and a 50-kDa light chain,
Lc) that are linked by a disulfide bond. The neurotoxic effects
occur in four sequential steps:
1. Binding: Hc responsible
2. Internalization: endocytosis into vesicle
3. Translocation: Lc released from vesicle into cytoplasm of presyn-
aptic neuromuscular junction
4. Intracellular proteolysis: Lc cleaves S1ARE protein (toxin A
cleaves S1AP-25, whereas toxin B cleaves synaptobrevin), pre-
venting vesicles containing acetylcholine (ACh) from fusing with
the presynaptic membrane and thus blocking the release of this
neurotransmitter
Thus the toxin produces chemodenervation by preventing the
release of acetylcholine at the neuromuscular junction of the
peripheral nervous system and at ganglionic nerve terminals of
the autonomic nervous system. This occurs within 6 to 36 hours
of exposure to the muscle, yet the clinical effects of flaccid paral-
ysis are not seen for several days, possibly related to spontaneous
release of ACh at the neuromuscular junction. The maximum
effect of the toxin takes place 7 to 14 days after injection, and the
extent of muscle paralysis and atrophy correlates directly with the
amount of toxin injected.
At therapeutic doses the toxin produces paralysis limited to
the injected muscle; however, the toxin has the potential to cause
paralysis or weakness of adjacent muscles by diffusion or spread.
These terms are oftentimes erroneously confused.
1. 'L̵XVLRQ results from toxin moving down its concentration gra-
dient and is related to the total dose of toxin and local receptor
concentration.
2. Spread is the physical pushing of toxin from the area of injection
and is related to the solution volume and injection technique.
Therefore, diffusion and/or spread are a function, in part, of
concentration gradient and physical force and may not be attrib-
utable to the specific formulation of toxin. This concept has been
supported by multiple studies showing no difference in diffusion
between the different brands or neurotoxin, while other research
and clinical experience has opposed this concept, suggesting
there may be some subtle differences in what some call ´field of
effect,µ whereby there is an apparent and differential effect on
neighboring muscles with seemingly equivalent dosing.
Treatment with botulinum toxin has a temporary effect that
last an average of 3 to 4 months. There is ongoing turnover of neu-
romuscular junctions, so muscle function gradually returns. For
unknown reasons, even with high doses of toxin, it is estimated
that paralysis occurs in only 80 of the muscle; although the
functional 20 is not clinically relevant, it may have a protective
effect on the muscle. It is believed that axonal sprouting and reori-
entation of muscle fibers prevent permanent paralysis of muscles
that are treated repeatedly.
15.6 Toxicity
The lethal dose of Botox Cosmetic is measured in units, with
1 unit being the lethal dose of toxin causing death in 50 of a
group of 18- to 20-g female Swiss :ebster mice within 3 days of
intraperitoneal injection. The median lethal dose (LD50) has been
estimated to be 2,700 units in a 70-kg human, based on the same
LD50 of approximately 40 units/kg in primates. Species-specific
sensitivity to the toxin precludes a precise calculation of the
human LD50. It is not known what normal dose should be to pre-
vent toxicity; however, single doses exceeding 500 units of Botox
Cosmetic may produce acute symptoms and signs of botulism.
Botulinum toxin is one of the most potent and neurospecific
toxins known. It is also one of the most studied, discussed, and
published substances used in medicine, and it has a long track
record of safety. It is estimated that in a 70-kg adult, the lethal
dose of crystalline botulinum type A would be approximately 0.09
to 0.15 mg by the intravenous or intramuscular route, 0.7 to 0.9 mg
by inhalation, and 70 mg if ingested orally. Considering the type
available in the United States, it would be inaccurate to consider it
as a potential bioterrorism agent (each vial contains only 0.3 of
the estimated lethal inhalation dose for humans and 0.005 of the
estimated lethal oral dose). The toxin does not penetrate intact
skin, and person-to-person transmission does not occur.
The maximum total recommended dose of Botox Cosmetic is
300 to 400 units at any one session and not more than 400 units
over a 3-month period. The maximum dose of Dysport is 1,000
units over a similar period. (.eep in mind that these higher doses
are almost exclusively utilized for noncosmetic purposes.) The
dosage should be adjusted for the following reasons:
1. Anatomic location
2. Muscle mass
3. Age
4. Sex of patient
5. Desired outcome/effect
6. Patient prior experiences/dose of toxin
7. Condition being treated
8. Time interval since last exposure to toxin
15.7 Dilution/Storage
The FDA approval for treatment of with glabellar lines is based
on a dilution of 2.5 mL of 0.9 preserved saline into a 100-unit
vial of Botox Cosmetic and Xeomin or 2.5 mL and 1.5 mL dilutions
into 300-unit vial of Dysport. In practice, there is a large variety
of dilutions that are acceptable and commonly used, as the
injection technique is much more important than the specific

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dilution. Most dilution occurs in the range of 1.0 mL to 4 mL.
Large dilutions with lower concentration of toxins require larger
volumes of injection to achieve the desired result. Utilizing a
higher level of dilution can increase the potential for spread (not
diffusion) of the toxin to neighboring muscles. It has also been
suggested that the higher volume of injection may also give a
shorter duration of effect, but this is anecdotal and longevity
may perhaps relate more largely to dosing than to dilution. For
this reason, a low volume and high concentration of botulinum
toxin is preferred for more targeted treatments.
The manufacturer recommendation for diluent for all of the
neurotoxins is nonpreserved 0.9 sodium chloride (based only on
the methods utilized in the registration trials); however, we (and
many) prefer to use benzoic acid–preserved (bacteriostatic) 0.9
saline. In addition to the bacteriostatic properties that help avoid
bacterial contamination, the preserved saline has been shown to
decrease procedural pain during injection in randomized con-
trolled trials. The fragility of the toxin also raises concern during
reconstitution. It is thought that agitation or foaming during
reconstitution can degrade the toxin and decrease the potency
of the injection, but this concept as well has never been proven.
Although studies have shown this is not necessarily true and the
toxin is less fragile than previously anticipated, it is still our prac-
tice to avoid turbulence and foaming by reconstituting the toxin
with a larger-bore (18-gauge) needle.
An additional area of controversy is the length of time neu-
rotoxin can be stored after reconstitution. The manufacturer
recommendations are as follows:
• Botox Cosmetic: Unopened vials require refrigeration at
2 to 8ƒC (35.6–44.4ƒF) for up to 36 months; reconstituted vials
should be used within 24 hours
• Dysport: Unopened vials require refrigeration at 2 to 8ƒC
protected from light for up to 12 months; reconstituted vials
should ideally be used within 4 hours, 24 hours maximum
• Xeomin: Unopened vials can be stored at room temperature or
in a refrigerator or freezer for up to 36 months; reconstituted
vials should be used within 24 hours
• Myobloc: Unopened vials should be stored in refrigerator;
do not freeze or shake; diluted vials should be used within 4
hours, as the formulation does not have a preservative
The length of time a neurotoxin can be stored after reconstitu-
tion has been studied numerous times, with strong evidence to
suggest it can be stored up to 4 to 6 weeks in the refrigerator with-
out any change in potency of the toxin. :e make every attempt to
use the toxin within 48 hours after reconstitution but would not
hesitate to use it if stored longer, as long as it is kept refrigerated.
15.8 Aesthetic Indications and
Contraindications
:hen discussing the use of botulinum toxin for aesthetic facial
rejuvenation, it is important to decipher between the FDA-
approved indications and the numerous off-label uses of the
toxin. The FDA approved aesthetic uses are as follows:
• Botox Cosmetic:
1. Temporary treatment of moderate to severe glabellar lines as-
sociated with corrugator and/or procerus muscle activity
2. Moderate to severe canthal lines associated with orbicularis
oculi activity
3. Moderate to severe forehead lines associated with frontalis
muscle activity
• Dysport:
Temporary improvement in appearance of moderate to severe
glabellar lines associated with procerus and corrugator muscle
activity in adult patients  65 years old
• Xeomin:
Temporary improvement in appearance of moderate to severe
glabellar lines with corrugator and/or procerus muscle activity
• -euveau:
Temporary improvement in the appearance of moderate to
severe glabellar lines associated with corrugator and/or pro-
cerus muscle activity in adult patients
• Myobloc
The off-label uses of botulinum toxin are far more encompass-
ing and address the muscles in all regions of the face. Although
often discussed in terms of upper, middle, and lower face, it is
always important to treat the face/patient as a whole and tailor
the treatment to a patient’s specific anatomy. Common indications
and their target muscle for treatment with botulinum toxin are as
follows, divided by facial region.
• Upper face: Glabellar lines (procerus, corrugator, orbicularis
oculi), horizontal forehead lines (frontalis), lateral canthal
lines/crow’s feet (orbicularis oculi), brow shape and position
(lateral: orbicularis oculi; medial: procerus, corrugators, orbi-
cularis oculi, depressor supercilii)
• Midface: Infraorbital rhytids (orbicularis oculi), eye aperture
(orbicularis oculi), nasal flare (dilator nasalis), nasal tip ele-
vation (depressor septi nasi), nasal oblique lines/bunny lines
(nasalis, levator labii superioris alaeque nasi, depressor nasi
septi), excessive gingival show/gummy smile (convergence of
levator labii superioris alaeque nasi and zygomaticus minor
with insertion of levator labii superioris)
• Lower face: Downturned commissures (depressor anguli oris),
chin cobblestoning (mentalis), masseter hypertrophy (mas-
seter), perioral rhytids (orbicularis oris), platysmal banding
(platysma)
• Additional uses are following surgical procedures to improve
the result and/or allow healing to occur without tension
caused by movement of neighboring muscles, and in combi-
nation with other facial rejuvenation procedures (fillers/peels/
lasers) and scarring prophylaxis
The contraindications are as follows:
1. Patients with known hypersensitivity to any of the ingredients
in the formulation (botulinum toxin, albumin, sodium chloride)
2. Active infection at the injection site

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III Nonsurgical Cosmetic Treatments
3. Patients with a neuromuscular disease (myasthenia gravis,
Eaton-Lambert syndrome, motor neuron disease)
4. Patient with allergy to cow’s milk protein (Dysport)
5. Pregnant or lactating women
6. Patients on other medications that interfere with neuromuscu-
lar transmission (certain antibiotics, including aminoglycosides,
penicillamine, quinine, calcium channel blockers, neuromuscu-
lar blocking agents, anticholinesterases, magnesium sulfate, and
quinidine) that may increase paralytic effect of toxin
7. Patients with unrealistic expectations or poor understanding of
effects of toxin
8. Patients on anticoagulation/antiplatelet therapy or a propen-
sity to bleed from a medical condition (hemophilia; relative
contraindication)
Botulinum toxin treatment in the elderly (over 65 years old) has
been shown to be safe, but these patients are often not ideal candi-
dates for toxin treatment alone. :ith age, patients experience an
increase in tissue elasticity as well as a loss of soft tissue and bony
volume. Rhytids are less likely a result of hyperdynamic muscles
and more likely from loss of volume, which botulinum toxin does
not address. Because of the greater frequency of comorbid medi-
cal conditions, if it is decided that an elderly patient is appropriate
for botulinum toxin treatment, we recommend starting with low
initial doses due to changes in muscle mass and function with age.
15.9 The Ideal Patient
1. Has a good understanding of the cause of his or her aesthetic
issue and the potential role of botulinum toxin in improving it
2. Is aware that botulinum toxin’s mechanism of action is to address
hyperkinetic muscles of facial expression, causing them to relax
and therefore releasing the overlying wrinkle rather than filling
it in or decreasing its depth
3. Has relatively isolated defects that are not necessarily the result
of overlapping conditions (dermal or subcutaneous fat atrophy,
excess skin) in addition to the rhytids
4. Understands the chronology of botulinum toxin’s onset of action
and need for continued dosing to maintain effects
5. Understands the value of different surgical and nonsurgical
treatments, how these treatments can be used in combination to
improve their aesthetic and address different issues, and the var-
ious timelines of their effectiveness (botulinum toxin: 3 months,
fillers: 6 months or more, surgery: even longer)
15.10 Pertinent Anatomy
Many facial changes associated with aging are in part related to
facial animation. It is obvious that facial cosmetic procedures
are destined for regression if these known causes are not
addressed. The application of botulinum toxin to modify facial
expression can be used for line reduction, for facial shaping, and
as an adjunct to a variety of plastic surgery procedures. A clear
understanding of the facial musculature anatomic influence on
facial animation and subsequent aging is essential to delivering
the most appropriate application of botulinum toxin. A patient’s
specific anatomy and functional disposition will dictate where
treatment will be most effective.
An injector must have a thorough understanding of the facial
muscles, especially those in which botulinum toxin is most
commonly injected. The use of botulinum toxin for rhytids or to
reshape or reposition structures requires an in-depth mastery
of the function and location of the muscles of the face, their
interaction with other muscles (agonist versus antagonist), and
the unique anatomic features of each region of the face. The
muscles must be precisely located by having the patient animate,
and the amount and depth of toxin injection must be tailored to
the patient-specific strength of animation and muscle mass. The
effects of facial aging may likely have more to do with different
animation patterns rather than the actual anatomic component.
The most animated and facially expressive persons seem to exhibit
more facial lines, so these patients should be treated differently
than less expressive individuals (Fig. 15.1).
15.11 Pretreatment Assessment
When a patient presents for consideration of management of
facial aging, it is important to determine treatment options that
specifically address the patient’s desired outcomes and pathol-
ogy. Patients who are candidates for aesthetic improvement with
botulinum toxin range from those who are not quite ready for
surgery because of early age, emotional disposition, multiple
previous surgical procedures, or financial conditions to those
who desire improvement of dynamic and functional facial lines
and furrows, facial asymmetries, and improvement in facial
shape. The patient must be evaluated in three dimensions, noting
the quality of skin, dynamic and static rhytids, and areas of soft
tissue loss or malposition.
A thorough history should take place during the initial consul-
tation, with focus on patient expectations and desired outcomes;
the patient’s current understanding of how botulinum toxin
works; past medical, surgical, and medication history; and any
previous botulinum toxin injections. The patient is asked in front
of a mirror what area or issue is the cause of concern. This allows
the injector and patient to come up with a treatment plan together
while also providing an opportunity for patient education about
what things can and, more important, cannot be treated with bot-
ulinum toxin alone. The patient is asked to frown (glabellar lines),
squint or smile (lateral canthal lines), or look surprised (forehead
lines) to accentuate dynamic facial rhytids. Facial asymmetries
should be pointed out at this time, and photodocumentation is
recommended for future reference. It is also important to identify
any ptosis masked by an overactive frontalis so as to avoid treat-
ment in this area, which will lead to ptosis posttreatment.
As with any medical procedure, patients are required to sign
an informed consent document before treatment. Benefits and
limitations of botulinum toxin treatment are discussed, and alter-
native and supplemental treatments that could benefit the patient
are reviewed. It is important to explain the role of botulinum
toxin, the intended results, the length of time before results are
typically seen, the average length of its effectiveness, and potential
complications. It is emphasized that patients should return to the
clinic within 2 weeks if they have any concerns about asymmetry,
complications, or therapeutic failures. A patient is then given an
opportunity to have any additional questions answered.

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15.12 Pretreatment Planning
Prior to injection, all areas of the face that are going to be
treated are cleansed with alcohol to decrease the bacterial load
on the skin and remove makeup. Although we prefer separating
neurotoxin and soft tissue filler treatments (we prefer to treat
with neurotoxin and then have patient follow up 2 weeks later
to address residual soft tissue issues), if both are going to be
injected in the same session, the skin should be cleansed
with chlorhexidine. Every effort should be made to reduce
patient discomfort during injection. The patient is offered
cold compresses, topical anesthesia if requested, for which the
smallest-gauge needle is selected (30-gauge or higher) to lessen
the discomfort. The patient is injected in the upright position,
with the chair placed at a height that is most comfortable for
the injector.
Marking the areas or points to be injected is unnecessary and
inefficient. The patient is an active participant during botulinum
toxin treatment and is asked to exaggerate facial expressions to
guide injection sites. If the patient is going to be injected intra-
operatively, markings can be made in the preoperative holding
area.
15.13 Injection Technique
The toxin is reconstituted with 2 to 4 mL of 0.9 preserved
saline. The toxin is then drawn into a single-use plastic syringe
with an 18-gauge needle to minimize turbulence, or directly
into an insulin syringe. Preferably, a 32-gauge needle is used for
injection. The skin is then cleansed with alcohol and allowed to
dry completely prior to injection. :ith the patient in an upright,
seated position, each muscle of concern is identified and isolated.
The intended muscle is isolated and stabilized or grasped with
the injector’s nondominant hand. Although there are many vari-
ations in injection technique, we have found our technique to be
safe and reliable while providing consistent results, so it will now
be discussed organized by target muscle/indications (Fig. 15.2).
15.14 7DrgeW-SSeFiÀF 'RVing
Recommendations and Pearls
The following section will discuss our dosing recommendations
and technical pearls for injection of Botox Cosmetic or Xeomin
into specific areas. It is recommended that dosing of Dysport be
2.5 to 3 times more units per muscle area.
Fig. 15.1 Pertinent facial muscular anatomy most commonly injected with botulinum toxin.

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III Nonsurgical Cosmetic Treatments
15.14.1 Glabellar Lines
(Corrugator and Procerus)
Dosing Recommendations
Product labeling recommends 20 units divided into five equal
injection points; we recommend starting with 10 to 20 units on
average and going up to 30 or even 40 in those with stronger
muscles (particularly men or otherwise refractory patients).
Patients also may require fewer injection points or sometimes
as many as seven or eight injection points, and particularly two
injections to the procerus, depending on individualized activity.
This is all based on a good preinjection assessment.
Technical Pearls
Identify or occlude supratrochlear vessels when injecting medial/
deep corrugator. Identify the supraorbital notch to avoid the
supraorbital artery. Follow the tail of the muscle and inject more
superficially as you move laterally. Inject deep, directly into the
muscle belly of the procerus. Too superficial of an injection at the
lateral corrugator may inadvertently target the frontalis muscle,
causing medial brow ptosis.
15.14.2 Crow’s Feet
(Lateral Canthal Lines)
Dosing Recommendations
Eight to 16 units on each side of the face, usually three to four
injection points per side.
Technical Pearls
1ote regional veins and avoid them; do not inject deep, or it will
cause bruising. Always inject with the needle pointing away
from the eye. Insert needle tangential and superficial to skin
surface to decrease pain.
15.14.3 Lower Eyelid
Dosing Recommendations
0.5 unit per eyelid starting dose in two points: the central lower
eyelid and at the lower eyelid at the lateral canthus; maximum
2.5 units per eyelid.
Muscle
Frontalis
Corrugator
Procerus
Nasalis
Masseter
Orbicularis oris
Depressor anguli
oris
Mentalis
Platysma
Platysmal bands
Vertical band on
neck
Intermediate
15–25 per band/
40–75 per band
Cobblestoning of chin
Bumps on chin
Deep
5–10/15–30
Downturned oral commissures Month always looks
unhappy
2.5–7.5/8–20
Intermediate if treating
midportion of muscledeep
if treating caudal aspect
over mandible
Lip lines/gummy
smile
Superficial
5–10/15–30
Vertical peri-oral rhytids:
excessive gingival show
Masseteric hypertrophy
Widened jaw
Intermediate to deep
25–50/75–150
Vertical/transverse nasal lines
Bunny lines
Deep
5/15
Lateral orbital
orbicularis
Lateral orbital rhytids
Flat brow, brow ptosis
Decreased eye aperture
Eyelook small/
squinting
Brow ptosis
Superficial (just under dermis)
Very superficial
1–2/4–8
5–10/15–30
Superior orbital
orbicularis
Inferior pre-tarsal
orbicularis
Crow’s feet
Superficial (just under dermis)
7.5–15/20–45
Transverse glabellar rhytids
Frown lines
Deep
5–10/15–30
Vertical glabellar rhytids
Frown lines
Deep medially, becoming
superficial at lateral head
Transverse forehead rhytids
Surprise lines
Subdermal
10–25/30–75
15–25/40–75
Deformity/Aesthetic Concern
Patient Concern
Depth
Average Treatment
Dose(Female) Botox
Xeomin:Dypsort
Technique
( PHOTOS)
Fig. 15.2 Graph of injection target/depth/dosing.

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Technical Pearls
Inject just subciliary or at junction of tarsal plate and orbicularis
oculi when appropriate; avoid this injection in patients with dry
eyes, loose lower lids, and scleral show. Stabilize the head with
the nondominant hand to avoid patient movement.
15.14.4 Upper Eyelid
Dosing Recommendations
0.5 units per eyelid starting dose in two points: central upper
eyelid and at upper eyelid at the lateral canthus; maximum 2.0
units per eyelid.
Technical Pearls
Inject very superficial, just above the lashes at the far medial
and far lateral upper eyelid. Avoid this technique in patients
with significant dry eye symptoms. Stabilize the head with the
nondominant hand to avoid patient movement.
15.14.5 Horizontal Forehead Lines
Dosing Recommendations
On-label dosing recommends 20 units in five locations starting
at midforehead and cephalad to this. This paradigm will work for
many but not all, and clinical assessment will dictate optimum
injection points and dosing. General dosing may be very variable,
dosing from 4 to 20 units, but usually between 10 and 20; number
of injection sites varies greatly.
Technical Pearls
Goal is to reduce or remove lines while avoiding a frozen appear-
ance. :hen treating frontalis, you often need to treat the glabella
as well to avoid ptosis. Stay 1 to 2 cm above orbital rim. Inject
laterally, sometimes past temporal fusion line, to avoid ´Spock
eye.µ Evaluate patient beforehand to make sure the patient is not
using the frontalis to keep the eyebrows elevated.
15.14.6 Lips
Dosing Recommendations
5 units total, 2.5 per side.
Technical Pearls
Inject superficial and symmetrical. Ask patient to pout lips to
target area of most orbicularis recruitment; alter dosing based
on individual experiences. Injection here is often performed in
conjunction with lip fillers or fillers for upper lip fine lines.
15.14.7 Dimpled Chin
Dosing Recommendations
4 to 5 units with two injection sites.
Technical Pearls
Inject deep at/just above the jawline. A single ´bulletµ injection
central to this paired muscle is often both effective and avoids
injection asymmetries.
15.14.8 Depressor Anguli Oris
Dosing Recommendations
2.5 units per side.
Technical Pearls
Two locations can be injected: (1) deep 1 cm lateral to oral com-
missure at jawline or (2) more superficial halfway between the
oral commissure and 1 cm lateral from this at the jawline.
15.14.9 Platysmal Bands
Dosing Recommendations
Variable results and higher risk of adverse events are found in
this area, so there is no recommended dosing. Often at least 2
units are required per injection point, spaced 1 cm along each
band.
Technical Pearls
If you are going to inject in this area, inject superficial (subcuta-
neous) or directly into band in several points along the length of
the band; typically 1 cm spacing.
15.15 Combination/Ancillary
Treatments
As previously stated, most patients seeking facial rejuvena-
tion would benefit from a multimodal approach addressing
all areas that are affected by aging. :hile botulinum toxin
injection is an effective treatment for dynamic rhytids caused
by hyperkinetic muscles during facial expression, it is just
one tool in the armamentarium that we have as providers.
The old adage was to treat the upper face with botulinum
toxin, the midface with soft tissue fillers, and the lower face
with a combination of both. After years of experience, it is
becoming clearer that a precise understanding of underlying
pathology will guide which treatments are preferred, and a
more even combination of neurotoxin and filler often gives
the best aesthetic result. :hen botulinum toxin is combined
with filler treatment, it tends to prolong the longevity of
the filler by decreasing the metabolism in the surrounding
tissue. Chemical peels, lasers, IPL, and dermabrasion address
more superficial issues such as photodamage, fine rhytids, or
dyschromias. Soft tissue fillers counteract the natural volume
loss and descent that occurs with aging. Excess skin and
dramatic ptosis are best addressed by surgical intervention.
Mastering how and when to combine the different modalities
is the art of facial rejuvenation.

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III Nonsurgical Cosmetic Treatments
15.16 Posttreatment Care
Reasons that botulinum toxin treatments have become popular
and widespread include the lack of posttreatment restrictions
and minimal to no social downtime. After injection, any site
that is noted to be bleeding is immediately compressed with
moistened gauze to avoid ecchymosis. The patient is offered cold
compresses to help minimize bruising and swelling. :ithin 30
minutes, most patients have no noticeable sequelae of having a
procedure. The patient essentially has no restrictions. Some pre-
viously recommended restrictions (remaining upright, avoiding
lifting, contracting treated muscles to increase toxin takeup,
avoiding air travel, avoiding exercise) have never proven to
increase or decrease the effectiveness of the treatment or change
the rate of adverse events. :hen possible, it is preferred that
patients avoid anticoagulants, nonsteroidal anti-inflammatory
drugs (1SAIDs), and other drugs that could increase bruising.
15.17 Complications
:hen botulinum toxin is injected appropriately, the rate of compli-
cations is low, but an injector must be aware of the most common
complications and be able to treat or manage them. Complications
can be thought of in three categories: local complications from the
injection, inadvertent muscle paralysis, and therapeutic failures.
15.17.1 Local Complications from
Injection
One could argue that local complications are nothing more than
normal sequelae of having any injection. These include injection
site pain, swelling, edema, erythema, rash, bruising, ecchymosis,
tenderness, headache, and short-term hyperesthesias. Avoidance
of anticoagulants, aspirin, and herbal medications that can thin
the blood for 7 to 10 days prior to injection can help reduce
ecchymosis and bruising. :hile injecting, holding immediate
pressure over any site that bleeds will also ameliorate some of
these complications. :hen injecting the lateral canthal lines, it
is important to recognize and avoid any superficial vasculature.
Last, providing cold compresses after treatment can decrease
these complications. Local complications are usually self-limited
and resolve within a short period of time.
15.17.2 Inadvertent Muscle Paralysis
The most notable and discussed complications occur when neigh-
boring muscles are inadvertently chemodenervated by diffusion,
spread, or imprecise injection of toxin. Some common examples
of this are lip asymmetries and imbalances of the lower face
(6.9), brow ptosis (3.1), and blepharoptosis (2.5). A thorough
understanding of the agonist and antagonist muscles of the face
can guide treatment in each of these situations. :hen asymme-
tries are noted, it is crucial to review preinjection photos to see
whether they existed prior to the intervention. There are three
types of eyelid ´ptosisµ:
1. Drug-induced eyelid ptosis results from diffusion or spread of
the toxin to the upper eyelid elevators after injection of the cor-
rugator, crow’s feet, or orbicularis oculi. For mild to moderate
degrees of upper eyelid ptosis, the treatment is typically topical
medications/eye drops that stimulate Muller’s muscle (adrener-
gics), such as naphazoline/pheniramine (1aphcon A, Alcon Lab-
oratories, Fort :orth, Texas) eye drops three to four times daily
or apraclonidine 0.5 after consulting with the patient’s oph-
thalmologist (drops should not be used in patients with glauco-
ma). These drops provide approximately 1 to 2 mm of elevation
and require continued use for sustained effect. For more severe
lid ptosis, this treatment might be ineffective. Mild to moder-
ate degrees of upper eyelid ptosis usually gradually resolves in
about 2 to 4 weeks. A clue to a prediction of resolution can be
the time of onset postinjection. Late and mild onset, not noted
for at least a week or so, usually portends a quicker recovery,
while severe or complete ptosis occurring in a few (2–3) days
after injection more often suggest that the ptosis might last as
long as the beneficial intended cosmetic effect (months). The
severe cases typically do not respond well to eye drops.
2. Preexisting eyelid ptosis reflects the unmasking of preexisting
upper lid ptosis that has been compensated for by frontalis
muscle activity; treating the frontalis muscle with neurotoxin
unmasks this. Ideally, this would be recognized as pretreat-
ment by having the patient close and relax the eyes; then
the provider stabilizes the frontalis muscle before having the
patient slowly open the eyes. However, if this complication
does occur, treatment with adrenergic eye drops may be indi-
cated and helpful.
3. True brow ptosis is caused by loss of frontalis muscle activity,
which is attributed to injection of the lower border of the fron-
talis muscle one fingerbreadth below or above the brow. Patients
may present complaining of heavy eyelids despite true eyelid
ptosis, or inability to put on eye shadow. The correct treatment
is avoidance. Once encountered, treating the antagonists brow
depressor orbicularis oculi at the M point can help. Fortunately,
this complication usually gradually resolves in 2 weeks.
15.17.3 Therapeutic Failures
Therapeutic failures can consist of unacceptable or minimal
results after neurotoxin as judged by the patient, the provider, or
both. If presenting within the first 2 to 3 weeks after initial injec-
tion (as stated before, we prefer our first-time injection patients
to return at 2 weeks for evaluation), these failures can be easily
addressed. If asymmetries exist or the patient desires a denser
chemodenervation, reinjection of more neurotoxin may resolve
the issue. The injector must decide whether the asymmetry is
due to the target muscle not being effectively treated or to its
being overinjected. In the former situation, reinjecting of more
neurotoxin is the treatment, while in the latter, injection of the
muscle’s antagonist is indicated.
Rarely, patients return to the office having or claiming to have
had no effect of the treatment. This situation may occur for sev-
eral reasons: for complete nonresponse (extremely rare), either
the neurotoxin was not handled appropriately or the patient has
a previous immunologic reaction to botulinum toxin. It has been
suggested that the immunologic reaction may be attributable to
human serum albumin and results in circulating antibodies. The
development of antibodies seems to correlate with an increasing
number of injections, frequency of treatment, and total cumula-
tive dose; the reported incidence of this problem has gone down
dramatically since the reduction of protein in the formulation in
1997. Both of these can be tested by reinjection with botulinum

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145
neurotoxin A into one side of the forehead. If this treatment is
effective, it was likely an issue with toxin storage, reconstitution,
or injection. A theoretical alternative cause is that they patient
had a prior, subclinical exposure to botulinum toxin (botulism).
If the patient once again has no response, the patient can be
treated with an alternative neurotoxin, including botulinum toxin
B (Myobloc).
15.18 Outcomes
Botulinum toxin injection has an excellent safety and tolerability
profile across a spectrum of aesthetic and therapeutic applica-
tions. :hen it is injected appropriately for the right indications,
it is nearly 100 effective. Some of the keys to successful out-
comes are as follows:
Fig. 15.3 Views of 40-year-old woman pretreatment (left image in each view) and 3 weeks post combined treatment with 3.75 units of Botox
Cosmetic to forehead, glabella, and tail of brow as well as Juvpderm Ultra Plus (Allergan, Irvine, CA) to her forehead, nasolabial folds, and commis-
sures (right image in each view). (a) Frontal views. (b) Right oblique views. (c) Left oblique views. (d) Right lateral views. (e) Left lateral views.
a
c
e
b
d

146
III Nonsurgical Cosmetic Treatments
• Comprehensive pretreatment discussion with patient to set
reasonable patient expectations
• Proper storage, reconstitution, and handling of toxin before
and during treatment
• Using a patient’s functional anatomy to guide injections and
dosing
• Thorough understanding of anatomy and avoidance of danger
zones that can lead to ptosis or inadvertent chemodenervation
of adjacent muscles
• Avoidance of masklike countenance from excessive paralysis,
´frozen lookµ
• Combining botulinum toxin with other treatments (fillers,
peels, surgery) to address the aging process in three dimensions
15.19 Patient Results
Fig. 15.3, Fig. 15.4, and Fig. 15.5 show various views of a 40-year-
old woman who received combined treatment with 3.75 units
of Botox Cosmetic to her forehead, glabella, and tail of brow as
well as -uvpderm Ultra Plus (Allergan, Irvine, CA) filler to her
forehead, nasolabial folds, and commissures.
The 58-year-old woman in Fig. 15.6 and Fig. 15.7 received neu-
rotoxin injections into her platysmal bands. One day posttreat-
ment, the bands are smoothed out even in a grimace. Similarly,
the 59-year-old woman in Fig. 15.8 showed strong and asymmet-
ric platysmal bands; 2 weeks post Botox Cosmetic injection, the
bands are much less evident and more symmetric.
The 47-year-old woman in Fig. 15.9 showed perioral rhytids,
some even in repose. After upper lip injection with 3 units of
Fig. 15.6 A 59-year-old woman in repose. (a) Planned injection
points along anterior platysmal bands. (b) At 1 day post treatment of
platysmal bands with neurotoxin.
a
b
Fig. 15.7 The woman in Fig. 15.6 with animation. (a) Planned injection
points along length of bands. (b) At 1-day post treatment with
neurotoxin resulting in softening of bands.
a
b
Fig. 15.4 Close-up view of glabella and nasal dorsum of the patient
shown in Fig. 15.3. (a) Pre Botox treatment during animation with
evidence of multiple vertical rhytids along the nasal dorsum. (b)
Posttreatment view during animation with decreased vertical rhytids.
(c) Pretreatment view in repose. (d) Posttreatment view in repose.
a
c
b
d
Fig. 15.5 Close-up view of forehead and glabella of the patient shown
in Fig. 15.3. (a) Pre Botox treatment during frontalis animation with
multiple deep transverse rhytids. (b) Post Botox treatment during
frontalis animation with resolution of transverse rhytids. (c) Pre Botox
treatment during glabellar animation with vertical rhytids (“11 lines”).
(d) Post Botox treatment during glabellar animation with resolution of
vertical lines.
a
c
b
d

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Botox Cosmetic, at 2 weeks the static perioral rhytids were gone
and the dynamic ones much less evident.
The 52-year-old woman in Fig. 15.10 and Fig. 15.11 received
treatment of forehead, glabella, and crow’s feet with 50 units of
Botox Cosmetic. At 16 days post treatment, forehead rhytids and
crow’s feet were smoothed out, but there was distinct right brow
ptosis.
The 49-year-old woman in Fig. 15.12 and Fig. 15.13 under-
went treatment of forehead, glabella, and lateral orbit with 37.5
units of Botox Cosmetic. The treatment has nearly resolved the
pronounced rhytids in her forehead and glabella that appear in
animation.
a
c
b
d
Fig. 15.8 A 58-year-old woman who received Botox Cosmetic injec-
tions to platysmal bands. (a) Pretreatment frontal view of platysmal
bands on animation. (b) Frontal view 2 weeks post neurotoxin treat-
ment with near resolution of medial banding. (c) Pretreatment lateral
view on animation. (d) Posttreatment lateral view on animation.
a
c
b
d
Fig. 15.9 A 47-year-old woman with static and dynamic perioral
rhytids treated with 3 units of Botox Cosmetic to the upper lip. (a)
Pretreatment of upper lip in repose with early static perioral rhytids.
(b) At 2 weeks post treatment in repose, showing resolution of rhytids.
(c) Pretreatment of upper lip with pursing of lips, showing deep peri-
oral rhytids. (d) At 2 weeks post treatment with lip pursing, showing
softening of perioral rhytids.
a
b
Fig. 15.10 A 52-year-old woman who received treatment of forehead,
glabella, and crow’s feet with 50 units of Botox Cosmetic. Frontal view
in repose. (a) Pre treatment. (b) At 16 days posttreatment, revealing
right brow ptosis.
a
b
Fig. 15.11 Close-up view of brows of the patient in Fig. 15.10. (a)
Pretreatment. (b) At 16 days post treatment, with evidence of right
brow ptosis.

148
III Nonsurgical Cosmetic Treatments
a
c
b
d
Fig. 15.13 Animation views of the patient in Fig. 15.12. (a)
Pretreatment animation view of forehead with transverse rhytids.
(b) Posttreatment animation view of forehead with near resolution
of rhytids. (c) Pretreatment animation view of glabella with vertical
rhytids. (d) Posttreatment animation view of glabella with near
resolution of vertical rhytids.
Fig. 15.12 Views of 49-year-old woman pretreatment (left image
in each view) and 2 weeks post treatment of forehead, glabella, and
lateral orbit with 37.5 units of Botox Cosmetic (right image in each
view). (a) Frontal views in repose. (b) Right oblique views. (c) Left
oblique views. (d) Right lateral views. (e) Left lateral views.
a
c
e
b
d

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Clinical Caveats
• A thorough conversation with your patient prior to injection
with botulinum toxin, explaining the risks, benefits, and
limitations, is crucial for setting patient expectations.
• The injector as well as the office staff should be trained on
storage and reconstitution of the product.
• The injector must have a comprehensive understanding of
the different available products and recognize that they are
not interchangeable on a unit-for-unit basis.
• Photodocumentation can help guide pre- and postprocedural
discussions.
• A 30-gauge needle or smaller should be used to minimize
patient discomfort.
• Reconstitution with preserved 0.9% saline has been shown to
decrease pain during injection.
• Higher concentration of toxin and lower volume injection is
preferred.
• Avoidance of the “frozen” or masklike facies by overinjection.
• Inject into the mass of the muscle, not the rhytid itself.
• Staying 1 fingerbreadths above the superior orbital rim can
help avoid brow ptosis.
• Treatments should be patient specific based on their functional
anatomy and not “cookie cutter”; the risks and benefits of
injection sites should be weighed for each individual patient.
• Recognize treatment failures or complications early and treat
appropriately.
Suggested Reading
>1@ Carruthers -D, Carruthers -A. Treatment of glabellar frown lines with C. botuli-
num-A exotoxin. J Dermatol Surg Oncol 1992;18(1):17–21
>2@ .lein A, Carruthers A, Fagien S, Lowe 1. Comparisons among botulinum toxins:
an evidence-based review. Plast Reconstr Surg 2008;21(6):413e–422e
>3@ Lorenc =P, .enkel -M, Fagien S, et al. A review of onabotulinumtoxinA (Botox).
Aesthet Surg J 2013; 33(1, Suppl)9S–12S
>4@ 1ahai F, Lorenc P, .enkel -, et al. A review of abobotulinumtoxinA (Dysport).
Aesthet Surg J 2013; 33(1, suppl)13–17
>5@ Lorenc =P, .enkel -M, Fagien S, et al. IncobotulinumtoxinA (Xeomin): back-
ground, mechanism of action, and manufacturing. Aesthet Surg J 2013; 33(1,
Suppl)18S–22S
>6@ Lorenc =P, .enkel -M, Fagien S, et al. Consensus panel’s assessment and recom-
mendations on the use of 3 botulinum toxin type A products in facial aesthetics.
Aesthet Surg J 2013; 33(1, Suppl)35S–40S
>7@ Rzany B, Ascher B, Avelar R, et al. A multicenter, randomized, double-blind,
placebo-controlled single-dose, phase III, non-inferiority study comparing
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>8@ Sundaram H, Signorini M, Liew S, et al; Global Aesthetics Consensus Group.
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150
III Nonsurgical Cosmetic Treatments
16 Soft-Tissue Fillers
Vic A. Narurkar
Abstract
Soft tissue fillers continue to grow in popularity due to their ease
of use, predictability, and low complication profile. :e continue
to a broadening of the products available, giving both patients
and physicians more options to help achieve their goals. Their
use extends beyond simple line filling and now encompasses the
spectrum of volume enhancement and superficial treatment of
the face and neck. As with any treatment, a thorough history
and physical exam, including a detailed analysis, is essential to
determine what is best for each patient.
Keywords
soft tissue filler, -uvpderm, Restylane, Belotero, Sculptra, Radiesse,
nonsurgical rejuvenation, liquid facelift, hyaluronic acid
16.1 Introduction
The past ten years have seen a revolution in minimally invasive
and noninvasive approaches to facial and nonfacial rejuvena-
tion. At the forefront of this revolution is the development of a
palette of soft tissue fillers, primarily for facial rejuvenation and
more recently for nonfacial areas such as the neck, decolletp,
and buttocks. The trend in soft tissue fillers has shifted from
isolated filling of lines to a more global approach in rebalancing
various anatomic areas, as well as the development of fillers
in various classes and different biologic characteristics. This
allows the physician to tailor treatments in a more precise
and predictable manner. This chapter will review the various
types of materials used for soft tissue augmentation. The word
´fillerµ is generally used for these materials, but many are more
appropriately named devices, as their effects are beyond simply
´fillingµ in areas of volume deficit. Table 16.1 summarizes the
current U.S. Food and Drug Administration (FDA)-approved soft
tissue fillers.
16.2 Patient Assessment
Appropriate patient assessment is essential to optimize treat-
ment with soft tissue augmentation. Cultural/ethnic factors,
gender, and age-related concerns are all critical in creating a
treatment algorithm. :hile there may be established ideals
of facial beauty, the consultation should be individualized to
determine patient goals. This includes a thorough medical
history, patient expectations, and budgetary concerns. In addi-
tion to age-related volume loss, factors such as acne, traumatic
and surgical wounds, facial asymmetries, and conditions such
as lipodystrophy from human immunodeficiency virus (HIV)
infection should be taken into consideration. Finally, realistic
goals that can be achieved with soft tissue augmentation should
be discussed in detail, as well as the use of combination ther-
apies, surgical and nonsurgical, that can optimize these goals.
The main goal is to create symmetry and balance between the
upper, mid, and lower face/neck areas, and fillers play a critical
role in accomplishing these goals. Table 16.2 summarizes the
etiologies of facial aging and the corresponding noninvasive
treatment modalities. They include loss of subcutaneous fat
(in which soft tissue fillers can play a major role), changes in
intrinsic muscles of facial expression (leading to exaggeration
of hyperdynamic rhytids), and loss of skin elasticity (leading
to gravitational changes). Underlying bone and cartilaginous
changes can amplify soft tissue changes but are not listed
in the table, because in general they require more invasive
treatments. Photoaging can contribute to significant changes
in the skin, which soft tissue augmentation and injectables in
general cannot treat. Therefore, a thorough treatment algorithm
needs to be established, carefully delineating the role of fillers
in global rejuvenation.
The upper third of the face primarily has age-related changes
with hyperdynamic rhytids from underlying muscle. Temporal
atrophic changes are where soft tissue fillers play a primary role,
while fillers in the upper face are primarily used in combination
with neuromodulators, such as in deep glabellar lines or deep
forehead rhytids. The midface is an area where soft tissue fillers
have truly revolutionized facial aging. A blunting of the ogee curve
of the midface can produce a more sunken in appearance and
obliteration of the so-called ´applesµ of the cheeks. :eakening of
the orbital septum can produce protrusion of upper and lower lid
compartments, while in others, loss of periorbital subcutaneous
tissue can result in a skeletonized appearance to the orbits and
prominent tear troughs. Rebalancing of these fat loss areas, starting
first with the midface, can collaterally improve the appearance of
lateral tear troughs. The lower third of the face shows age-related
changes in the neck, lower cheeks, chin, and lips. Rotation of the
chin forward can produce a smaller-appearing face. Blunting of
the jawline and development of jowling can further exaggerate
a squarer, lower face in a woman instead of the ideal oval shape.
Dermal fillers placed along the jawline and chin can redefine
these areas and lead to a more balanced lower face, strengthening
these deficient areas.
The optimal approach to treating the face and neck with soft
tissue fillers is to first start at the temples, then the midface, and
finish with the chin and lower face. Fine lines such as the perioral
rhytids can then be treated to complement facial rebalancing. A
careful knowledge of the rheologic characteristics of fillers as well
as their behavior in vivo will determine appropriate selection of
soft tissue augmentation materials. Areas where greater struc-
tural support is needed, such as the jawline) and midface, require
fillers with higher viscosity, while areas where movement is more
dominant, such as the perioral region, require lower-viscosity
fillers. Finally, cultural, ethnic, and gender considerations need to
be taken into consideration.

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151
Table 16.1 FDA-approved fillers
7rDde nDme
&RmSDny
3rimDry
mDWeriDO
Concentration
Anesthetic
)'A-DSSrRYed indiFDWiRn
Juvéderm Ultra
Allergan
HA
24 mg/mL
None
Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Juvéderm Ultra Plus
Allergan
HA
24 mg/mL
None
Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Juvéderm Ultra Plus XC
Allergan
HA
24 mg/mL
0.3% lidocaine
Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Juvéderm Ultra XC
Allergan
HA
24 mg/mL
0.3% lidocaine
Correction of moderate to severe facial
wrinkles and folds (such as NLFs) and into the
lips and perioral area for lip augmentation in
patients > 21 years of age
Juvéderm Volbella XC
Allergan
HA
15 mg/mL
0.3% lidocaine
Injection into the lips for lip augmentation and
for correction of perioral rhytids in patients
> 21 years of age
Juvéderm Vollure XC
Allergan
HA
17.5 mg/mL
0.3% lidocaine
Correction of moderate to severe facial
wrinkles and folds (such as NLFs) in patients
> 21 years of age
Juvéderm Voluma XC
Allergan
HA
20 mg/mL
0.3% lidocaine
Deep (subcutaneous and/or supraperiosteal)
injection for cheek augmentation to correct
age-related volume deficit in the midface in
patients > 21 years of age
Restylane
Galderma
Laboratories, L.P.
HA
20 mg/mL
None
Correction of moderate to severe facial
wrinkles and folds, such as NLFs, and for
submucosal implantation for lip augmentation
in patients > 21 years of age
Restylane Defyne
Galderma
Laboratories, L.P.
HA
20 mg/mL
3 mg/mL
Correction of moderate to severe, deep facial
wrinkles and folds (such as NLFs) in patients
> 21 years of age
Revanesse Versa
Revanesse
HA
22–28 mg/mL
0.3% lidocaine
Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Restylane Lyft with
lidocaine
Galderma
Laboratories, L.P.
HA
20 mg/mL
0.3% lidocaine
Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Restylane Refyne
Galderma
Laboratories, L.P.
HA
20 mg/mL
3 mg/mL lidocaine
hydrochloride
Correction of moderate to severe facial
wrinkles and folds (such as NLFs) in patients
> 21 years of age
Restylane Silk
Galderma
Laboratories, L.P.
HA
20 mg/mL
0.3% lidocaine
Submucosal implantation for lip augmentation
and dermal implantation for correction of
perioral rhytids in patients > 21 years of age
Restylane-L
Galderma
Laboratories, L.P.
HA
20 mg/mL
0.3% lidocaine
Correction of moderate to severe facial
wrinkles and folds, such as NLFs, and
submucosal implantation for lip augmentation
in patients > 21 years of age
Sculptra Aesthetic
Galderma
Laboratories, L.P.
PLLA
367.5 mg in vial
None
For use in immunocompetent patients as a
single regimen for correction of shallow to
deep NLF contour deficiencies and other facial
wrinkles in which deep dermal grid pattern
injection technique is appropriate
Belotero Balance
Merz
Pharmaceutical
HA
22.5 mg/mL
None
Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Radiesse
Merz
Pharmaceutical
CaHa
-
None
Correction of moderate to severe facial
wrinkles and folds (such as NLFs) and also for
restoration or correction of the signs of facial
fat loss (lipoatrophy) in patients with HIV
Bellafill (ArteFill in UK
and Australia)
Suneva Medical,
Inc
PMMA beads,
collagen,
lidocaine
20% PMMA
microspheres
3.5% bovine
collagen
0.3% lidocaine
Correction of NLFs and moderate to severe,
atrophic, distensible facial acne scars on the
cheek in patients > 21 years of age
Abbreviations: CaHa, calcium hydroxyapatite; FDA, U.S. Food and Drug Administration; HA, hyaluronic acid; HIV, human immunodeficiency virus; NLF, nasolabial fold;
PLLA, poly-L-lactic acid; PMMA, polymethylmethacrylate.

152
III Nonsurgical Cosmetic Treatments
16.3 Techniques
Factors to consider when planning for soft tissue augmentation
include the site to be treated (dermis vs. soft tissue), the type of
filler, and the use of delivery systems (needles, cannulas). Areas
that require deep placement of filler include the temple region;
the zygomaticomalar, anteromedial, and subcutaneous areas of
the midface; the chin; and the jawline. Placement in these areas
is done along the periosteum and/or deep subcutaneous plane.
If superficial placement is performed in these areas, especially
with high-viscosity fillers, unsightly nodules can appear. Areas
to be treated in the deep dermis and superficial subcutaneous
areas include the marionette lines and nasolabial folds (NLFs).
Placement of fillers in the superficial dermis is indicated only in
areas of fine lines, such as the perioral rhytids and superficial
lateral cheek rhytids. The type of filler (to be discussed further
in other sections) is also based on the anatomic location. Areas
requiring more structural augmentation necessitate a thicker
filler, while areas of high motility require a thinner filler. The
use of needles versus cannulas is a hotly debated issue. At the
moment, the majority of commercially available fillers come
prepackaged with needles, some which are often not ideal for the
filler. Cannulas can be used as an alternative to needles and may
be beneficial in areas that have a high risk for vascular injury
(Fig. 16.1), such as the anteromedial cheek, orbital rim, and tear
trough. Alternatively, needles may be preferred to treat dermal
volume issues such as perioral rhytids, lip projection, and/or lack
of volume (Fig. 16.2; Fig. 16.3). While no region of the face is
immune to intravascular injury, certain areas³the glabella, nose,
and 1LF³carry with them a higher risk for intravascular injury.
Finally, bruising is reduced but not entirely eliminated with the
use of microcannulas. The main disadvantages of microcannulas
are the lack of precision and often the overuse of filler due to
technique.
Another major advance in the use of soft tissue augmentation
has been the addition of anesthetics to the filler material. The
majority of hyaluronic acid (HA)-based fillers and calcium
hydroxyapatite (CaHa) now are manufactured with lidocaine. This
has virtually eliminated the need to perform local anesthesia with
nerve blocks. On rare occasions, some physicians choose to per-
form infraorbital and mental nerve blocks for lip augmentation.
In addition, materials such as poly-L-lactic acid (PLLA) are diluted
with lidocaine as well to increase comfort. :ith the advent of a
variety of classes of fillers to address different anatomic areas,
diluting of fillers is less common. Prior to the development of mul-
tiple classes of fillers, the rheologic characteristics of fillers were
modified by blending the filler with saline and/or lidocaine. This is
done routinely with PLLA, as it comes as a solid material that needs
to be reconstituted. It is also done with CaHa to permit better flow
and, lately, also to create a hyperblended form for volumetric defi-
cits. HA-based fillers are often blended in areas requiring softer
fillers such as the tear trough and perioral rhytids. It is a matter
of controversy whether blending fillers creates a more uneven dis-
tribution of the parent filler versus using optimally manufactured
fillers with different rheologic characteristics.
16.4 Rheologic Considerations
Rheological factors affect the performance of soft tissue fillers,
with emphasis on what happens to fillers when they are exposed
to mechanical stress such as shear deformation and compres-
sion/stretching forces. Viscoelasticity has four main parame-
ters: G (overall viscosity or hardness), Gɼ (elastic modulus), Gɽ
(viscous modulus), and tan Ƕ (ratio between viscous and elastic
properties). Gɼ alone has been emphasized, but all four factors
are important for all biologic fillers. Cohesivity describes how
fillers behave once they are implanted in live tissue. The strength
of internal adhesion forces is a function of concentration of
filler and the cross-linking and nature of filler (smooth versus
granular). Both cohesivity as well as viscoelastic properties are
important in selecting fillers for appropriate anatomic locations.
Areas that require more structural augmentation include the
midface, nose, temples, jawline, and chin. Hence, fillers with a
sufficient elastic modulus (a higher Gɼ) as well as sufficient cohe-
sivity are optimal (Voluma, Restylane Lyft, Radiesse). Lower facial
areas require more tolerance of mobility. These areas require
intermediate characteristics in Gɼ and cohesivity (-uvpderm Ultra
Plus, Restylane, Restylane Defyne). Finally, fine line fillers require
the lowest Gɼ and cohesivity for placement in the subdermis and
intradermal areas (Volbella, Restylane Silk).
The aforementioned factors are in vitro measurements. Recent
studies have compared in vivo behaviors of soft tissue fillers in
an animal model, which provides a platform to make compara-
tive evaluations among fillers. Results indicated that biologic
Table 16.2 Noninvasive approaches to aging face and neck according
to etiology
Etiology
3rimDry mRdDOiWy
Changes in intrinsic muscles
of facial expression
Neuromodulators
Loss of subcutaneous fat
Dermal filler
Loss of skin elasticity
Noninvasive skin-tightening devices
Photoaging
Energy-based devices; skin care and peels
Fig. 16.1 Areas at highest risk of intravascular injury after use of soft
tissue fillers.

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153
Fig. 16.2 (a) This 51-year-old woman requested lip augmentation. (b) Restylane was injected into the vermilion border (1) and philtral columns (2)
to achieve a narrower appearance. The Restylane was injected from the inside of the lip from the vermilion border to the wet–dry junction (3). With
care, irregularities can be avoided. (c) Patient is shown 3 months after injection with good persistence of the filler. This patient is a good candidate for
treatment with Restylane. She maintained good volume correction for 6 to 7 months, requiring less volume when she returned for a touch-up with
Restylane. The patient was started on acyclovir for herpes prophylaxis.
a
b
c
Fig. 16.3 (a,d) This 48-year-old woman had periorbital hollowing as well as prominent periorbital fat in the central and medial aspects of her lower
lids. She described this as her “polar bear” appearance and sought a more normal look and contour in her orbital and midface areas. A nonsurgical eye
lift was planned as well as a midface augmentation. (b) The malar bone was augmented with Perlane to increase malar projection and camouflage the
prominent lower lid. Perlane was placed at the depth of the periorbital hollow on the bone and was also placed on the malar bone to augment cheek
projection and minimize negative vectors. A total volume of 1.1 mL was placed per side, mainly in the periorbital hollow (1) but also a smaller amount
was on the malar bone to increase malar projection relative to the eyeball (2). (c,e) The patient is seen 6 months after treatment. She was pleased
with the improvement around her eyes and the increased projection and contouring in the midface.
a
d
b
e
c

154
III Nonsurgical Cosmetic Treatments
interaction plays an important role in how filler performs. Filler
lift capacity correlated best with filler composition or type,
with homogeneous fillers having greatest capacity, followed by
nonanimal stabilized HA (1ASHA) and CaHa. Rheology alone was
insufficient to understand filler performance but was most useful
when comparing within fillers of similar composition.
16.5 Types of Soft Tissue Fillers
Table 16.1 summarizes the different types of soft tissue fillers
currently approved for use by the FDA in the United States. Fillers
can be divided into the following classes:
• Biodegradable fillers (nonpermanent)
̑ HA-based fillers
̑ CaHa
̑ PLLA
• 1onbiodegradable fillers
̑ Polymethylmethacrylate
(PMMA)
microspheres
with
bovine collagen
The most commonly used class of fillers comprises the HA-based
fillers. They have the unique advantage of reversibility with the
use of the enzyme hyaluronidase. They differ in characteristics
based on manufacturing process, which leads to differing rheo-
logic characteristics. The HA-based fillers also offer the widest
range for panfacial augmentation, ranging from structural to fine
line improvement. CaHa- and PLLA-based fillers have a more bio-
stimulatory role, with the former offering a dual effect of filling
and biostimulation and the latter being primarily biostimulatory.
Most dermal fillers have some degree of biostimulatory effects,
but these two classes have the strongest ability. There is some
anecdotal evidence of reversibility of CaHa, but more studies need
to be conducted. PLLA, by contrast, is not reversible. Finally, the
permanent filler containing PMMA with bovine collagen seems
best suited in indications such as acne scarring, where a more
durable product may be advantageous. The main disadvantage
is lack of reversibility if there are any adverse side effects and
permanence in this case.
16.5.1 Hyaluronic Acid–Based Fillers
At present there are four classes of HA fillers approved for use by
the FDA in the United States:
1. 1ASHA
2. Hylacross-based
3. Cohesive densified matrix-based
4. Vycross-based
All are based on the use of HA, a naturally occurring linear
polysaccharide composed of alternating residues of the mono-
saccharides D-glucuronic acid and 1-acetyl-D-glucosamine. The
molecular weight of HA depends on the number of pairs of these
two monosaccharides occurring in the HA molecule. HA lacks any
tissue specificity and, in theory, in its pure form, has no immu-
nogenicity. By chemically cross-linking molecules of HA, gener-
ations of more stable macromolecules can be created, resulting
in more prolonged tissue residence time after injection compared
with free-standing HA. Degradation occurs by a process known
as isovolemic degradation, which clinically translates into the
implant maintaining a high proportion of its initial space-filling
volume until complete resorption of the material. Moreover, there
is evidence that repetitive injection of HA-based fillers may have a
biostimulatory effect on fibroblasts, potentially leading to greater
duration after subsequent injections.
The 1ASHA-based fillers include the Restylane family
(Restylane, Restylane Lyft, and Restylane Silk) and the Emervel
family (Restylane Refyne and Defyne). HA can be cross-linked
using 1,4-butanediol diglycidyl ether (BDDE), and the degree
of cross-linking varies based on the filler, producing different
degrees of elasticity and viscosity as measured by Gɼ, with the
lower-Gɼ products indicated for lips and fine lines, while the
higher-Gɽ products are indicated for the midface and nasolabial
folds. As with all fillers, off-label use of 1ASHA is performed, with
the most popular areas being the tear trough, where a filler with
moderate Gɼ is desirable (Restylane), and the jawline, temples, and
chin, where a higher-Gɼ product is desirable (Restylane Lyft).
Hylacross is a process in which HA molecules of the same
molecular weight are cross-linked. Hylacross-based fillers include
-uvpderm Ultra and Ultra Plus and are indicated for lip augmenta-
tion (Ultra) and lines and folds such as the NLFs (Ultra and Ultra
Plus). These are highly cross-linked fillers, and while the Gɼ may
be lower than that of 1ASHA, the cohesivity of these fillers may
overcome the Gɼ issue. Off-label uses include the use of -uvpderm
Ultra Plus in the midface, temples, chin, and jawline, where a
highly cohesive, highly cross-linked HA may be optimal.
Vycross is a process in which HA molecules of higher and lower
molecular weights are cross-linked. Vycross-based fillers include
Voluma, Vollure, and Volbella. Vycross fillers have the unique
ability to have more intercalation in the dermis and subcutaneous
tissue. This can lead to longer duration but also more resilience
to degradation by hyaluronidase. The intercalation coupled with
a higher Gɼ in Voluma may produce a unique ability to lift the
midface.
Cohesive fillers include Belotero Balance. This is indicated
for lines and folds such as the nasolabial folds but is often used
off-label for tear troughs and perioral lines for its ´softerµ feel. The
duration limits are used in many areas.
Recent studies have shown in vivo effects of fillers in an animal
model. It demonstrated that non-Vycross-based fillers tend to be
more isolated materials in the deep dermis and subcutaneous
tissue, while Vycross-based fillers intercalate more, potentially
leading to greater duration and ´liftingµ with higher-Gɼ Vycross-
based fillers such as Voluma.
Global facial treatment with HA-based fillers is rapidly gaining
momentum. Our approach is to start at the superior aspect of
the face, generally the temple, which can serve as the anchoring
point above the supraorbital ridge using thicker HA fillers. This
is followed by treatment of the zygomaticomalar area, generally
defined by Hinderer’s lines to delineate the three components of
the midface (Fig. 16.4). Injections here are along the periosteum.
It has been shown that this injection laterally improves the tear
troughs as well as the superior aspect of the NLF. The two other
components of the midface are addressed next: the anteromedial
cheek and the submalar area. In the midface, higher-viscosity
fillers are optimal. The marionette lines are treated next with
moderate-density HA fillers, and finally the jawline or chin if

 SRIW-7iVVue )iOOerV
155
needed to define the lower face further. Fine lines such as perioral
rhytids are generally treated last. This approach can produce
dramatic changes, sometimes referred to as a ´liquid facelift.µ In
fact, it is a rebalancing of the facial fat pads, creating the ideal
inverted triangle or heart-shaped face with a well-defined ogee
curve (Fig. 16.3c).
16.5.2 Calcium Hydroxyapatite
CaHa filler (Radiesse, Radiesse Plus) consists of two components:
a gel carrier and the matrix particle. The aqueous gel contains
glycerin, sodium carboxymethylcellulose, and water. The matrix
particle component consists of bioceramic spheres of calcium
hydroxyapatite ranging in diameter from 25 to 125 microns. It is
a radiopaque substance. :hen injected, the gel is absorbed and
the residual matrix grows into the scaffolding of the surrounding
tissue, inducing fibroblasts to produce collagen. Hence, it is both a
´fillerµ in a traditional sense and a material that is biostimulatory.
The FDA-approved indications for CaHa are treatment of lines
and folds such as the nasolabial folds and hand augmentation
due to volume loss in the dorsum of hands (Fig. 16.5). Off-label
use is in structural areas such as the midface, temples, chin and
jawline. Recently, the use of hyperblended CaHa is being investi-
gated as a true volumizer in areas requiring significant defects,
such as midface atrophy and temples. The addition of lidocaine in
CaHa (Radiesse Plus) reduces the need for mixing and makes the
material more comfortable as well as produces better flow char-
acteristics. Although there is no established standard of reversal
of CaHA, recent anecdotes using sodium thiosulfate have been
reported. Moreover, anecdotal reports have also suggested using
hyaluronidase if vascular compromise is suspected.
16.5.3 Poly-L-Lactic Acid
PLLA (Sculptra) is polymerized lactic acid in a powdered lyo-
philized form, similar to the material used in Vicryl sutures.
The primary mechanism of PLLA is biostimulatory, with results
becoming apparent over time and usually after serial injections.
The material needs to be reconstituted with sterile water and
lidocaine, with volumes of diluent that vary based on location,
with a general consensus of 8 to 10 mL total. This is a shift from
the original on-label dilution, which may have contributed to the
development of nodules. The FDA-approved indications include
HIV-associated lipoatrophy and lines and folds. The material is
primarily used off-label, most commonly for volume-depleted
areas such as the midface and temples. Recently, off-label uses in
body areas such as buttocks and extremities are being advocated.
Duration of effect can last up to 2 years. Variability in response
can be seen, as this is primarily a biostimulator agent.
16.5.4 Polymethylmethacrylate
PMMA (Bellafill) is the only permanent filler approved by the
FDA. It is approved for the use of nasolabial folds and for acne
scars. It consists of microspheres or ´beadsµ of PMMA (a non-
resorbable synthetic material), 30 to 42 microns in diameter,
suspended in 3.5 partially denatured bovine collagen. A skin
test is generally recommended. The collagen serves as a vehicle
for the PMMA beads, degrading after several months, and the
Fig. 16.4 Hinderer’s lines.
Fig. 16.5 (a) Pre-treatment and (b) 6-month post-treatment results are shown after injection of 1.3 mL of Radiesse to the left hand in a 60-year-old
woman.
a
b

156
III Nonsurgical Cosmetic Treatments
microspheres induce a long-term foreign body reaction that
encapsulates them in fibrous connective tissue, producing long-
term augmentation. The main indications for this filler are the
treatment of nasolabial folds and acne scars; this is the only filler
for the latter FDA-approved indication. Off-label use has been
performed in lips (Fig. 16.6) and panfacial regions (Fig. 16.7), but
caution is advised, as there is higher risk of developing nodules,
which can be permanent in these areas.
16.6 Complications
Complications with soft tissue fillers are rare, but a thorough
understanding of the nature of complications and their manage-
ment is essential for optimal patient outcomes. Transient adverse
events for all fillers include bruising, edema, erythema, Tyndall
effect, and asymmetry due to poor technique. Bruising can be
minimized by having the patient avoid blood thinners such as
nonsteroidal anti-inflammatory agents (1SAIAs) and aspirin. The
use of microcannulas can minimize but not eliminate bruising.
Postprocedure bruising can be treated with a variety of lasers
and light sources, usually optimal at 24 to 48 hours postinjec-
tion. Edema is most common in lips, and more with HA fillers,
with their ability to be more hydrophilic. For severe edema, use
of a short course of prednisone may be indicated. Asymmetry
is generally technique-related, but most patients have inherent
asymmetry, which can be exaggerated by improper technique.
The Tyndall effect occurs because of improper plane of placement,
primarily with HA fillers; the superficial placement of fillers that
should be placed more deeply results in a bluish hue. It is also
quite common in the tear trough area and can be delayed due to
filler migration (Fig. 16.8).
Less common side effects of soft tissue fillers include true
allergic reactions, nodules, granulomas, infections, biofilm and
delayed onset nodules (Fig. 16.9). Fillers with longer duration may
have higher incidence of these complications, and certain classes
of fillers, such as the Vycross products (Fig. 16.10), have a higher
reported incidence of delayed-onset nodules, but these can be seen
with all classes of fillers. Lower dilution of PLLA used to result in
more nodules, but with modifications of dilution techniques this is
seen less. :ith permanent fillers such as PMMA, nodules and gran-
ulomas have been reported that can only be treated with excision.
Exceedingly rare complications include intravascular injection
of fillers, leading to tissue necrosis and, in rare instances, stroke
and visual compromise. Intravascular injection is of greatest risk
in areas such as the glabella, nose, forehead, temples, and antero-
medial cheek. The use of microcannulas in these areas may reduce
the risk but not entirely eliminate it. Very slow injection, constant
movement, and when possible, reflux prior to injection can also
reduce the incidence.
:ith HA fillers, most complications are reversible with the use
of hyaluronidase. Lower-viscosity and lower-cohesivity fillers
require less hyaluronidase. Resilient nodules can then be treated
with intralesional steroids and 5-fluorouracil. Biofilm is a difficult
condition to treat and sometimes requires systemic antibiotics
Fig. 16.6 Lip augmentation with ArteFill (Bellafill), first at the vermilion border (1); at the dry lip, which must be done with care (2); at the wet–dry
junction and the lateral lip, which can be turned out by injecting from the vermilion to the wet–dry mucosal junction (3).
Fig. 16.7 Use of ArteFill in the deep dermis, alone (1) or with Restylane Fine Lines/Touch at the dermal–epidermal junction (2).

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157
and, on rare instances, excision. Vascular impairment should be
treated aggressively with repeated, higher doses of hyaluronidase.
Visual compromise is the most serious complication, and it is
unclear whether retrobulbar hyaluronidase provides any benefit.
:ith non-HA fillers, resolution of complications generally
requires ultimate resorption of the material. As with HA filler
complications, biofilm and infection can be treated with systemic
antibiotics, intralesional steroids, and 5-fluorouracil. :ith PMMA,
this does not occur, and excision of the nodules is often the only
option.
16.7 Concluding Thoughts
The 21st century has seen a renaissance in soft tissue augmen-
tation with fillers. Prior to this, options were limited to few
space-filling products such as collagen. At present, four subtypes
of fillers exist that are approved by the FDA: HA-based (the most
widely used), CaHa, PLLA, and PMMA, the only permanent filler.
Techniques of soft tissue augmentation have evolved from these
materials simply being used to ´fill in the linesµ to panfacial
rebalancing and sculpting. On-label indications for fillers include
the nasolabial folds, perioral lines, lips, and midface. Off-label
use includes the temples, forehead, nose, chin, jawline, necklace
lines, dpcolletage, and body areas such as buttocks. The availabil-
ity of a variety of classes of soft tissue fillers with varying degrees
of thickness (viscoelastic properties) enables the physician to
tailor treatments based on anatomic location. In the future, we
will continue to see expanded indications for current materials
as well as the development of de novo materials, specifically
fillers that can mimic elastin, as well as those from autologous
tissue (e.g., the patient’s stem cells) to expand the palette of soft
tissue augmentation options.
Clinical Caveats
• The use of soft tissue fillers continues to grow, as do the
options the physician has. Product choices are determined by
a myriad of factors: recipient bed, degree of motion, thick-
ness of tissues, location of product, risk for adverse events.
• Hyaluronic acid products are used most commonly and enjoy
a variety of options depending on the goals desired. They are
reversible with the use of hyaluronidase.
• Balanced soft tissue filling focusing on both deeper soft tissue
augmentation and superficial line effacement is now the
norm. This is often complementary to the use of skin surface
treatments and neuromodulators.
• Complications can be minimized by thoroughly understand-
ing the product characteristics as well as the implementation
of proper technique. Anatomic danger zones should be
familiar to the injector, and an outlined and detailed plan
for complication treatments should be well known by the
injector and the team.
Fig. 16.8 Tyndall effect due to superficial placement of hyaluronic acid
(HA) fillers.
Fig. 16.9 Delayed-onset nodules and biofilm after calcium hydroxyap-
atite (CaHa) injection midface.
Fig. 16.10 Delayed-onset nodules after placement of Vycross-based
fillers infraorbital area.

158
III Nonsurgical Cosmetic Treatments
Suggested Reading
>1@ Alam M, Tung R. Injection technique in neurotoxins and fillers: planning and
basic technique. J Am Acad Dermatol 2018;79(3):407–419
>2@ Alam M, Gladstone H, .ramer EM, et al; American Society for Dermato-
logic Surgery. ASDS guidelines of care: injectable fillers. Dermatol Surg
2008;34(Suppl 1):S115–S148
>3@ Beleznay ., Carruthers -D, Humphrey S, -ones D. Avoiding and treating blindness
from fillers: a review of the world literature. Dermatol Surg 2015;41(10):1097–1117
>4@ Bhojani-Lynch T. Late onset inflammatory response to hyaluronic acid dermal
fillers. Plast Reconstr Surg Glob Open 2017;5(12):e1532
>5@ Carruthers -, Carruthers A. Three-dimensional forehead reflation. Dermatol Surg
2015;41(Suppl 1):S321–S324
>6@ Gavard Molliard S, Albert S, Mondon .. .ey importance of compression proper-
ties in the biophysical characteristics of hyaluronic acid soft-tissue fillers. J Mech
Behav Biomed Mater 2016;61:290–298
>7@ Gold MH, Sadick 1S. Optimizing outcomes with polymethylmethacrylate fillers. J
Cosmet Dermatol 2018;17(3):298–304
>8@ Haneke E. Skin rejuvenation without a scalpel. I. Fillers. J Cosmet Dermatol
2006;5(2):157–167
>9@ Hermann -L, Hoffmann R., :ard CE, et al. Biochemistry, physiology and tissue
integration of contemporary biodegradable injectable fillers. Dermatol Surg
2018;44(Suppl 1):SS19–S31
>10@ Hee C., Shumate GT, 1arurkar V, Bernardin A, Messina D-. Rheological properties
and in vivo performance characteristics of soft tissue fillers. Dermatol Surg
2015;41(Suppl 1):S373–S381
>11@ Hinderer UT, de Rio Legarreta -. Aesthetic surgery of the malar region. In: Reg-
nault P, Daniel R, eds. Aesthetic Plastic Surgery: Principles and Techniques. Boston,
MA: Little, Brown; 1984.
>12@ .ontis TC, Bunin L, Fitzgerald R. Injectable fillers: panel discussion, controversies
and techniques. Facial Plast Surg Clin North Am 2018;26(2):225–236
>13@ Lorenc =P, Greene T, Gottschalk R:. Injectable poly-L-lactic acid: understanding
its use in the current era. J Drugs Dermatol 2016;15(6):759–762
>14@ Luebberding S, Alexiades-Armenakas M. Facial volume augmentation in 2014:
overview of different filler options. J Drugs Dermatol 2013;12(12):1339–1344
>15@ 1arurkar VA, Cohen -L, Dayan S, et al. A comprehensive approach
to multimodal facial aesthetic treatment: injection techniques and
treatment characteristics from the HARMO1< study. Dermatol Surg
2016;42(Suppl 2):S177–S191
>16@ Patel U, Fitzgerald R. Facial shaping: beyond lines and folds with fillers. J Drugs
Dermatol 2010;9(8, Suppl ODAC Conf Pt 2):s129–s137
>17@ Pierre S, Liew S, Bernardin A. Basics of dermal filler rheology. Dermatol Surg
2015;41(Suppl 1):S120–S126
>18@ Ridley MB, Van Hook SM. Aesthetic facial proportions. In: Papel ID, Frodel -, Park
SS, Holt GR, Sykes -M, Larrabee :F, et al, eds. Facial Plastic And Reconstructive
Surgery. 2nd ed. 1ew >19@ Sundaram H, Cassuto D. Biophysical characteristics of hyaluronic acid soft-tissue
fillers and their relevance to aesthetic applications. Plast Reconstr Surg
2013;132(4, Suppl 2):5S–21S
>20@ Sundaram H, Voigts B, Beer ., Meland M. Comparison of the rheolog-
ical properties of viscosity and elasticity in two categories of soft tis-
sue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol Surg
2010;36(Suppl 3):1859–1865
>21@ Vedamurthy M. Beware what you inject: complications of injectables–dermal
fillers. J Cutan Aesthet Surg 2018;11(2):60–66
>22@ :ollina U. Facial rejuvenation starts in the midface: three-dimensional volumet-
ric facial rejuvenation has beneficial effects on nontreated neighboring esthetic
units. J Cosmet Dermatol 2016;15(1):82–88

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17 Non-Light-Based Skin Resurfacing
Christodoulos Kaoutzanis, Blair A. Wormer, and Galen Perdikis
Abstract
Dermabrasion, microdermabrasion, and microneedling are some
of the most frequently used non-light-based skin resurfacing
techniques for the face. Although all three modalities have a
mechanical component that causes some disruption of the skin,
they have distinct technical profiles for targeting skin anatomy
for rejuvenation in different ways. This chapter reviews the three
procedures in detail and specifically discusses their mechanisms
of action, indications and contraindications, relevant prepro-
cedural preparation, required equipment, technical execution,
important postoperative considerations, and safety profiles and
efficacy. It also examines skin changes that occur following these
procedures. Despite their widespread use, current literature is
fairly limited, with a paucity of large randomized, controlled
trials. Future evidence-based medicine will need to include all
skin types and compare different treatment modalities in order
to provide further insight into the short- and long-term effects of
these modalities.
Keywords
aesthetic medicine, dermabrasion, full dermabrasion, micro-
dermabrasion, microneedling, skin cosmetic, skin rejuvenation,
skin resurfacing
17.1 Introduction
Facial aging is an inevitable dynamic process involving changes
to both the skin and underlying tissues through intrinsic and
extrinsic factors. Intrinsic aging consists of the impact of genetic,
chronological, hormonal, and biochemical changes that occur
over time. The effect of these changes is accelerated with the
influence of extrinsic factors, predominantly photodamage via
ultraviolet (UV) light exposure. Photodamage is cumulative from
the first day of exposure until death, with approximately 50 of
the person’s exposure to UV light occurring before the age of 18.
Although multiple factors are responsible for visible skin aging, it
is estimated that sun exposure accounts for up to 90.
Several factors can affect UV light exposure and thus affect
extrinsic
aging,
including
geography,
environment,
and
occupation as well as lifestyle, such as the type of clothing the
person wears. UV radiation increases with decreasing latitude
and is compounded 4 for every thousand feet above sea level.
Environmental conditions, such as heat, wind, humidity, pollut-
ants, and reflected sunlight from sand or snow, can also influence
the exposure potential. In addition, the working environment
may play an important role in radiation exposure. For instance,
occupations that require outdoor exposure will increase skin
damage, especially if education on skin protection is lacking and
the appropriate clothing and sunblocks are not used. Smoking
has also been implicated in facial aging, since it causes cutaneous
injury through various mechanisms. It decreases capillary flow to
the skin, depriving it from oxygen and nutrients. It also results in
fewer collagen and elastin fibers in the dermis, which decreases
the elasticity of the skin. Interestingly, previous authors have
found a dose-response relationship between smoking and skin
wrinkling, with smoking being a greater contributor to facial
wrinkling than sun exposure.
17.2 Evolution of Techniques
The importance of resurfacing and restoring the facial skin was
recognized hundreds of years ago. One of the oldest reports
originates from Egypt around 1500 BC and describes removal of
the upper layer of skin to improve surface texture and smooth
out scars using sandpaper-like material. In 1905 Ernst .romayer,
a German dermatologist, pioneered facial skin resurfacing with
the use of a motorized dermabrader with rotating burs, which
allowed for removal of skin at various depths. This technique
was encouraging at the time, as it provided healing without a
scar so long as resurfacing was not carried below the papillary
dermis. Greater interest in skin resurfacing began again after
:orld :ar II in 1947, when Preston Iverson, an American plastic
surgeon, noted promising results in treating tattoo injuries by
sandpaper ablation. A few years later Abner .urtin and 1oel
Robbins developed instruments driven by an electric motor
incorporating the use of wire brushes and diamond-impreg-
nated fraises that allowed the depth of the ablation to be more
controlled.
In the 1980s, the microdermabrasion technique was developed
in Italy as an alternative to more aggressive wounding techniques.
This technique was publicly presented by G. Monteleone at the
Third Meeting of the Southern Italy Plastic Surgery Association in
1998. The first paper in a journal appeared in 1995; in it Tsai et al.
proposed the use of aluminum oxide crystal microdermabrasion
for superficial rhytides. This new technique of microdermabrasion
encompassed some of the concepts of traditional dermabrasion
but utilized a fine beam of aluminum oxide microcrystals to peel
the skin surface precisely and superficially. It was felt to improve
certain types of scars from aged and sun-damaged skin while
avoiding some of the problems seen with traditional dermabra-
sion. Mattioli Engineering brought microdermabrasion to the
United States in 1996. The Food and Drug Administration (FDA)
classified the device as a type I device, which does not require the
manufacturer to establish performance standards through clinical
trials but only to follow appropriate manufacturing practice
guidelines. The device also received an exemption status from
the FDA, which means that it can be sold to and used by anyone
(e.g., spas and beauty salons) without the need for a clearance
letter from the FDA. As a result, it is currently used by physicians,
nurses, and licensed aestheticians.

160
III Nonsurgical Cosmetic Treatments
As the understanding of skin regeneration and scar formation
has become clearer in the past few decades, so has the evolution
of other nonsurgical techniques for skin resurfacing. One such
method gaining in popularity is microneedling, which is based
on the mechanism of noninflammatory wound healing through
percutaneous collagen induction. 1orman and David Orentreich
first elucidated this property in 1994 in their description of
subcutaneous incisionless (subincision) release of tethered scars
and rhytides. They identified two key features of subincision;
first, the mechanical release of the tethered scar by subcutane-
ous sweeping of the beveled needle, and second, the induction of
neocollagenesis without significant epidermal disruption. These
two events led to significant improvement of scar appearance
and texture. Shortly after, in 1997, Andrp Camirand and -ocelyne
Doucet, in an attempt to tattoo achromic scars in two facelift
patients, incidentally found that there was loss of the tattoo
pigment at long-term follow-up but a significant improvement
in scar appearance. This built on Orentreich’s subincision find-
ings as a newly reported technique of needle dermabrasion.
Unfortunately, both subincision with a single-bevel needle
and needle tattoo technique lacked larger surface application.
Knowing this, Des Fernandes, a plastic surgeon from South
Africa, developed and showcased the first microneedling
roller (Fig. 17.1) at the International Confederation for Plastic,
Reconstructive, and Aesthetic Surgery conference in 1999. He
published his findings in 2002, marking the genesis of the many
microneedling devices we have today. He built on the theory
of percutaneous collagen induction by using subcutaneous
mechanical disruption to induce neocollagenesis, without abla-
tion of the epidermal layer, and all while being able to treat larger
surface areas with his microneedling roller. Since then, there
has been a rapid acceptance of this nonsurgical technique, with
literature supporting its efficacy and safety leading to the devel-
opment of different application devices, from the traditional
roller to newer pen-shaped electronic microneedle devices.
More recently, clinicians are using the microneedle device to
facilitate the delivery of topical products such as platelet-rich
plasma, minoxidil, acid peel agents, or even radiofrequency
energy. :ith these advancements and growth of its acceptance
in aesthetic treatments, microneedling has poised itself to be
a critical adjunct to the plastic surgeon’s armamentarium for
nonsurgical skin resurfacing.
The key to successful facial resurfacing is safety and precision
that can be achieved only with appropriate patient selection, with
understanding of the skin anatomy and the histologic effects of
the numerous treatment modalities, as well as proper application
of the chosen treatment technique. Incorporating the patient’s
desires and expectations into the treatment plan is a crucial
component of patient compliance and satisfaction. Outstanding
results are obtained not only with experience with the various
techniques but also with critical evaluation of that experience. It
is important for beginners to err on the side of undertreatment
to avoid complications, such as facial scarring, and for them to be
critical of their results on serial patient evaluations.
17.3 Pertinent Anatomy
Regardless of how minimally invasive skin resurfacing may
appear, it is essential to have a thorough understanding of
Fig. 17.1 Initial microneedling device reported by Des Fernandes in 2002. Drum-shaped roller has fine protruding needles used to puncture the skin.

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161
and systematic approach to the relevant anatomy before any
technique is attempted. For the techniques discussed in this
chapter, the relevant anatomy is confined to skin, including its
components, primarily epidermis, dermis, and subcutaneous
tissue.
Beginning with an analysis of the epidermis, it consists of a
constant turnover of epithelial cells divided into five major strata.
It makes up a tiny fraction of the skin thickness, roughly 0.1 to
0.15 mm in thickness as opposed to the dermis, which measures
0.5 to 3 mm depending on the region of the face and the patient.
The most superficial layer of the epidermis and critical for skin
resurfacing is the stratum corneum (SC). This stratum involves
anucleate cells that are filled with keratin filaments, which have
replaced their original organelle components. There are multiple
layers of these desiccated cells that are continuously sloughed
off through a process of exfoliation. This layer provides a critical
role in epidermal protection and aesthetic appearance of the skin
surface. Microdermabrasion is focused solely on removing this
layer to facilitate minimally invasive skin rejuvenation. The SC is
additionally an important component targeted in the exfoliation
process of many topical therapies and is often a focus of targeted
thickening in skin rejuvenation.
Deep to the SC lies the stratum lucidum, a thin clear layer of
cells in the face but much more robust in the glabrous skin of
the palms and soles of feet with dense keratin for support. The
stratum granulosum is deep to this and functions to prevent
trans-epidermal water loss with lipid rich membrane-coated
granules. This waterproof barrier is a target of humectants in
topical skin treatments. 1ext deepest is the stratum spinosum,
named for the thick layer of spiny cells rich in cytokeratin. The
final layer is a basement membrane, or stratum basale. This is
the mitotically active layer of cells from which all epidermal cells
originate, slowly migrating toward the surface until they exfoliate.
Deep to the epidermis, the dermis is a much thicker layer of
connective tissue and primarily consists of the papillary and
reticular layers. The papillary dermis lies directly deep to the
stratum basale of the epidermis and is most notable for its
dense capillary plexus. The clinical end point of this anatomical
feature is seen in pinpoint bleeding following puncture of the
dermis with dermabrasion, microneedling, erbium laser, or
other skin resurfacing techniques that reach this depth. This
is a very important endpoint for clinicians to be aware of. This
layer also contains the nerve endings of different sensation and
mechanoreceptors, along with other skin appendages. Deeper to
this is the reticular dermis, composed of dense bundles of colla-
gen, glandular elements, and hair follicles. The reticular dermis
makes up the bulk of the skin thickness and tensile strength. On
clinical exam, it is a white-color layer of parallel lines of collagen.
For the clinician, it is important to know that resurfacing to this
depth will actually decrease bleeding, as it has proceeded deep
to the capillary plexus of the papillary dermis. It is essential to
realize this change quickly during dermabrasion or other ablative
skin resurfacing techniques, as further ablation deep to this may
lead to full thickness dermal violation and dyspigmentation or
scarring. The hypodermis or subcutaneous tissue lies deep to the
dermis and is usually immediately recognizable by the presence
of yellow adipose tissue. Further discussion of this layer is not
relevant for this chapter, as resurfacing techniques will be limited
to the reticular dermis.
17.4 Dermabrasion
17.4.1 Mechanism of Action
Dermabrasion is the controlled mechanical planing of the epider-
mis and a variable portion of the upper dermis using a rotating
abrasive mechanical wheel. Achieving a precise depth of wounding
can smooth and lower rhytides and level irregular scars, producing
a more uniform skin surface. The predictable degree of neocollagen
formation at the upper level of the dermis, along with the re-epi-
thelialization that occurs from the dermal appendages, makes this
technique useful for addressing actinically damaged facial skin.
17.4.2 Patient Selection and
Contraindications
A thorough history and physical should be performed at the
initial consultation to ensure that there are no contraindications
to the procedure, such as clotting disorders, abnormal scarring
tendencies, and wound healing deficiencies. Any pertinent
history should be noted, including the use of anticoagulants and
nonsteroidal anti-inflammatory drugs (1SAIDs), previous history
of poor scarring or keloids, history of koebnerizing disorders,
thyroid disorders, malnutrition, prolonged use of steroids, organ
transplants, immunosuppressive disorders, hepatitis C, human
immunodeficiency virus (HIV), and previous herpetic outbreaks.
If the patient is taking anticoagulants, clinicians should consider
temporary periprocedural discontinuation of such medications
if appropriate after consultation with the prescribing physician.
Dermabrasion is not recommended for individuals with koeb-
nerizing disorders due to their increased risk for skin lesions
after stripping the SC. Isotretinoin, an antiacne drug, has been
implicated in delayed wound healing, hypertrophic scarring, and
keloid formation; therefore, it should be discontinued for at least
a year prior to dermabrasion. Also, patients with bloodborne
pathogens should not undergo dermabrasion, because the blood
can become aerosolized during the procedure, carrying a risk of
infection to the person performing the procedure. Patients with
history of herpetic disease should be definitely managed with
periprocedural prophylactic antiviral medications, such as acy-
clovir, to reduce the risk of inducing a herpetic outbreak. Since
the history of herpetic disease is not always clear, it is common
practice for many practitioners to provide all their patients with
periprocedural prophylactic coverage.
Dermabrasion has numerous applications as a skin resurfacing
technique, but it is typically used for the treatment of perioral
rhytides and fine wrinkles in other areas of the face. Deep rhytides
will also respond to dermabrasion, potentially better than some
laser resurfacing techniques with less hypo- or hyperpigmenta-
tion and less downtime. Of note, the upper and lower eyelid skin
is too thin to tolerate aggressive mechanical abrasion and should
be addressed with other forms of resurfacing. Rhinophyma, which
is characterized by an insidious enlargement of the nose due to
severe hyperplasia of the sebaceous glands, is commonly debulked
with dermabrasion. It is then allowed to heal by secondary inten-
tion, since rapid re-epithelialization occurs. Moreover, dermabra-
sion can be employed to improve the appearance of scars from
acne, trauma, and surgical incisions as well as hypertrophic scars

162
III Nonsurgical Cosmetic Treatments
and keloids. Its use has been encouraged in tattoo removal as a
complement to laser therapy.
Accurate evaluation of the skin condition and, more important,
the depth of the deformation is crucial in determining the suit-
ability of the technique. Typically, dermabrasion is considered
a good therapeutic option if the lesion penetrates but does
not extend deeper than the superficial reticular dermis. The
Fitzpatrick classification system of sun-reactive skin type (Table
17.1) is also a good measure of identifying ideal candidates for
the procedure. Individuals with Fitzpatrick skin type I or II are
ideal patients for a predictable outcome with dermabrasion.
Individuals with Fitzpatrick skin type III or higher have an
increased risk of pigmented abnormalities following the pro-
cedure, such as hypo- or hyperpigmentation. This risk must be
discussed with these patients, and it has to be weighed against
the problems related to the preprocedural aesthetic appearance
of the skin. For this patient population, bleaching creams, such
as hydroquinone, have to be used in the periprocedural period
to diminish melanocytic activity and thus decrease the risk of
pigmentation abnormalities.
17.4.3 Preprocedural Preparation
Once the clinician identifies the appropriate patient, it is imper-
ative to allocate enough time for counseling about the procedure
and its limitations. Perhaps one of the key components of a
successful outcome and a satisfied patient is realistic expecta-
tions. Face diagrams or digital computer programs can be used
to ensure that the patient understands what areas of the face
will be addressed and the degree of improvement. Before-and-
after photos of similar cases can be a useful adjunct to these
conversations.
Skin care before and after the procedure is also very important.
Tretinoin (Retin-A; Ortho-1eutrogena, Flemington, 1-), an agent
that promotes wound healing by increasing collagen formation,
is used to pretreat some patients for several weeks. As previously
mentioned, patients at risk for hyperpigmentation may receive
preprocedural hydroquinone for 4 to 6 weeks, which can be com-
bined with a retinoic acid cream. The patients are also advised
to avoid direct sun exposure for 2 months before and after the
treatment.
Dermabrasion is painful without anesthesia. The best type of
anesthesia is different for every patient, and it has to be individ-
ualized and determined preoperatively. This is a joint decision
between the physician and the patient and is mostly based on
the patient’s pain tolerance and the extent of dermabrasion.
Topical anesthetic creams can be used for superficial derm-
abrasion. 1erve blocks are useful for regional dermabrasion.
Several options exist for full facial dermabrasion. Intravenous
sedation combined with regional nerve blocks (cutaneous
branches of the trigeminal nerve) is an attractive option for
anxious patients who will not tolerate the procedure while
awake. General anesthesia is another option but is usually
preserved for patients who undergo other surgical procedures
in addition to the dermabrasion. To avoid the last two options,
prior authors have recommended the use of tumescence anes-
thesia, which creates a turgid skin surface that responds well to
mechanical ablation.
17.4.4 Equipment
Physicians performing dermabrasion should familiarize them-
selves with the required equipment. The technique involves
using a small, handheld, electrically powered motor that rotates
an end piece of choice, the speed of which is controlled with
a knob or a foot pedal rheostat. The motor speed can be up to
85,000 revolutions per minute (rpm). :e prefer the use of a
foot pedal, because it allows a wide range of speeds during the
procedure, as opposed to the knob, which limits the control of
speed. The rotational speed and the pressure exerted by the
operator determine the depth of wound penetration and are two
of the main factors that determine the outcome. The faster the
speed and the higher the pressure exerted by the operator, the
deeper the wound penetration. These two variables should not
be increased simultaneously but rather adjusted one at a time, to
avoid the risk of penetrating the skin too deeply.
The end piece comes in different sizes and shapes with variable
coarseness. The operator decides on the most appropriate tip
based on the area requiring dermabrasion and the anticipated
depth of penetration. The two most commonly employed end
pieces are diamond fraises and wire brushes. The diamond fraise
is a diamond-studded tip that is currently offered in various sizes
and shapes, such as cylinder, cone, wheel, and bullet. The diamond
surface is also available in different surfaces, from fine to extra
coarse. Finer surfaces are utilized for superficial scars and small
areas with a more delicate skin, whereas coarser surfaces are
better indicated for deeper scars and larger areas. The diamond
fraise works by causing frictional injury to the skin in a controlled
manner. This end piece is ideal for small areas and delicate skin. It
is also very helpful for skin resting above bony landmarks, such as
the zygomatic arch and nasal bone, because deep abrasion should
be avoided in these regions. If maximal mechanical abrasion is
desired, the speed of the rotatory motor has to be turned up to
60,000 to 85,000 rpm. The wire brush is another commonly used
end piece. Its tip is made up of a cylinder with multiple short
wires (2–3 mm in length) protruding from the central core.
Similar to a diamond fraise, it is available in several sizes, shapes,
and level of coarseness based on the diameter of the wires. Its
mechanism of action involves producing microlacerations to
the skin. The wires are more powerful than the diamond fraises.
Therefore, dermabrasion with a wire brush should not exceed
motor speeds of 25,000 rpm. The operator should also beware
of the orientation of the wire ends. If they are curved, then the
brush rotation should follow the curve of the wire ends. This end
Table 17.1 Fitzpatrick’s classification of sun-reactive skin type
SNin
Type
Color
5eDFWiRn WR )irVW Summer ([SRVure
I
White
Always burns, never tans
II
White
Usually burns, tans with difficulty
III
White
Sometimes mild burn, tanning moderate
IV
Moderate brown
Rarely burns, tans with ease
V
Dark brown*
Very rarely burns, tans very easily
VI
Black
No burn, tans very easily
*For example, East Indian, Asian, Hispanic, or light African descent.

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piece is preferred for large surface areas, more problematic scars,
and tattoo removal.
17.4.5 Technique
Prior to the procedure, the area to be dermabraded is marked. If a
large surface area will be treated, it can be divided into sections
or facial subunits to ensure uniformity. It is important that the
patient remove all skin topical ointments, lotions, and makeup
prior to arrival for the procedure. The skin surface is then pre-
pared with an ophthalmologically safe surgical scrub. Protective
personal equipment should be used by the operator and patient
at all times during the procedure. Magnifying loupes can be used
to magnify the surface of the skin and the rhytides.
A variety of dermabrasion techniques have been described.
Operators must be aware of these techniques and apply them
properly based on the patient’s needs. Irrespective of the tech-
nique, appropriate manipulation of the instrument is essential to
ensure maximal control and accuracy. There are two main ways
of holding the dermabrader: it can be held like a pencil or like
the handle of a spatula (Fig. 17.2). Both grips allow the device to
be held securely in order to move in short, controlled sweeps at
different skin angles when necessary. However, the pencil grip
can be less accurate at times, as it can lead to accidental beveling
that can increase the contact of the sharp edge of the instrument
with the skin, leading to undesired deeper wound penetration
(Fig. 17.3).
Several working patterns exist for dermabrasion: left to right,
superior to inferior, back and forth, and opposing right angles.
The selection depends on the preference of the operator and
the treatment indication. Continuous movement across the skin
surface with application of gentle pressure is key. The advantage
of continuously moving the end piece across the skin is that the
instrument is in contact with a debris-free surface at all times,
since the skin and debris are elevated and left behind the device
along its path. The pattern of opposing right angles with the use
of the wire brush can be effective when dealing with acne scars
because the microlacerations created by the brush can have a
=-plasty effect. It is critical to apply gentle spreading tension to
the skin that will be treated using the nondominant hand, partic-
ularly near mobile structures such as the lip. Also of paramount
importance is that the rotating tip always be at 90ƒ to an edge,
such as the lip, and the contacting surface of the wheel or brush
must be moving off the edge. For example, for the upper lip the
wheel should be at 90ƒ to the lip edge, and the contacting surface
of the spinning wheel should be spinning in an inferior direction
(Video 17.1).
As with any other procedure, dermabrasion should be per-
formed systematically by treating one facial subunit or prede-
termined facial section at a time. Typically, it is advisable to start
with the outermost areas (i.e., lateral cheek) and move inward
(i.e., toward the nose and lips). This technique, with the help of
gravity, ensures that blood flows away from the next facial area to
be treated. The borders of the treated areas should be feathered
to minimize visible areas of transition. Another technical tip to
avoid transition lines is to treat the forehead to the hairline, the
perioral area to the vermilion border, and the chin and cheeks
slightly below the edge of the jaw line. It should be noted again
that mobile structures are at significant risk during dermabrasion,
given the mechanism and speed of the rotary wheel. Special care
and attention must be taken at the hairline and near the eye-
brows, as hair can be caught in the rotary and lead to traumatic
disruption or degloving.
Determining the correct depth of wounding is crucial for a
successful outcome (Table 17.2). When the planing begins, the
outer, tan-colored epithelium is removed, revealing the pinker
dermal–epidermal junction. 1o bleeding should be seen when
the epidermis is treated because it does not contain vasculature.
As the depth increases, sparse punctate bleeding on a smooth pink
background is noted, indicating entry into the papillary dermis.
More bleeding points are visualized as the depth of the abrasion
increases, and the smooth background has a rougher appearance.
This represents the deep papillary dermis or papillary–reticular
junction, which should be the end point for most patients with
mild to moderate rhytides. A yellow color suggests entry into the
reticular dermis. Entering the deeper reticular dermis, which is
indicated by frayed white strands of collagen, is not advisable
given the high risk for scarring. An absence of pinpoint bleeding
may also be noted, prompting cessation of further dermabrasion.
If the rhytides persist after dermabrasion reaches such a depth, a
secondary procedure should be considered. Of note, an assistant
can dab the bleeding skin with a cotton cloth during the proce-
dure. Any gauze and drapes need to be kept well away from the
dermabrader at all times, because the fibers can get caught in the
rotating tip of the instrument.
Fig. 17.2 Different ways to hold the dermabrader securely and
comfortably.

164
III Nonsurgical Cosmetic Treatments
17.4.6 Postoperative Considerations
Immediately following the procedure, the dermabraded areas
are thoroughly cleansed with saline solution and gauze. Gauze
soaked in saline solution with epinephrine can be temporarily
applied on the open wounds to achieve hemostasis. A moist
environment is needed to promote wound healing during the
re-epithelialization period. This can be achieved in multiple ways,
including petroleum-based or non-petroleum-based creams and
emollients, petroleum-based and non-petroleum-based antibiot-
ics, occlusive dressings, hydrating creams, and biologic dressings.
The type of dressing and the depth of dermabrasion will deter-
mine how long the dressing will stay on. Typically, physicians
avoid the use of bulky dressings that are left in place for several
days and use occlusive ointments. Such dressings can become
sticky and hard to remove, and they trap dry blood and sweat that
not only produces an unbearable odor but also can make these
wounds more prone to infection. The wound is gently cleansed
two or three times a day, and ointment is applied. The patient
should be informed that some erythema, edema, and crusting
are normal postoperative sequelae and should be expected.
Re-epithelialization is completed within 7 to 14 days, and the
erythema can take up to 1 to 6 months to subside. 1ormally by
the end of the first week, patients can apply makeup. During the
first 2 months, it is advisable for patients to wear nonallergenic
makeup. After re-epithelialization, minimizing sun exposure and
using appropriate sunblocks are of utmost importance for 6 to 12
months to avoid pigmentation-related complications. It has to be
emphasized that sunblock must be worn as the first application
on the skin each morning before makeup is applied and before
leaving the house. In patients with Fitzpatrick skin type III to
VI, Retin-A and hydroquinone should also be considered to help
prevent postinflammatory pigmentation.
17.4.7 Skin Changes and Treatment
(ffiFDFy
Evaluating the efficacy of dermabrasion, as with most other
noninvasive facial rejuvenation procedures, is rather challeng-
ing, because the criteria for a good outcome are subjective. It is
not surprising that the data are limited; however, the available
studies have shown improvement at both the histologic and the
clinical levels following the procedure.
Histologically, mechanical ablation of the dermis disrupts the
collagen infrastructure, which increases fibroblast activity. As a
result, more collagen is produced that remodels the dermis. In
addition, several skin proteins are modified. The amount of col-
lagen formed with dermabrasion seems to be similar to that fol-
lowing Baker’s phenol solution, whereas melanocytic function is
affected to a lesser degree by mechanical ablation than by phenol.
A robust clinical outcome is far more important than histologic
improvement, since it is the only proof of the effect of the treat-
ment for the patient. Regardless of the outcome, patients should
be advised that it is not unusual to notice some change in the color,
tone, and texture of the treated skin. Several studies have demon-
strated the clinical benefit of dermabrasion for the treatment of
photoaged skin and some of its associated conditions, such as
lentigo and actinic keratosis. Other authors have attempted to
compare the two commonly used dermabrasion instruments:
the diamond fraise and wire brush. They have shown a significant
clinical improvement of photoaged skin at 3 and 12 weeks after
the procedure, but no statistically significant difference between
the two methods with regards to clinical efficacy.
17.4.8 Problems and Complications
The results of dermabrasion should be rewarding and predict-
able with the proper patient selection in the hands of a skilled
operator. However, as with any other procedure, problems and
Table 17.2 Useful signs to determine the depth of wounding during
dermabrasion
SNin ODyer
Sign
Epidermis
No bleeding
Superficial papillary
dermis
Sparse punctate bleeding on a smooth pink
background
Deep papillary dermis
Abundant punctate bleeding on a rougher
background
Reticular dermis
Absence of bleeding on a yellow background
Fig. 17.3 The bleeding pattern is a good indicator of depth. The skin should be wiped frequently so that this bleeding pattern can be observed. Care
must be taken to not angulate the fraise or wire brush, because the leading edge can cut into the skin surface and cause undesired pitting, grooving,
and/or scarring. It is critical to maintain the drum parallel to the skin surface.

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165
complications can occur. Some of the main reasons for these issues
include the patient’s preoperative skin condition or pathology, a
noncompliant patient, and a careless or inexperienced operator.
Hyperpigmentation of the skin is more common for patients with
Fitzpatrick skin types III to VI. Although it is usually self-limited,
it can be improved by starting hydroquinone 4 to 6 weeks after
the procedure. Hypopigmentation is less common but can occur if
dermabrasion is very deep. This is due to a decrease in the number
of melanocytes. The formation of milia (small white keratin-filled
cysts) is not unusual. They appear over the surface of the treated
area within 2 to 4 weeks after the procedure. In most patients
they clear spontaneously. Occasionally they persistent and can be
treated with abrasive soaps, extraction, or electrodesiccation.
As mentioned previously, an important principle of the technique
is the application of gentle and even pressure. If the pressure is not
applied evenly, the skin can appear streaky or blotchy. More serious
issues can occur with inadvertent angling of the instrument pene-
trating deep to the reticular dermal layer. This can lead to abnormal
scarring, including hypertrophic scars and keloids. Scarring can
also be seen in patients with genetic predisposition, or patients
taking certain medications. If penetration to the subcutaneous
tissue is noted during the procedure, small sutures can be placed
to reestablish dermal continuity and allow normal healing. Steroid
injections may be helpful, especially early in the scar formation.
One of the limitations of dermabrasion is the inability to erad-
icate very deep lines fully. Attempting to remove every deep line
can lead to scarring. Surgical judgment is critical in knowing when
to stop. This is particularly true for postacne scarring. Several
treatments might be required to reach maximal improvement.
Even then, the scars might not be completely removed, which will
make some patients unhappy, especially if they were not informed
of this possibility prior to the initial procedure.
Infectious complications are rare but have to be recognized
promptly and managed appropriately to avoid scarring. Common
causes include Staphylococcus aureus (a bacterium), herpes
simplex (a virus), and Candida (a fungus). Staphylococcal infec-
tions present early on, typically 3 to 5 days after the procedure,
with erythema, edema, and lesions with a honey-colored crust.
Sometimes patients will also have constitutional symptoms.
Antibiotics are used for treatment. Herpes simplex virus infection
usually occurs within the first 5 days following dermabrasion. It
presents with pain out of proportion to the exam findings and the
procedure. It can be treated with an antiviral medication, such as
acyclovir, for a minimum of 7 days. Most of these infections occur
in patients who have a history of herpes simplex virus exposure,
and they can be prevented by giving these individuals a prophy-
lactic course of acyclovir to start the day of the procedure and
continue for 7 to 10 days after the procedure. Candida infections
present later, usually 5 to 7 days after the procedure. Patients
experience itching and edema, and the wound has exudate and
delayed healing. Treatment is with topical or oral antifungals.
For example, the 42-year-old woman in Fig. 17.4 underwent
perioral dermabrasion for rhytides before prophylactic acyclovir
therapy. She gave no history of ´cold soresµ at any time during her
life. A single lesion of herpes simplex occurred in the central por-
tion of her upper lip 5 days after dermabrasion. Her outbreak was
treated with acyclovir without sequelae. It is recommended that
all patients, despite a negative history, be placed on prophylactic
acyclovir therapy for any resurfacing procedure.
17.4.9 Patient Example
The woman shown in Fig. 17.5 presented with severe sun damage
resulting from an active outdoor lifestyle. She requested improve-
ment of the deep rhytids in the perioral area as part of her facial
rejuvenation, and perioral dermabrasion was recommended.
Fig. 17.5a shows the patient marked and the dermabrader with a
barrel-shaped, coarse bur prior to the initiation of the procedure.
Fig. 17.5b demonstrates uniform punctate bleeding, which is the
desired end point, and the smaller, less aggressively surfaced bur
used for final smoothing. Fig. 17.5c presents the preoperative
(left) and postoperative (right) images of the patient. The perioral
rhytids have been smoothed.
17.5 Microdermabrasion
17.5.1 Mechanism of Action
Microdermabrasion is a closed-loop process that employs the
ablative properties of chemically inert crystals to achieve partial
skin ablation. During the procedure, a hand-held device, either a
controlled-graduated vacuum pump or a compressed air source,
is used to spray inert crystals continuously onto the skin at sub-
stantial pressures. The crystals transfer their kinetic energy to the
uppermost layer of the epidermis (the SC), leading to detachment
of sebum concretions, corneocytes, and debris. The concomitant
use of suction allows aspiration of the crystals and skin debris,
which are deposited into a disposable waste compartment. The
depth of ablation depends on several factors including the vacuum
pressure, the particle flow rate, the particle size, the angle of
impaction, the speed of movement of the probe, and the number
of passes. Unlike dermabrasion, in which skin ablation is more
operator-dependent, skin penetration during microdermabrasion
is mostly based on the programmed settings of the device.
Fig. 17.4 This 42-year-old woman underwent perioral dermabrasion
for rhytids before prophylactic acyclovir therapy. She gave no history
of “cold sores” at any time during her life. A single lesion of herpes
simplex occurred in the central portion of her upper lip 5 days after
dermabrasion. Her outbreak was treated with acyclovir without
sequelae. It is recommended that all patients, despite a negative
history, be placed on prophylactic acyclovir therapy for any resurfacing
procedure.

166
III 1RnVurgiFDO &RVmeWiF 7reDWmenWV
Another approach to microdermabrasion involves the use of
a vacuum tube with an abrasive diamond tip. Suction is used to
bring the skin up into contact with the abrasive component of
the device. The operator then slides the tip across the skin, which
causes friction and results in subsequent exfoliation.
17.5.2 Patient Selection and
Contraindications
During the initial consultation, a history should be obtained from
the patient, and a focused physical exam should be performed to
ensure that this is a suitable technique for that particular individ-
ual. Microdermabrasion is used to treat multiple skin conditions,
predominantly cosmetic in nature, aiming to improve the tone and
texture of the skin. It can be employed to correct photodamaged
skin, superfi cial fi ne rhytides, actinic keratosis, dyspigmentation,
shallow surgical and acne scars, enlarged pores, and striae dis-
tensae. It can also be used as an adjunct to laser tattoo removal or
simply done to enhance the glow and smoothness of the normal
skin. In addition, since microdermabrasion removes the SC, it can
be utilized to improve topical drug delivery. In contrast to derm-
abrasion, microdermabrasion is limited to a more superfi cial skin
resurfacing, as penetration into the dermis is limited.
Microdermabrasion has a high safety profi le with very mini-
mal risk of complications. It is safe in almost all skin types with
extremely low risk of scarring or pigmentation-related changes.
However, practitioners recommending this technique should
be aware of some contraindications. Treatment should not be
off ered to individuals with pustular or cystic acne before it is well
controlled. Similarly, viral or bacterial infections should be treated
fi rst with the appropriate oral or systemic agent prior to consid-
ering microdermabrasion. Also, this technique should be avoided
for patients with hypertrophic scarring, history of radiation to the
aff ected area, facial surgery within the past 2 months, or use of
isotretinoin within a year of treatment.
17.5.3 Preprocedural Preparation
Unlike dermabrasion, microdermabrasion does not cause signifi -
cant pain. Therefore, patients do not need anesthesia and can be
fully awake during the procedure. Depending on the individual’s
pain tolerance, an oral analgesic can be administered 30 to 60
minutes prior to the procedure. This decision has to be made in
advance between the patient and the practitioner performing
the procedure. As previously discussed, active acne or any other
type of skin infection has to be addressed prior to the procedure.
Fig. 17.5 Patient example of dermabrasion. (a) Preoperative, showing the dermabrader with a barrel shaped bur prior to the initiation of the
procedure. (b) Uniform punctate bleeding, which is the desired end point. The smaller, less aggressively surfaced bur was used for fi nal smoothing.
(c) Preoperative (left) and postoperative (right) images of the patient. The perioral rhytids have been smoothed.
a
c
b

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17.5.4 Equipment
As previously described, the most commonly used device for
microdermabrasion involves a closed-loop system. The distal end
of a hand-held device contains coarse crystals, and when in contact
with the skin it fires crystals against the skin at a programmable
pressure. Various inert, nonabsorbable solid crystals have been
effective with this technique, such as aluminum oxide, magnesium
oxide, sodium oxide, and sodium bicarbonate. The concurrent use of
a vacuum suction allows collection of the spent crystals and debris
that was produced from the abrasive action of the crystals, which
runs through a separate tubing system into a waste container and
discarded. Of note, the handpiece can be disposable or sterilized. As
mentioned above, a crystal-free device is also available and involves
a handpiece with diamond-studded tip. With the assistance of suc-
tion, the skin is brought up to the tip of the handpiece, which then
exfoliates the skin with its abrasive surface while sliding over it.
17.5.5 Technique
Prior to the initiation of the procedure, all makeup should be
removed from the face with soap and water. The face can be
also wiped with isopropyl alcohol, especially if the patient
has oily skin. During the procedure, patients lie supine on the
examination table. They are instructed to keep their eyes closed
to avoid crystal contact with the conjunctiva. Some practitioners
prefer to use moist gauze pads over the eyes for this purpose. It is
important to warn the patients that some stinging and pulling of
the skin during the procedure is to be expected.
The operator should wear universal precautions and grasp the
handpiece in the dominant hand while holding tension on the area
of the skin to be treated with the other hand to keep it flat. The tip
of the handpiece is placed on the skin, which occludes the opening,
resulting in crystal flow. As with dermabrasion, it is advisable to
approach the face systematically by treating one facial subunit or
predetermined facial section at a time. Typically, three passes are
performed over each area in different directions (vertical, horizontal,
and oblique) to minimize streaking and ensure that the entire surface
is addressed appropriately. Some areas of dry skin are more adherent
to the face and require additional passes. Thinner areas of skin, such
as the eyelids, have to be approached with caution by decreasing
the crystal outflow pressure and vacuum suction in order to avoid
purpura. Erythema indicates the end point of the treatment.
17.5.6 Postoperative Considerations
At the end of the procedure, it is not unusual to notice a chalky
residue on the skin due to crystals and debris from exfoliation.
The treated areas should be wiped with a warm washcloth. A
protective moisturizing cream with sunscreen is then applied
to the skin. The patient is advised to plan on having at least six
treatments, usually on a weekly or bimonthly basis, followed by
additional touch-up treatments as needed.
17.5.7 Skin Changes and Treatment
(ffiFDFy
Although microdermabrasion predominantly ablates the SC of
the epidermis, several reports suggest that it has an effect on
the epidermis and dermis with changes at both the histologic
and physiologic levels. Treatment has been shown to promote
thinning of the SC, thickening of the remaining strata of the
epidermis with hyperplasia of the basal cells, and flattening of
the rete ridges. It has also been reported to redistribute the mel-
anosomes and decrease conversion to melanin. All these changes
can positively impact photodamaged skin with aging-related
changes. Additional physiologic changes that may occur after
microdermabrasion include decreased transepidermal water
loss, decreased skin sebum content, and increased epidermal
concentration of ceramide. These changes, along with alteration
of the skin pH, enhance the hydration and texturing of the skin.
Furthermore, microdermabrasion has been described as stimulat-
ing fibroblastic activity and enhance collagen synthesis and depo-
sition with a more regular arrangement of collagen bundles. This
may also be explained by the induction of type I and III procollagen
expression. Elevation of proinflammatory transcription factors (e.g.,
activator protein-1 and nuclear factor-kappa binding) and cytokines
(e.g., interleukin-1-beta) that affect the release of matrix metallopro-
teinases and in turn collagen replacement is also proposed to play a
role in the observed changes during the healing process. However,
not all the available studies have confirmed these findings. Similarly,
some investigators noted an increase in the elastic fibers at the junc-
tion of the papillary and reticular dermis following the procedure,
while others found no change in elastin content. Further histological
improvements that have been documented by other researchers
include increased dermal edema, vascular ectasia, and changes in the
microcirculation. More advanced research is required to verify these
changes and determine the exact dermal remodeling pathways.
17.5.8 Problems and Complications
Complications following microdermabrasion are rare as long as
the patient is appropriately selected and has no contraindications
to the procedure, and provided the operator is thoughtful and
well trained. This is mostly due to the superficial nature of this
ablative technique. Common complaints by patients include tran-
sient mild discomfort, tingling, and erythema shortly after the
procedure. Occasionally, prolonged erythema can be observed,
but it is important to reassure patients that it will resolve with-
out intervention. Patients may develop purpura or petechiae,
especially if they have thin and friable skin or if they are taking
blood-thinning medications, but these issues resolve within days.
A case of severe urticarial reaction has been reported in a patient
with latex allergy. It was unclear whether the rash was related to
hidden latex in the system or was an amplified dermatographism
reaction or a true pressure-induced phenomenon. Regardless,
operators not only must evaluate patients for allergies before
treatment but also should be prepared to deal with unexpected
complications. Minor abrasions may also occur if the operator is
aggressive. Likewise, aggressive ablation can potentially cause
scarring, but this is extremely rare given the limited penetration
of the device. Additionally, ocular complications, such as corneal
irritation due to adherence of crystals to the cornea, is a possible
risk if protective eye equipment is not used by the patient and
the operator. Autoinoculation of certain viral diseases, such as
warts, is another potential hazard. In such cases, a linear pattern
of the disease is noted along the path of the ablative handpiece
that delivered the virus from the affected area.

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III Nonsurgical Cosmetic Treatments
17.6 Microneedling
17.6.1 Mechanism of Action
Microneedling works by noninflammatory wound healing through
percutaneous collagen induction. This was initially described as a
subcutaneous incisionless (subincision) release of tethered scars
and rhytides. It was thought to result in the mechanical release of
the tethered scar by subcutaneous sweeping of the beveled needle,
and induction of neocollagenesis without significant epidermal
disruption. Application of this technique to larger surface areas
became possible with the introduction of the microneedling roller.
The initial microneedling roller had needles penetrating at a depth
of 1.5 mm and was reported to stimulate percutaneous collagen
induction by inducing a complex cascade and release of plate-
let-derived growth factor, fibroblast growth factor, and transform-
ing growth factor-beta-3 (TGF-Ǵ3). Subsequently, these changes
lead to production of collagen, elastin, and epidermal thickening.
By inducing these controlled skin injuries, there is neocollagenesis
from fibroblast proliferation. Then, a fibronectin network is devel-
oped that provides a scaffold for initial type III collagen deposition
and subsequent replacement with type I collagen in a standard
wound remodeling cascade. Rhytides or areas of depressed scar
benefit most from this healing cascade, as it is believed that the
new collagen formation will fill in and elevate the scar or furrow.
Additionally, the relatively undisturbed epidermis can thicken and
avoid more significant damage that may cause pigment or texture
changes that occur with inflammatory wound healing. Histologic
analyses have since confirmed the altered upregulation of TGF-Ǵ3
to promote scarless wound healing, as opposed to TGF-Ǵ2-related
healing, which is associated with fibrotic scarring. Increased elas-
tic fiber deposition, preserved stratum corneum, and rete ridges
have also been demonstrated following microneedling, further
supporting its wound healing mechanism of action.
The mechanical penetration with the microneedling device has
also been shown to facilitate enhanced delivery of medications or
radiofrequency. Topical medications, such as minoxidil, trichloroace-
tic acid, and 5-fluorouracil, were found to have improved delivery with
microneedling. In addition, a synergistic effect has been observed
in concomitant therapies. One such example occurs in intradermal
platelet-rich plasma injections performed with microneedling; the
effect is believed to be through the increased concentrations of plate-
let-derived growth factor. 1ewer devices have combined the benefits
of microneedling with radiofrequency to deliver energy directly
to the papillary and reticular dermis. These combination devices
cite the benefits of therapy of both established modalities working
together to promote neocollagenesis and improved skin resurfacing.
17.6.2 Patient Selection and
Contraindications
Microneedling has a wide variety of applications for skin
resurfacing and treatment (Table 17.3). Initial patient selection
criteria by Fernandes, the Dermaroller inventor, were focused
on selecting patients with early stages of facial aging: those
seeking to restore skin tightness, diminish fine wrinkles, and
seeking to avoid more invasive dermabrasion or laser treatment.
This technique is reasonable for those patients seeking healthier
skin, using a less expensive technique and with a shorter heal-
ing phase compared with lasers. Microneedling also avoids
sun-sensitive skin following treatment by maintaining the intact
epidermis as opposed to more ablative techniques of resurfacing.
Additionally, patients desiring resurfacing with topical anesthe-
sia only and rapid recovery can also benefit from being selected
for microneedling over more intensive peels or laser therapy.
1umerous other indications for microneedling beyond tra-
ditional skin resurfacing have also been studied, such as using
microneedling as a method of drug or energy delivery. These
indications include scars (atrophic, acne, hypertrophic, burn),
alopecia (androgenetic, areata), striae rubrae (stretch marks),
pigmentary disorders (melasma, vitiligo, periorbital melanosis),
verruca, primary axillary hyperhidrosis, and actinic keratosis.
Contraindications for microneedling are few and minimally
reported. Most notable are those at risk of inflammatory or hyper-
trophic scarring, such as patients with a keloid predisposition,
inflammatory acne, or local infection. Care should also be taken to
avoid patients with active herpes labialis or immunosuppression
(chemotherapy or radiation). Practitioners should avoid areas with
chronic skin diseases such as eczema, rosacea, or potential skin
malignancy to avoid disseminating abnormal cells by microneedle
implantation. Counsel and precaution are necessary when patients
have clotting disorders or in patients who are on therapeutic anti-
coagulation, as there can be bleeding. Another avoidable compli-
cation is performing microneedling in the local area of botulinum
toxin injection, as it may lead to diffusion to undesired areas.
17.6.3 Preprocedural Preparation
After screening for appropriate contraindications already listed,
patients should undergo a strategic preoperative planning and
Table 17.3 Microneedling: indications and contraindications
Resurfacing indications:
• Early stages of facial aging or photodamage
• Fine rhytides and furrows
• Restore skin tightness and thickness
• Seeking to avoid dermabrasion or laser treatment
• Seeking rapid recovery with topical anesthesia only
• Seeking to avoid less sun-sensitive skin post-treatment
Other cutaneous indications:
• Scars (atrophic, acne, hypertrophic, burn)
• Alopecia (androgenetic, areata)
• Pigmentary disorders (melasma, vitiligo, periorbital melanosis)
• Primary axillary hyperhidrosis
• Striae rubrae (stretch marks)
• Verruca
• Actinic keratoses
Contraindications:
• Inflammatory acne
• Keloidal predisposition
• Local infection
• Chronic skin conditions (eczema or rosacea)
• Local botulinum toxin use
• Any skin lesion with malignant potential
• Active herpes labialis
• Immunosuppression (chemo or radiation therapy)

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169
preparation along with informed consent that includes the
benefits, risks, and potential complications of microneedling.
Preoperative pictures are essential in all patients for documen-
tation and meticulous assessment of outcomes following treat-
ments. Practitioners should also consider waiting for any recent
suntan to have faded prior to treatment to avoid post-treatment
dyspigmentation. Also, as with other skin resurfacing techniques,
patients with a history of herpes labialis should be treated with a
1-week prophylactic oral antiviral beginning the day of treatment.
Skin preparation on the day of treatment is essential. Patients
should meticulously clean the area of planned treatment and
ensure that all makeup, lotions, and other topicals are removed
prior to arrival. Depending on the size of the treatment area, topical
anesthesia with lidocaine and prilocaine cream can be applied to
the area and covered with an occlusive dressing for 15 to 45 minutes
before treatment. Other options include compounded 30 lidocaine
cream (nonoccluded) for 20 to 30 minutes. Regardless of the local
topical anesthetic used, once anesthetic effect is reached, it should
be removed with saline-soaked gauze and the skin cleansed with
alcohol before microneedling. In certain sensitive areas such as the
upper lip, local anesthetic injection or nerve block can be beneficial
in certain patients, but this is typically not needed.
17.6.4 Equipment
An understanding of the equipment is important given the wide
variety of microneedling devices and goals of therapy, as it can
also serve as a method of medication or energy delivery.
The original and simplest microneedling device is the drum-
shaped roller pictured in Fig. 17.1. There is a great variability in the
types of rollers, with needles ranging from 0.5 to 3 mm in length
and 0.1 to 0.25 mm in diameter. The microneedles can be made
from any number of nonallergenic materials, including stainless
steel, gold, and titanium. Rollers are typically presterilized with
gamma irradiation. They are mostly one-time-use devices, as
repetitive use can lead to dull or loose needles. Rollers tend to
offer the best treatment effect over larger flat areas such as the
cheek and forehead. They can become entangled with hair around
the scalp, and their use is difficult for narrow areas as in perioral
resurfacing.
The next most common device is an electronic pen device (Fig.
17.6a), which uses disposable needle cartridges with titratable
needle length and penetration speed. These devices tend to offer
improved control over narrower channels as in the lip, nasal, and
periocular areas of treatment. In addition to the mechanical roller
and pen devices, there are now combination devices that include
microneedling with concomitant fractional radiofrequency deliv-
ered at the needle tip, vacuum-assisted infusion of medications,
or light-emitting diode (LED) therapy. Each has been touted to
provide specific applications and advantages beyond traditional
microneedling alone, but robust evidence is limited at this time.
17.6.5 Technique
Specific technical considerations when performing micronee-
dling must be adhered to in order to provide optimal results.
The needle length and penetration depth should be determined
based on the area of treatment. Thin skin or bony surfaces, as
in the periocular, lip, and nasal areas, require shorter needle
lengths ranging from 0.25 to 0.5 mm. Scars or areas with a
thicker surface, such as cheek, chin, or nonfacial areas, are
much more able to tolerate needle lengths up to 2 mm with
ease. The needle speed can be increased to help minimize pain
during treatment, especially as needle length is increased. After
skin preparation with anesthetic and cleansing as described
previously, the device is often used with a lubricating agent.
Topical hyaluronic acid–based gel is often selected for its active
ingredient and lubricating benefit during treatment. The needle
Fig. 17.6 (a) An example of a microneedling electronic pen device that is commercially available. (b) A patient being treated with a microneedling pen.
a
b

170
III Nonsurgical Cosmetic Treatments
length and speed are selected for the area, and the nondominant
hand is used to stretch the face while the dominant hand holds
the device and performs the microneedling (Fig. 17.6b). The
instrument is moved in a direction perpendicular to the direc-
tion of the stretching force of the other hand. The microneedling
device should be passed in multiple directions to avoid creating
track marks or microchannels of larger injury in the same plane.
The clinical end point of treatment is an evenly spread erythema,
mild swelling, and transient punctate/pinpoint bleeding. The
number of passes with the device may be anywhere from 3 to
15 times based on the location, pathology, specific device, and,
more important, when the clinical end points are reached. Once
the end points are reached in one area, saline-soaked gauze
can be placed until other areas are treated. Direct pressure is
usually sufficient for any areas of persistent bleeding. :hen the
microneedling is completed, the skin is cleansed with sterile
saline to remove any lubricating agent or debris. At this time, if
an additional topical medication is planned for delivery, it can
be smoothly applied over the areas of microneedling treatment.
The treatment takes no longer than 15 to 20 minutes in total,
depending on the size of area treated, and can be repeated at
monthly intervals until the desired outcome is reached.
17.6.6 Postoperative Considerations
Immediately following the microneedling procedure, the patient
will often have mild swelling, superficial bruising, and punctate
bleeding. After any persistent bleeding has been controlled with
direct pressure and any topicals have been applied, ice-water-
soaked dressings can be used in the immediate setting. There
is often serosanguinous drainage, which may require collection
with dressing changes in the first few hours. At this point a layer
of hyaluronic acid gel can be applied and allowed to dry. After
4 hours, a moisturizing cream or 1 hydrocortisone cream can
be applied to the treatment area up to 4 times a day for the first
3 days, and the patient should avoid any makeup or cosmetic
products during this time.
Although risk of sun exposure is less with epidermal preserva-
tion, protection of the area from sun exposure and an additional
sunblock of SPF 30 or higher over the hydrating cream is recom-
mended in the first 2 weeks after treatment.
Regarding pain control, the patient should expect a mild, sun-
burnlike level of discomfort that should be adequately controlled
with acetaminophen as needed. Depending on the pathology
being treated, repeat microneedling can be performed at monthly
intervals and may require multiple treatments to reach the
desired effect. In resurfacing patients, many will pursue annual or
semiannual treatments to maintain skin quality from photodam-
age and aging changes.
17.6.7 Skin Changes and Treatment
(ffiFDFy
Following
treatment,
skin
changes
will
occur
in
a
non-inflammatory wound-healing cascade. After the initial
punctate bleeding resolves in the hours after treatment, a mild
swelling, superficial bruising, and erythema will remain. These
will begin to improve along with any skin flaking within 3 days.
These skin changes are part of the healing process after injury
from microneedling that leads to platelet and neutrophil release
of platelet-derived growth factor, fibroblast growth factor, and
TGF-Ǵ3. This will subsequently lead to the intercellular matrix
production of collagen, elastin, and epidermal thickening. These
clinical and histologic findings will resolve in the first week after
treatment and are followed by fibroblast deposition of collagen
type III, increased gene and protein expression of collagen and
glycosaminoglycans, as well as skin regeneration. Further col-
lagen organization, neovascularization, and remodeling of scar
tissue will lead to clinical improvement seen in 2 to 3 weeks
after treatment with thickened epidermis, improved texture,
and elevation of depressed scar or rhytides. Results can vary,
and multiple treatments may be necessary depending on the
indication of treatment. It is thus important to continue taking
patient photos after each treatment so that both the provider and
the patient can track the progress.
17.6.8 Problems and Complications
Given the relatively noninvasive nature, topical anesthesia, and
preservation of the epidermis, there are few significant complica-
tions that develop following microneedling treatment. Most of the
complications can be avoided if practitioners adhere to the criteria
in the patient selection and preoperative preparation sections,
specifically avoiding patients with active herpes simplex, and
providing prophylaxis in those with a previous history to avoid
reactivation. Infections and hypersensitivity reactions are rare.
They are typically reported secondary to patient use of topical
cosmetic products, makeup, or nonprescribed skin treatments
in the first few days after the procedure. This can lead to immu-
nogenic particles deep within the dermis and, potentially, to the
formation of small granulomas or a skin hypersensitivity reaction.
Some advocate topical antibiotic ointment (e.g., mupirocin) during
the first few days to minimize chances of bacterial infection, but
this is not routinely recommended in the general population.
Dyspigmentation in patients with Fitzpatrick skin type IV to
VI or those with immediate sun exposure is always a concern
in skin resurfacing but has not been as severe in microneedling.
Histologic studies following microneedling have demonstrated an
intact SC and no change in melanocyte number or gene expression
rates, which are typically affected in cases of dyspigmentation.
Protection from UV light is still recommended, but microneedling
appears to tolerate sun exposure better than more invasive resur-
facing techniques that disrupt or ablate the epidermis.
Bleeding and bruising are typically self-limited and rarely a
problem in patients undergoing microneedling. Of note, longer
needle lengths, extending up to 3 mm, may lead to more swelling
and bruising with an extending recovery into the first week after
treatment. More important, the operator should avoid micronee-
dling across the same area beyond the clinical end points,
especially in thinner skin or over a bony prominence. Selection of
appropriate needle length for the specific area of treatment and
avoidance of multiple passes in sensitive areas are essential. There
have been reported cases of tram track–like scarring following
microneedling treatment of acne scars. Practitioners should be
concerned for these complications when treating patients with
significant hypertrophic scarring or predisposition to keloid
formation.

 1Rn-/igKW-%DVed SNin 5eVurIDFing
171
17.7 Concluding Thoughts
Currently various modalities exist for facial rejuvenation and
skin resurfacing. This chapter reviewed dermabrasion, micro-
dermabrasion, and microneedling.
Although dermabrasion can achieve excellent skin resurfacing
outcomes, it requires a certain level of expertise and a consider-
able amount of experience to master the technique. As a result,
its utility in skin resurfacing has been somewhat diminished after
the widespread adoption of lasers, which can deliver a similar
outcome with much less technical involvement by the operator.
Microdermabrasion and microneedling have gained popularity
over the past two decades since they are easy to perform, cheaper,
and less invasive and provide a fast recovery with very low com-
plication profiles, which makes them very attractive for patients
looking for mild to moderate improvement. It is not surprising
that many plastic surgeons and dermatologists dealing with
facial rejuvenation have added these less invasive procedures to
their current practice. Overall, all three techniques are safe and
effective for facial skin resurfacing when performed correctly on
appropriately selected patients.
Comprehensive patient education on the procedure and post-
procedural care, as well as setting realistic expectations, are of
utmost importance for achieving an optimal result and ensuring
patient satisfaction. Given the increasing use of these techniques
in facial rejuvenation, it is vital to continue scrutinizing their
efficacy and safety. In particular, there is a need for randomized
controlled trials that include all skin types and compare different
treatment modalities in order to provide further insight and
evidence-based data on the short- and long-term utility of these
modalities, aiming to optimize patient outcomes.
Clinical Caveats
• Dermabrasion removes the epidermis and penetrates to the
level of the papillary or reticular dermis, whereas microderm-
abrasion removes only the uppermost layer of the epidermis.
Microneedling does not remove any skin layers and works by
penetration of skin with needles.
• Dermabrasion requires a certain level of expertise and expe-
rience to master the technique, whereas microdermabrasion
and microneedling are less invasive and simpler to perform.
• Isotretinoin has been implicated in delayed wound healing
and hypertrophic scarring; therefore, it should be discontin-
ued for at least a year prior to these procedures.
• Patients with history of herpes simplex infection should be
treated with a 1-week prophylactic oral antiviral beginning
the day of treatment to prevent reactivation of the disease
and untoward aesthetic outcomes.
• Although microdermabrasion and microneedling are less
invasive and allow faster recovery than dermabrasion, they
usually require multiple treatments to achieve a less aggres-
sive result. Therefore, realistic goals and expectations should
be set prior to the initiation of treatment to ensure better
patient satisfaction.
• All three techniques are safe and effective for facial skin resur-
facing and can be used either alone or in conjunction with
other procedures for facial rejuvenation.
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