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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III Nonsurgical Cosmetic Treatments
cosmetic surgery. Although the results were quite remarkable, the
factors just discussed and the long and difficult recovery prevented
this peel from gaining widespread acceptance.
The next development in chemical skin resurfacing was the
popularization of trichloroacetic acid (TCA) peels by dermatologist
=ein Obagi. TCA peels had been around for some time, but Obagi and
-ohnson’s work in the 1990s brought them to the attention of plastic
surgeons. They popularized the concept of skin pretreatment, as well
as documenting and controlling the depth of TCA penetration. Obagi’s
role was controversial at the outset because of unseemly commer-
cialization with ´secret formulasµ and very expensive training pro-
grams, but his book, Obagi Skin Health Restoration and Rejuvenation,
remains an important contribution, especially for plastic surgeons
less familiar with peels and skin anatomy and physiology.
TCA peels were an important addition in that Obagi showed
histologically that different concentrations varied the depth of the
peel and that the application technique was a major determinant
of the depth reached. Lighter to medium peels were possible with
a concentration of up to 25, and medium to deeper peels occurred
with 35 and 50 concentration for more pronounced rhytids. TCA
therefore largely overtook phenol as the peeling agent of choice,
because of the ability to control the depth of penetration and tailor
the peel to the patient’s skin type. Although higher concentrations
engendered more serious complications, namely scarring, TCA peels
at light- and medium-depth concentrations are viable and popular
options when chemical peels are considered for facial resurfacing.
Another significant advance in peel resurfacing was introduced
by Gregory Hetter in Las Vegas, 1evada. Interestingly, 1evada
was a state in which aestheticians could perform weak phenol
peels, and Hetter treated multiple patients who had had such
peels. These patients had not achieved significant improvement
but, more important, had not had any ill effects from the weaker
phenol concentrations, directly contradicting what had been
believed and taught about phenol peels for decades.
:ith this in mind, Hetter diluted the Baker formula in half and
successfully performed peels on patients without the hypopigmen-
tation that had attended the older peels. Clearly something different
was at play, and Hetter devised a series of experiments to explain
this phenomenon. Hetter performed peels on a series of patients
with different combinations of ingredients of the Baker formula; he
noted that phenol alone had scant effect and that adding croton oil
to phenol at different concentrations led to deeper peels that were
proportional to the concentration of the croton oil. An analysis of the
classic Baker formula revealed that the concentration of croton oil was
quite high at 2.1, which was responsible for the results as well as the
familiar drawbacks. Having convincingly shown that croton oil was
the critical peeling agent, Hetter was free to alter the concentration
of the ingredients as desired. He lowered the concentration of phenol
and varied the concentration of croton oil, and in so doing, Hetter
ushered in a new era in chemical peeling. The new formulas had the
advantage of being clinically effective, similar to the classic Baker
peel, without the troublesome complication of hypopigmentation.
Having the freedom to alter the croton oil concentration as needed is
a major advance that allows the peel to be performed superficially or
deep, depending on the circumstance. This versatility makes the peel
applicable to patients of all ages and skin types.
Having the ability to alter the croton oil concentrations has
further ramifications. It is now possible to use croton oil concen-
trations weak enough that the application technique becomes one
of the important factors in determining the depth reached. The
entire process is slowed down, so the surgeon can observe the skin
changes and have the opportunity to stop at whatever depth is
deemed appropriate. The all-or-none phenomenon seen with the
Baker peel was simply because the croton oil concentration was
so high that it immediately resulted in dense frosting. This consis-
tently resulted in a peel deep enough to cause hypopigmentation.
Current peeling agents provide physicians with increased
flexibility when treating wrinkles, creases, and skin pigmentation
problems. It is now possible to use chemical peels to achieve
the desired clinical results without reaching a depth that causes
hypopigmentation. Another critical difference is that the surgeon
can choose different concentrations on different areas of the
face, depending on relative skin thickness. Many practitioners of
the traditional peel were reluctant to apply a peel to the eyelids
because of the fear of scarring, but now, with the option of a weak
concentration of peeling solution, the delicate eyelid skin can be
effectively improved with safety and predictability.
18.3 Pharmacology of Chemical
Peeling Agents
18.3.1 Jessner’s Solution
-essner’s solution is a standardized mixture of lactic acid, salicylic
acid, and resorcinol (14 each) compounded in 95 ethanol. Alone,
it causes a superficial epidermal peel. It may be an option for
superficial peeling as an adjunctive treatment for acne. It can also
be used as a pretreatment before a TCA peel to enhance penetra-
tion of the TCA solution. It should be noted that salicylate toxicity
(known as salicylism) can cause tinnitus, nausea, and headaches.
18.3.2 Trichloroacetic Acid
TCA, also known as trichloroethanoic acid (CCl3COOH), is an
analog of acetic acid in which the three hydrogen atoms of the
methyl group have been replaced by chlorine atoms. TCA acts
to dissolve keratin and coagulate surface proteins. This produces
a frost as the salts precipitate. It is neutralized by contact with
tissue fluids or topically applied saline solution for surface TCA.
Lower concentrations (10–30 solutions) will produce a super-
ficial epidermal peel. Higher concentrations (35–50) penetrate
into the superficial dermis, creating a medium-depth peel.
Concentrations above 50 produce a deep peel, which is usually
avoided, because this can result in scarring.
18.3.3 Phenol
Phenol, also known as carbolic acid or hydroxybenzene (C6H5OH),
is an aromatic hydrocarbon derived from coal tar. The stock phar-
macologic solution of phenol is known as OLTXHfiHG SKHQRO 863 This
contains 88 phenol, which is the highest concentration that will
stay in solution at room temperature; 100 phenol is a crystalline
material at room temperature. Similar to TCA, phenol causes
protein coagulation and produces a skin frost almost immediately.
Liquefied phenol USP with croton oil dissolved in it penetrates into
the upper reticular dermis, causing a medium-depth peel. Baker’s
mixture (Table 18.1) is the most commonly used and reproducible

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175
formula; it is approximately a 50 (w/v) solution. These ingre-
dients do not combine easily. The liquid soap (Septisol) acts to
saponify the solution. The solution must be stirred vigorously
before application to ensure even mixture of the components.
Recently Septisol has become problematic because of the preser-
vative Triclosan and has been taken off the market. The very small
volumes used in the peel solutions do not pose a health problem,
but the reality is that Septisol is no longer available.
The necessity to replace Septisol has resulted in an excellent
alternative. The company ´CT) has devised a new surfactant, 1ovisiol, which results in a
more even solution which remains well mixed throughout the
course of a standard peel.
18.3.4 Croton Oil
Croton oil is an extract of the seed of the plant Croton tiglium.
Croton oil is the source of the organic compound phorbol.
Internally, it is a purgative that causes severe diarrhea. Its action
on the skin is related to free hydroxyl groups. It produces a
caustic, exfoliating effect on the skin, even in low doses. As men-
tioned earlier, Hetter showed that croton oil was the essential
peeling ingredient in Baker’s mixture. Altering the concentration
of croton oil directly alters the depth of the peel. Commonly used
concentrations range from 0.1 to 0.8 croton oil solutions.
Croton oil dissolved in phenol is the basis of the original Baker
peel and subsequent formulations discussed here. 1egative conno-
tations ascribed to the Baker peel have been a significant imped-
iment to the acceptance of the modern iteration of these peels.
1ow, with 17 years of peeling experience and extensive teaching, I
have identified four misconceptions about croton oil peels, which
will be dealt with in detail in later portions of the chapter:
1. Cardiac toxicity
2. Hypopigmentation
3. Difficult recovery
4. Difficult to perform
By understanding and dealing with these issues, the peels can
be more easily assimilated.
18.4 Indications and
Contraindications
As with all aspects of plastic surgery, patient selection for chemi-
cal peels is vital to ensure consistent, reliable outcomes. Chemical
peeling agents are ideal for treating wrinkled skin or skin with
blotchy, irregular pigmentation. There is also some evidence to
show that peeling the skin of patients with dysplastic epithelium
or actinic keratosis may reduce or prevent the development of
skin malignancy. The patient must understand that there is a
difference between chemical resurfacing and face lifting. The
chemical peel will improve rhytids and pigmentary changes but
does not treat the gravitational and volumetric effects of aging.
Patient evaluation requires accurate assessment of skin color
and type, skin thickness, and the amount of skin damage (such as
rhytids, actinic damage, and pigmentary changes). Thicker, more
sebaceous skin can tolerate deeper peeling than thin skin can.
However, peeling is not a good treatment for large pores; pore size
is rarely reduced by the peeling process, and in fact, large pores
can become more noticeable and may seem larger after the peel.
Traditionally, the ideal patient has been considered to be one with
thin to moderate skin, a fair complexion, blue eyes, fine to moderate
rhytids, and actinically damaged skin. However, recent experience
and increased knowledge have led to the understanding that chemi-
cal peels can be safely used in a broader spectrum of patients. Still, not
everyone is a suitable candidate. All patients must be fully informed of
the risks of hyperpigmentation and hypopigmentation, as well as the
possibility of a line of demarcation at the margin of the peel. As usual
with all plastic surgery, a thorough history, physical examination, and
pertinent investigations should be performed before the procedure. A
history of renal insufficiency should be investigated, and an electro-
cardiogram (ECG) should be obtained depending on history and age.
18.4.1 )iW]SDWriFN &ODVViÀFDWiRn RI SNin
Type
The Fitzpatrick classification system can be a useful guide for
evaluating a patient’s skin type and response to sun exposure.
Generally speaking, patients who burn and do not tan (type I) have
a lower incidence of postpeel hyperpigmentation and are more
prone to hypopigmentation. Conversely, patients with higher skin
types (types V and VI) are more likely to develop postpeel hyper-
pigmentation. Fitzpatrick types III and IV tan easily; this implies
that melanocyte proliferation (known as rebound) may occur after
peeling. This tendency must be controlled with a prepeel skin
care regimen. Therefore, the greater the skin pigmentation, the
longer and more intense the skin pretreatment regimen must be
to control this rebound phenomenon (Table 18.2; Fig. 18.1).
18.4.2 GORgDu &ODVViÀFDWiRn RI
Photoaging
Glogau developed a classification system for photodamage based
on the degree of skin wrinkling. This scale is commonly used to
help determine skin type and thus treatment options (Table 18.3).
Table 18.1 Baker’s phenol mixture
Liquefied phenol USP 88%
3 mL
Distilled or tap water
2 mL
Croton oil
3 drops
Septisol soap
8 drops
Table 18.2 Fitzpatrick classification of skin type
SNin 7ySe
Color
Tanning response
I
White
Always burns, never tans
II
White
Usually burns, tans less than average
III
White
Sometimes burns mildly, tans about average
IV
Brown
Rarely burns, tans more than average and with ease
V
Dark brown
Very rarely burns, tans very easily
VI
Black
Never burns, tans very easily

176
III 1RnVurgiFDO &RVmeWiF 7reDWmenWV
Patients in Glogau II with moderate aging and pigment spots
can be treated with a medium-depth peel. Medium-depth peels
penetrate the papillary dermis and are eff ective for fi ne facial
rhytids and pigmentary problems. Patients with Glogau III and
IV skin have deeper rhytids and therefore require deeper peeling
agents for eff ective results. Deep resurfacing agents such as
phenol/croton oil may be more appropriate for these patients.
Deep resurfacing is eff ective for fi ne and coarse rhytids, hyperpig-
mentation, and epidermal dysplasia.
As discussed earlier, patients with darker skin types are less
suitable for resurfacing. Other relative contraindications include
a history of keloid scarring, cardiac abnormalities, and diabetes
mellitus (unless the disease is well controlled and stable).
Signifi cant medical comorbidities such as hepatorenal disease or
Table 18.3 GORgDu FODVViÀ FDWiRn RI SKRWRDging
Group
&ODVViÀ FDWiRn
Typical age
Description
SNin FKDrDFWeriVWiFV
I
Mild
28–35
No wrinkles
Early photoaging: mild pigment changes, no keratosis, minimal wrinkles; minimal or
no makeup
II
Moderate
35–50
Wrinkles in motion
Early to moderate photoaging: early brown spots visible, keratosis palpable but not
visible, parallel smile lines begin to appear; wears some foundation makeup
III
Advanced
50–65
Wrinkles at rest
Advanced photoaging: obvious discolorations, visible capillaries (telangiectasias),
visible keratosis; always wears heavier foundation makeup
IV
Severe
60–75
Only wrinkles
Severe photoaging: yellow-gray skin color, prior skin malignancies, wrinkles
throughout, no normal skin; cannot wear makeup because it cakes and cracks
Fig. 18.1 Fitzpatrick classifi cation of skin types: (top. left to right) types I, II, III; (bottom, left to right) types IV, V, VI. (Reproduced with permission from
Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)

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177
immunosuppression are contraindications to chemical peeling,
as are abnormalities of collagen or elastin, such as Ehlers-Danlos
syndrome, scleroderma, or collagen vascular diseases. As with
any plastic surgery, emotional or mental instability is a contra-
indication to chemical peeling. Peeling should be postponed until
at least 1 year and perhaps longer after any treatment with oral
isotretinoin (Roaccutane; Accutane; Hoffmann–La Roche, Basel,
Switzerland) because of the increased risk of unpredictable scar-
ring and keloid scar formation.
18.5 Pertinent Anatomy
Patients who request a chemical peel are commonly middle-aged
and older women with aged or sun-damaged skin. Chronologic
aging results from thinning of the epidermis and dermis along
with loss of elasticity. Actinic changes are the photochemical
effects of solar radiation damage. These changes manifest
histologically as degeneration of the elastic network (elastosis),
disorderly arrangement of the epidermis and collagen fibers,
and flattening of the dermal-epidermal junction with loss of the
rete ridges; thus the resulting dermis is more lax and less elastic.
Melanocytes tend to increase in number but are less evenly
distributed in the basal layer and contain variable amounts of
melanin. Clinically, chronologic aging and photoaging result in
coarse, dry skin that shows wrinkles and tissue sagging.
18.5.1 Depth of Peeling
The comparative depth of penetration of peeling agents can be
seen in Fig. 18.2. In superficial peels, the wounding extends to
the stratum granulosum. Superficial peels therefore affect the
epidermis only. Medium-depth peels extend into the papillary
dermis, and deep peels extend into the mid-reticular dermis.
18.5.2 Histologic Changes with Chemical
Peels
Biopsies taken 2 days after a Baker peel have shown necrosis of
the epidermis. Depending on the depth of the peel, this necrosis
can extend through the papillary dermis. There is a marked
inflammatory response. A medium-depth peel, injuring the
epidermis and papillary dermis, improves actinically damaged
epidermis as well as stimulating neocollagen formation in the
upper dermis. The wounded surface starts to reepithelialize
from the follicular and eccrine duct epithelium. While the epi-
dermis usually regenerates within 7 days, dermal regeneration is
slower. 1ew collagen formation begins within 2 weeks and may
continue for up to a year. Obagi compared biopsies from 48 hours
post TCA peel with similar biopsies taken 6 weeks after a peel
and found that medium-depth peels show a clearly defined new
layer of fibrillar collagen and delicate elastic fibers in the upper
reticular dermis. Deep peels showed that the neodermis formed
almost the full thickness of the reticular layer. Therefore deeper
peeling modalities produce a greater degree of neocollagen
formation, which is spread deeper into the dermis. The neoder-
mis shows horizontal, thin, compact bundles of collagen and a
dense network of fine elastic fibers. Melanocytes show fine, even
distribution of melanin granules. However, melanin synthesis is
impaired, and this can result in a generalized bleaching effect.
18.6 Prepeel Preparation
Regardless of the chemical peel to be used, adequate preparation
of the patient is an important factor contributing to the success
of the treatment. The patient must be motivated and understand
the recovery period required. The reward is a dramatic long-
term improvement in skin texture that is not easily replicated
by any other modality. However, to achieve this, the patient
must be prepared for the postpeel morbidity. The immediate
postpeel phase, although not particularly long, can be trying
for the patient; therefore it must be described realistically and
in considerable detail. Detailed photographs of a representative
patient’s day-by-day recovery are shown to the patient and, if
possible, to the patient’s caregiver. Some patients will not tol-
erate the postpeel morbidity associated with medium to deep
chemical peels. These patients can be treated with superficial
peels, but they must understand that the clinical improvement
will be less dramatic, and regular treatments may be required.
Patients with coarse rhytids requiring deep resurfacing can gain
a dramatic improvement but must be prepared for the signifi-
cant postpeel recovery. It is worthwhile to have a prospective
patient speak or, ideally, meet with patients who have had a
similar peel. Seeing someone in person who has successfully
gone through the process offers invaluable encouragement that
although the recovery is difficult, it will be well worth it. The
peel will be well tolerated and the experience will be a positive
one if the patient is well informed and the physician sets the
proper tone.
Preparation of the skin before the peel is a means of prevent-
ing such complications as pigmentary changes. This is done by
applying aggressive doses of tretinoin and hydroquinone 4, as
described subsequently. Some companies offer a complete ´setµ
of required products and a protocol for their use, such as the
complete Obagi 1u-Derm system (Skin Specialists PC, Omaha,
Fig. 18.2 Depth of peeling.

178
III Nonsurgical Cosmetic Treatments
1E), which may be of value to practitioners. :ith an appropriate
pretreatment regimen, the epidermis is stabilized, the dermis
is stimulated to create more collagen, and the melanocytes are
suppressed. The purpose is to regulate cell function and reduce
the risk of postoperative pigment change. The skin is in essence
´revved upµ for the injury to come.
Preparation begins at least 2 weeks (ideally, 4 to 6 weeks) before
the peel with applications of tretinoin 0.1 (Retin-A or Renova;
Ortho Dermatologics, Bridgewater, 1-), an acid form of vitamin
A. It acts to decrease the cohesiveness of epidermal cells, which
results in thinning of the stratum corneum. One inch (1 g) should
be applied to the whole face once per day. The application should
include the earlobes, tragus, and hairline, continue to 1 inch below
the mandibular border, and extend up to 1 to 2 mm below the
ciliary edge. The upper lids must be avoided, because application
to this tissue could lead to irritation. The neck can be prepared in
a similar fashion, less frequently, depending on whether irritation
develops.
Hydroquinone 4 or other bleaching creams are used both
preoperatively and postoperatively to reduce the risk of hyper-
pigmentation. Hydroquinone decreases melanin formation by
inhibiting tyrosinase in melanocytes. Therefore it produces a
reversible suppression and regulation of melanocytes. It is used
for 2 weeks preoperatively (again, the ideal is 4 to 6 weeks), then
again after the peel once the skin has resurfaced. Also, to prevent
postinflammatory hyperpigmentation, glycolic acid 8 or phytic
acid 2 is applied once daily to loosen desquamated cells in the
stratum corneum and help accelerate exfoliation.
This process accelerates cellular turnover and results in ery-
thematous, flaky skin; the patient must be prepared to accept this
phase. Retinoid dermatitis is also common preoperatively. This
can be lessened by decreasing the application of tretinoin to every
other day for the first 1 to 2 weeks. The preparation should be
stopped 4 or 5 days before the peel to allow the epidermis to settle.
The patient is instructed not to apply anything on the skin on
the morning of the procedure.
This skin preparation regimen is certainly a nuisance, and there
is controversy as to its absolute necessity. There are practitioners
who successfully perform peels or laser resurfacing without it;
greater experience and specific studies will be required before
consensus is reached. Our experience has been that omitting or
shortening the preparation has led to excessively long erythema.
18.7 Pretreatment Planning
18.7.1 Medications
Antiviral prophylaxis is routinely prescribed to all patients,
regardless of whether they have a history of oral herpes.
Valacyclovir hydrochloride 500 mg, 1 tablet two times a day,
or the equivalent dose of acyclovir or famciclovir, is begun 3
days before the procedure and continued for 7 days after the
peel. Although the postpeel phase is not particularly painful,
narcotic pain medication is prescribed along with ibuprofen 800
mg 3 times daily. Steroids are administered intraoperatively,
but a methylprednisolone dose pack (Medrol Dosepak, Upjohn,
.alamazoo, MI) prescribed in the past has been discontinued
due to a possible comedogenic tendency. Sleep medication is
prescribed, and a mild sedative may be considered to help the
patient cope with the inconvenience and isolation of the recov-
ery period.
18.7.2 Solution Preparation
TCA
These solutions are generally prepared by a compounding phar-
macist using appropriate weight-to-volume calculations (w/v)
to achieve the correct percentages. As an example, a 35 TCA
solution should be compounded by dissolving 35 g of anhydrous
TCA crystals in a little distilled water; then more water should
be added to bring the final volume to 100 mL. Dissolving 35 g
TCA in 100 mL of distilled water is incorrect, as this will result
in a more dilute solution than expected. The required variety of
concentrations should be compounded by the pharmacist and
not diluted from each other by the surgeon. If stored in acid-re-
sistant plastic bottles, the stock solutions are stable for at least 2
years. Small volumes of each concentration can be poured from
the stock bottles as required.
Using the correct concentration of TCA solution is vitally
important. If the physician does not know a reliable compounding
pharmacist, a national distributor can be used to ensure that the
TCA mixture has been accurately prepared.
Croton Oil
Preparation of the acid peeling solutions is a critical step that
ideally should be performed by the operating surgeon to ensure
accuracy and consistency. The ingredients, including water,
phenol, croton oil, and Septisol (now, 1ovisol), are the same as
in the classic Baker peel formula. They are inexpensive and can
be obtained from compounding pharmacies or from Delasco
(Council Bluffs, IA), a dermatologic supply company.
Traditional formulations used drops of croton oil, which can
be awkward to deal with and have the potential of dangerous
variability, especially when dealing with small volumes. The
process is simplified significantly by delivering the croton oil in
a standardized stock solution consisting of USP phenol 88 24
mL and croton oil 1 mL. This solution yields a reliably accurate
concentration of 0.04 mL croton oil to 1 mL stock solution. This
increased volume of ingredients enables easy measurement with
standard syringes. As can be seen in Table 18.4, the volumes of
water and Septisol (now, 1ovisol) remain constant, and by varying
the relative volumes of phenol and stock solution, different con-
centrations of croton oil are possible. As an example, to make a
0.8 croton oil solution, one would mix water 5.5 mL and Septisol
(now, 1ovisol) 0.5 mL, and add USP phenol 88 2 mL and stock
solution 2 mL. The 2 mL of stock solution contains croton oil 0.08
mL. Because the total volume of the solution is 10 mL, the final
concentration is 0.08 mL of croton oil in 10 mL total volume, or
0.8. :eaker solutions such as 0.1 and 0.05 are very useful; to
make these, one first makes 0.4 and 0.2 that are further diluted,
as noted in the table. The final concentration of phenol in all these
formulas is 35 by volume. If a greater concentration of phenol is
desired, the relative volume of the USP phenol 88 is increased
and the volume of the water is decreased. The stock solution, at
4% croton oil, should always be diluted³never applied full strength.

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18.7.3 Pretreatment Routine
Application of the peel is painful; therefore, intravenous
sedation or general anesthesia is usually necessary. Regardless,
adequate blocking of pain is important to prevent excessive
stimulation and allow the patient a pain-free emergence from
anesthesia and a comfortable initial postpeel course. If the
initial pain cycle is avoided, the entire recovery and general
experience will be better. Some patients report mild tingling
or burning on the first night, but they are usually pain-free the
following morning.
After sedation or general anesthesia, complete local sensory
facial nerve blocks are performed with bupivacaine (Marcaine;
Pfizer, 1ew supraorbital, supratrochlear, infratrochlear, zygomaticotem-
poral, zygomaticofacial, infraorbital, dorsonasal, mental, and
cervical nerve branches. Subcutaneous infiltration of dilute plain
bupivacaine throughout the entire operative site is very useful.
Color changes of the skin are important indicators of the depth
reached; therefore epinephrine is not used in the superficial
infiltration to prevent blanching. Intramuscular ketorolac tro-
methamine (Toradol; Hoffmann–La Roche, Basel, Switzerland)
is administered as an adjunct to anesthesia if a concomitant
operative procedure is not being performed. A steroid dose is
administered intraoperatively.
This anesthetic regime was used successfully for 13 years
and can certainly still be used. In recent years, an interesting
alternative has come to light. In an attempt to improve the for-
mulation, I constantly alter the proportions and, for expediency,
try them on my own skin. :hile working on a higher-concen-
tration phenol formula for brown spots on the hand, I made the
observation that my skin stung for about 10 to 15 seconds and
then became completely anesthetic, to the point that I could
stick a needle into it without any sensation whatsoever. This
finding was consistent, and therefore I decided to utilize it
during the peels.
My plan was to apply phenol 50 to 60 slowly, for example,
on the lower eyelid. The stinging lasted about 15 seconds and
then subsided, and I would repeat it on the opposite side. Once
both eyelids were comfortable, I could peel as usual without
discomfort. This was an important finding, because now lower
eyelid peeling could be performed as a simple office procedure,
done very expediently, and benefiting a large number of
patients.
:ith further experience, I advanced to peeling the full face,
under oral sedation, coating sector by sector with the dilute
phenol, then peeling. Although a full-face peel was feasible
in this manner, it was not consistently well tolerated toward
the end of the peel. An important observation was that any
discomfort postpeel was short-lived, and the following day
the skin remained anesthetic and any area that seemed under-
peeled could be easily touched up. This is extremely valuable,
especially when learning where there may be a tendency to
underpeel.
The fear of cardiac toxicity has been historically associated
with phenol peels, but rare reports of death are anecdotal, and
it is impossible to implicate phenol toxicity rather than com-
plications related to anesthesia. The occurrence of arrhythmias
during peeling is well documented, and although rare, these
are not clinically significant. Historically, traditional peels
were performed with anesthesia or sedation but without local
blocks. There is speculation that the catecholamine release from
the intense stimulation caused by the high concentration of
croton oil may have been the cause of the arrhythmias. :ith
a lower concentration of phenol (35 versus 49), a lower
concentration of croton oil, and thorough local anesthesia of the
face, cardiac complications have not been seen. Thomas Baker,
who popularized the traditional peel, has stated that in his vast
experience he has never encountered cardiac arrhythmias that
required treatment. General recommendations include cardiac
monitoring, adequate hydration, and peeling a full face in no
less than 45 minutes. Following these precautions, we have
encountered no cardiac complications in nearly 15 years of peel
procedures.
This technique of anesthesia had further ramification in
understanding the issue of cardiac toxicity. :hen I observed
that full-face peels were not consistently well tolerated with
oral sedation, I switched to intravenous sedation. In my first two
cases, under adequate sedation, I applied the dilute phenol more
quickly and tachyarrhythmias were seen. They were treatable
and transient but nonetheless worrisome. It was clear that the
rapid absorption of the phenol was having a systemic effect. :ith
this information, I altered my initial application by proceeding
sector by sector slowly and watching the ECG. If the pulse rose
quickly, I waited until it normalized. :ith these modifications,
there have been no further issues. A small dose of intravenous
narcotic is administered at the end of the peel, and usually
patients are comfortable. Any residual burning at discharge or
Table 18.4 Hetter peel formulas with a 35% phenol vehicle
Croton Oil
0.2%
0.4%
0.8%
1.2%
Water
5.5 mL
5.5 mL
5.5 mL
5.5 mL
Septisol (now Novisol)
0.5 mL
0.5 mL
0.5 mL
0.5 mL
USP phenol 88%
3.5 mL
3.0 mL
2.0 mL
1.0 mL
Stock solution containing phenol and croton oil (see below)
0.5 mL
1.0 mL
2.0 mL
3.0 mL
TOTAL
10 mL
10 mL
10 mL
10 mL
0.1% = 1 mL of 0.4% + 1.2 mL phenol + 1.8 mL water.
0.05% = 1 mL of 0.2% + 1.2 mL phenol + 1.8 mL water.
Stock solution = 24 mL phenol + 1 mL croton oil (0.04 mL croton oil/1 mL stock solution or 4% croton oil).

180
III Nonsurgical Cosmetic Treatments
the night of the peel is easily dealt with using oral analgesics.
From that point on, there is usually no further discomfort (see the
section on posttreatment care).
Ophthalmic ointment and corneal protectors can be used
during a peel to protect the eyes, but even when they are used,
extreme caution around the eyes is imperative. If excessive oint-
ment is used, any spilled or misplaced chemical may dissolve in
the ointment and prevent immediate flushing out if it becomes
necessary. Alternative measures include avoiding the use of oph-
thalmic ointment altogether or suturing the eyes shut.
18.8 Treatment
18.8.1 Application Routine
:ith the patient sedated and the nerves of the face well blocked,
the skin is thoroughly cleaned and degreased with acetone or alco-
hol. This step is vital to allow even penetration of the peeling agent;
a splotchy peel can occur as a result of uneven penetration if the
skin still has residual oil. The skin can also be numbed as described
in the preceding section. Thereafter, the application process should
be an orderly and nonintimidating one. The reason for this is that
practitioners can choose an adequately weak concentration to slow
down the process, depending on their preference and experience,
to give ample time to judge the depth achieved. Furthermore, there
are a number of factors at the surgeon’s disposal (as will be dis-
cussed) that can be used to fine-tune the control of the application.
In general, the different concentrations of solutions are placed in
separate, easily identifiable bowls or cups. Materials for application
are 2 ð 2 (2 in. ð 2 in. 5 cm ð 5 cm) gauze (preferably synthetic fiber,
which is less abrasive) and cotton-tipped applicators (Fig. 18.3).
Large round-tipped gyn swabs are also useful.
Eyewash solution should also be kept in reach, in case an
ophthalmic washout is required. For application, the gauze is
folded twice, dipped into the solution, and carefully wrung out
to avoid dripping. The solution is stirred before each application
to ensure even mixing of the ingredients. :ith the use of the new
surfactant 1ovisol, this is less important as the solution remains
stable during a typical peel. An assistant helps dry the applying
hand to prevent inadvertent application where it is not wanted. A
practical technique is to have the surgeon clip a surgical towel to
the shoulder, letting it drape to the front much like a chef’s towel.
The surgeon can then conveniently dry his or her hands with ease.
Consistent vigilance in this respect is imperative, especially in
segmental peels, where errors will be obvious.
18.8.2 TCA Peel
Epidermal peels are performed with a 20 TCA solution, whereas
medium-depth peels can be performed with more concentrated
solutions. :e generally use a 30 to 35 solution for medi-
um-depth peeling. Deeper peels are produced with 40 to 45
solutions. Concentrations higher than 50 are best avoided; at
such a high concentration, penetration into the dermis occurs
rapidly and can be difficult to control.
The wet (not dripping) gauze sponge is used to apply the TCA
solution in turn to each region to be treated. If the patient is
awake, holding a fan close to the peeled area can help decrease
the associated burning sensation. As the skin is treated, it develops
a whitened color, known as a frost. There is a delay between the
application of the solution and formation of the frost. In appropri-
ately pretreated skin, the delay is approximately 60 seconds (45 to
120 seconds on average). Therefore, after each pass with the gauze,
the physician should pause to observe the frosting before further
application to the area. This process requires patience on the part of
the physician but is essential to prevent undesirably deep peeling.
Each region of the face is treated in turn until the desired depth of
frosting is achieved, then attention is turned to the next region.
:e prefer to peel regions that require deeper penetration first (for
example, the perioral region and the forehead) and regions to be
peeled less deeply (such as the periorbital area) last.
Once the desired depth of peel has been achieved, ice-cold
saline-soaked gauzes are placed on the peeled region. This relieves
the burning sensation for the patient and helps neutralize any
remaining TCA solution on the skin surface to prevent further
penetration. The gauzes warm up quickly and should be replaced
or refreshed regularly with ice-cold saline solution. Removing the
gauzes also allows the physician to assess the resolution of the frost-
ing. Erythema appears after the frosting resolves, when serum in the
tissue and vessels neutralizes the TCA and the coagulated proteins
resolve. The time taken for the frosting to resolve and erythema to
occur is directly related to the depth of the peel: frosting resolves
more quickly with superficial peels than with deep peels. According
to Obagi, superficial epidermal peels will resolve in less than 20 min-
utes; the frosting in medium-depth (papillary dermal) peels lasts up
to 40 minutes; and deeper peels into the reticular dermis take longer
to resolve, with frosting persisting for up to 60 minutes (Table 18.5).
)DFWRrV 7KDW ,nÁuenFe WKe 'eSWK RI D 7&A 3eeO
As has been stated, low concentrations of TCA result in a more
superficial peel. Higher concentrations peel more deeply. Peel
depth is also related to the amount of acid and the preparation of
the skin. Therefore depth can also be increased by applying more
layers of solution or by pretreating the skin with either -essner’s
solution or mechanical abrasion (for example, with a gauze
Fig. 18.3 Eyewash solution. (Reproduced with permission from
Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)

 &KemiFDO 3eeOV
181
sponge). This becomes particularly important if the patient has
not completed the routine prepeel skin preparation regimen.
Assessing the Depth of a TCA Peel
Obagi has noted that the ability of the body to defend against the
acid depends on the concentration and volume of acid applied, as
well as on the thickness of the skin. Frost (or skin whitening) occurs
as the skin proteins precipitate on application of TCA. The speed
at which the frost develops varies with the concentration of the
TCA used: dilute concentrations take 15 to 60 seconds to produce a
frost, whereas higher concentrations may frost in less than 10 sec-
onds. The precipitated protein disperses with time and therefore
the frost disappears. Frosting of the skin is a helpful clinical sign to
aid the surgeon in deciding when to end the peeling process, as the
amount of frosting is related to the depth of the peel. Obagi grades
frosting as level 1 through 3, as shown in Table 18.5.
In level 1, the peel penetrates the epidermal layer only and
results in a combined pink and white frost that is disorganized or
´cloudy.µ Penetration into the papillary dermis produces a level
2 frost, which is a more uniform white frost, but with erythema
still showing through. Penetration of the peel into the reticular
dermis produces a solid white frost with no visible erythema; this
is level 3. Deeper dermal penetration of the peel is undesirable;
this produces skin with a grayish appearance and is associated
with long-term scarring (Fig. 18.4).
Obagi also suggested the epidermal sliding sign to show when
a TCA peel has penetrated the papillary dermis. At this level, the
epidermis can slide over the fi rmer, immobile dermis, since the
rete ridges have been disrupted. Skin fi rmness (turgor) can also
be palpated. Untreated skin is soft to the touch, whereas a deeper
peel results in fi rmer dermis caused by an increased amount of
protein precipitation.
Recommendations for TCA Peels
The following are general recommendations for TCA concentra-
tions in specifi c areas, but it is important to consider individual
variations and to remember that concentration choice is only one
factor infl uencing the depth of penetration of the peel. Regardless
of concentration, it is imperative to always judge the depth of the
peel as described in the previous section.
The whole face can be peeled with the same concentration
of TCA, with depth varied by increasing the number of layers of
solution applied or by using varied concentrations of solution. In
general, the author prefers to use a single concentration of solu-
tion, usually 30 to 35 TCA, to peel the entire face.
In general, the deepest peel should be performed in the perioral
region. This is followed by the forehead and cheeks, with the
lightest peels performed on the eyelids and earlobes. The perioral
region has deeper rhytids and is peeled until a level 3, dense white
frost is achieved.
Application
The 30 TCA is applied to the perioral region with a cotton-tipped
applicator; this ensures accurate application of the solution into
the perioral rhytids. The forehead and cheeks generally require
a medium-depth peel, depending on the patient. Penetration
into the papillary dermis is ideal; therefore frosting is carried to
level 2. The solution is usually applied with gauze 2 ð 2 squares
to cover a large area evenly (Fig. 18.5).
The solution is applied to the nose with a 2 ð 2 gauze square on
the dorsum and sidewalls, and cotton-tipped applicators are used
to ensure penetration into the alar grooves. Because the eyelids
have thin skin, the solution is carefully applied to this area with a
cotton-tipped applicator. This is usually the last area of the face to
which the solution is applied (Fig. 18.6).
If the neck or dpcolletp region is to be treated, a lower concen-
tration of TCA (such as 20) should be used. This is because the
skin in this area has fewer adnexal structures; therefore reepithe-
lialization can be delayed with deeper peels. If the neck is not to be
Table 18.5
Obagi levels of frosting and defrosting times in trichloroacetic acid peels
2EDgi OeYeO
RI IrRVWing
&OiniFDO reOeYDnFe
'eIrRVWing Wime
1
Limited to the epidermal layer; a nonorganized, foggy or cloudy white frost on a pink (erythematous) background
< 20 min
2
Penetration to the papillary dermis; a regular, white-coated frosting with erythema still showing through
Up to 40 min
3
Penetration into the reticular dermis; a solid, intense white to yellow frosting, with no background erythema
Up to 60 min
Fig. 18.4 This patient is shown partway through the peeling process;
she has undergone an upper blepharoplasty followed by a full facial
chemical peel with 30% trichloroacetic acid (TCA). Note the level 2
frosting of the forehead with visible erythema in the base, compared
with the dense, level 3 frosting of the perioral region, where no
erythema can be seen (left). At the end of the peeling process, there is
level 1 irregular frosting of the nasal tip, regular level 2 frosting of the
forehead, cheeks, and mental area, and level 3 frosting of the perioral
regions (right).

182
III 1RnVurgiFDO &RVmeWiF 7reDWmenWV
treated, the facial peel should be blended or feathered just below
the mandibular angle by applying solution to this area very lightly.
After the peel is applied to the desired depth, iced saline-soaked
gauze is placed across the patient’s face to cool and relieve the
burning. This is changed regularly to ensure that the gauze stays
cold and that the physician can review the resolution process.
Once the frost starts to resolve, a thin layer of petrolatum-based
occlusive ointment is applied across the peeled surface, and the
patient is transferred to the recovery suite. Complete resolution of
the frosting depends on the depth of the peel. The patient should
be checked in the recovery suite, and the physician should note
how long the resolution process takes. This is a good indication
of the depth of the peel and aids the physician in developing
judgment in the art of peeling (Fig. 18.7; Fig. 18.8).
18.8.3 Croton Oil Peel
:ith the damp gauze in hand, the physician makes multiple
passes, observing the color change of the skin to assess the frost
formation. As the application progresses, the depth is gauged by
the degree of frosting, which becomes progressively more dense
and opaque. The speed at which the frost appears depends on
the concentration used and the wetness of the gauze. :ith the
typical concentrations described and use of a damp (not wet)
gauze, the appearance of the frost is gradual and is seen in about
10 seconds. In contrast to TCA peels, with a croton oil peel there
is no need to wait several minutes to see the fi nal depth. Once the
croton oil solution is applied, there is no neutralizing agent and
the eff ect is irreversible. The only recourse in this respect is that
if a too-wet application is made, quickly blotting it will diminish
the depth (Fig. 18.9).
)DFWRrV 7KDW ,nÁ uenFe WKe 'eSWK RI D &rRWRn
Oil Peel
The versatility and safety of the peel are based on the fact that
there are a number of variables that determine the depth. Hetter’s
invaluable contribution was in demonstrating that the concentra-
tion of the croton oil is a key factor of the depth reached and, com-
pared with older peels, is the demarcation between an excellent
result and hypopigmentation. Regardless of the concentration
used, the number of coats applied has an additive eff ect; there-
fore a weak concentration applied repeatedly can lead to deep
involvement, even scarring. The safety of a weak concentration is
only relative and should never be taken for granted.
Fig. 18.6 Trichloroacetic acid application to the dorsum of the nose with a gauze square and to the eyelid using a cotton-tipped applicator.
Fig. 18.5 Trichloroacetic acid application to the perioral region with a cotton-tipped applicator and to the forehead using a gauze square.

 &KemiFDO 3eeOV
183
As previously described, the croton oil concentrations are
relatively weak, so the other main factor of the depth reached
is the application technique, which is directly controlled by the
surgeon. This is the fundamental diff erence between the modern
croton oil peel and its predecessors. A damp sponge can be rubbed
multiple times, variable pressures can be used, or the gauze can
be wetter and fewer passes made. Theoretically, the same depth
can be reached by using diff erent techniques or even diff erent
concentrations.
The location on the face to which the peel solution is applied
is signifi cant because of the relative thickness and recuperative
potential of the skin. For example, the perioral skin can sustain
a deeper peel than the thinner, more delicate skin of the eyelids.
Assessing the Depth of a Croton Oil Peel
The key to success with these peels, as with any resurfacing
technique, is choosing and safely reaching the appropriate end
point. This depends on the degree of frosting, which is mainly a
visual phenomenon, and therefore subjective and based on expe-
rience. Regardless of these apparent diffi culties, photographs and
available videos are very accurate references, and the process is
not as daunting as it may initially appear. Anatomically, a super-
fi cial peel wounds all the structures of the epidermis. Such a peel
may have an eff ect on pigmentary issues and be ´refreshing,µ but
it cannot be expected to improve real wrinkles. Usually croton
oil peels are deeper and eff ect change beyond the epidermis. A
medium-depth peel goes to the papillary dermis. Deep peels go
to the reticular dermis (upper to mid-dermis), and peeling to the
lower reticular dermis can be problematic, leading to hypopig-
mentation and possibly scarring. The recovery, of course, is more
involved with increased depth, but the harsh reality remains
that to provide real change, there must be injury into the dermis.
The visual clues are a thin, transparent frost with a pinkish
background denoting a peel to the papillary dermis. The pink hue
is caused by the subdermal vascular plexus, still intact, showing
through.
A solid, opaque, organized, even frost signifi es that the upper to
mid-reticular dermis has been reached (Fig. 18.10).
A thick, gray-white sheet of frost with eventual red-brown over-
tones indicates that the mid-dermis has been reached³as deep as
Fig. 18.7 Care after trichloroacetic acid application. (a) Cooling of the face with ice-cold, saline-soaked
gauze. (b) Petrolatum-based occlusive ointment applied after the frost begins to resolve. (c) The ointment
used.
Fig. 18.8 Patient in Fig. 18.4
through 18.7 shown 30 minutes
after the peel, with resolution of
the frosting.
Fig. 18.9 Croton oil application. (Reproduced with permission from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
a
c
b

184
III Nonsurgical Cosmetic Treatments
the peel should go. The red-brown overtones may take 15 minutes
or more to become evident and are a reliable and accurate sign.
Once a dense frost has been achieved, such as in the perioral area,
it is worthwhile to wait to see whether the red-brown appears
before considering further application (Fig. 18.11).
Practitioners familiar with the different degrees of frosting with
deeper TCA peels will have little difficulty transitioning to croton
oil peels. The important concept is that this is a gradual continuum
that is slow enough, with the visual changes easily recognizable and
predictable. An experienced practitioner can control the process,
peeling slowly enough to recognize the various stages, and is able to
stop at the appropriate depth and go no deeper.
Another indicator in evaluating the level of peel is epidermal
sliding, which is seen when the peel reaches the level of the
papillary dermis; the epidermis is separated from the underlying
reticular dermis and slides as a thin, independent sheet. This
sliding disappears when the reticular dermis is reached and the
epidermis and dermis bond together, forming a single protein
block. Epidermal sliding is most obvious in thin-skinned areas
such as the eyelids and lateral forehead, as opposed to the perioral
region. Epidermal sliding is a particularly telling indicator in the
very thin eyelid skin, where the margin for error is small.
Defrosting, or loss of the frost, can also be used to assess or
confirm the peel depth, although it is already after the fact (Table
18.6; compare with those for TCA in Table 18.5).
Recommendations for Croton Oil Peels
The following are general recommendations for croton oil
concentrations in specific areas, but it is important to consider
individual variations and to remember that the choice of con-
centration is only one factor. Regardless of the concentration, it
is imperative always to judge the depth of the peel, as described
in the previous section. The perioral area (including the lower
nose) is quite resilient and can be peeled with a strong concen-
tration, such as 0.8 or 1.2 for very pronounced rhytids. This
is extended beyond the chin onto the mental crease. Individual
rhytids are stretched out to allow even penetration. The peel can
be extended into the vermilion to improve lip wrinkles and gain
beneficial lip eversion. The commissures heal well and can be
peeled to a relatively deep level (Table 18.7).
The cheeks and forehead are peeled with 0.4 concentration. The
glabellar area and central forehead are relatively thick and can be
peeled to the mid-dermis (solid white frost). The lateral forehead
and temporal area are more delicate, and peeling to the papillary
dermis is usually more appropriate (a white frost will appear, with
a pinkish background). The peel can be safely extended to the
hairline and brows to avoid lines of demarcation. Deep peeling of
the cheeks is not often needed. Caution should be exercised in the
preauricular area and geniomandibular groove (Fig. 18.12).
The eyelids are peeled with 0.1, and 0.05 is a consideration for
the upper lids. In the lower lids, the peel is extended close to the
ciliary margin. The peel is applied with a cotton-tipped applicator,
and as in other areas, the relative dampness and number of passes
affect the depth of the peel. The thin eyelid skin responds well and in
Table 18.6 Defrosting times for croton oil peels
Papillary dermis
5–10 min
Upper to mid-dermis
15–20 min
Mid- to lower dermis
20–30 min
Fig. 18.11 Assessing the depth of a croton oil peel. A red-brown color
indicates that the mid-dermis has been reached. (Reproduced with permis-
sion from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.10 (a) Assessing the depth of a croton oil peel to the papillary dermis and (b) to the upper to mid-reticular dermis.
a
b

 &KemiFDO 3eeOV
185
a predictable way to these weak concentrations. Epidermal sliding
and an even white frost are easily recognizable and reliable findings
that denote the proper depth. If there is obvious redundancy of skin
in the upper lid, the peel can be safely extended below the tarsal
fold, possibly with a concentration of 0.05 (Fig. 18.13).
The peel is extended onto the neck using 0.1 (or weaker) with
light, wispy strokes, because this skin is thin and does not heal
as well as the face. The endpoint is a barely visible frost that is
not at all organized. ´Less is moreµ is a good philosophy in the
neck. The neck skin is too thin to withstand a peel deep enough to
improve wrinkles; doing so will result in hypopigmentation and
quite possibly scarring. The purpose of the neck peel is to prevent
the obvious demarcation that is commonly seen with laser resur-
facing and deeper peels.
Precise deeper peeling of individual rhytids without affecting
surrounding areas is a great advantage, especially in the perioral
area and chin. This is done with a wetter cotton-tipped applicator,
painting the individual line and then quickly drying it as a dense
frost appears. This is very useful in troublesome radial lip lines.
More precise application, as in the crow’s-feet, can be done with
the splintered wooden end of the applicator. Focal repeeling
of persistent rhytids is easy to do with the patient under local
anesthesia. Repeat peeling, either in part or in whole, has an addi-
tive effect. If peeling appears to be uneven or if there is a sharp
demarcation between areas peeled with different concentrations,
a weak concentration such as 0.2 or 0.1 is used to blend these
sections (Fig. 18.14).
The best way to learn these peels is to gain experience, but
this must be done safely. Like any difficult procedure worth per-
forming, whether a deep superficial musculoaponeurotic system
(SMAS) dissection for a facelift or a transverse rectus abdominis
myocutaneous (TRAM) flap in breast reconstruction, diligent
Fig. 18.12 Recommendations for croton oil peels to the forehead.
(Reproduced with permission from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008; 28:33-45.)
Table 18.7 General peel recommendations*
Location
Croton oil concentration
Forehead, temporal area
0.2–0.4%. The glabellar area can be peeled deeper than the lateral forehead and temporal area.
Precise deeper peeling of individual lines is possible with a wetter cotton-tipped applicator and blotting
dry as frost appears.
Perioral area (including lower nose)
Precise deeper peeling of individual lip lines is useful.
Cheeks, preauricular area
0.2–0.4%. Deep peeling is rarely needed.
Eyelids
0.1% lower eyelids; 0.1% upper eyelids. Consider 0.05% in upper lids, especially below the tarsal fold.
Neck
0.05% (or weaker). Very light, wispy peeling for blending of color, not for wrinkles.
*Predictable problem areas that require careful attention include the temporal area, immediate preauricular area, geniomandibular area, and the medial upper lid where it
abuts the nasal skin. These are general recommendations. The key to the peel is to always judge the depth by the visual clues described, whatever technique or concentration is
used. There is only relative safety in using a weaker concentration, and similar depths can be reached by the use of different techniques, even different concentrations.
Fig. 18.13 Recommendations for croton oil peels to the eyelids.
(Reproduced with permission from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.14 Recommendations for croton oil peels to individual lip
rhytids. (Reproduced with permission from Bensimon RH. Croton oil
peels. Aesthet Surg J. 2008; 28:33-45.)

186
III Nonsurgical Cosmetic Treatments
study and attention to detail are required. It is always worthwhile
to watch another surgeon perform a peel, and to this end there
are now live surgery video workshops that are very practical
and useful. Good color photographs in publications and available
videos are valuable to familiarize oneself with the visual aspects
of the frost. One approach is to purposely plan on a lighter peel
using a maximum concentration of 0.4, with the thought of
performing a repeat peel should it become necessary. Thus, the
surgeon gains experience mixing and handling the solutions and
visualizing the appearance of frost after application. It is never
wrong to underpeel, and once this threshold is crossed, it is not
difficult to progress to full-fledged peels.
18.8.4 Variation of Chemical Peels
Segmental peels are possible with any resurfacing agent but carry
the risk of a mismatch in coloration; therefore good judgment
must be exercised. Skin with widespread solar damage carries a
risk of demarcation, so a full-face peel is preferable. Segmental
perioral peels can be done, peeling to a medium depth at most.
The color takes 8 to 10 weeks to blend adequately, and the patient
can manage color differences in the meantime with makeup.
In selected individuals with isolated upper lip lines, peeling of
the mustache area can produce excellent results (Fig. 18.15).
The skin of the lower eyelid responds very well to chemical peeling.
:hen peeled to the appropriate depth, the thin eyelid skin contained
within the borders of the orbital rim is very forgiving. Healing is well
tolerated and easily camouflaged with makeup or glasses, making
this an excellent location for segmental peeling. However, we would
add a note of caution when treating this area: very low concentra-
tions of peeling agents should be used. With croton oil peels we limit
the concentration to 0.1, and with TCA we limit the concentration
to 20 or a very light pass with 30 (Fig. 18.16).
A major advantage of the lower eyelid peel is that it can easily
be done under local anesthesia or with dilute phenol and in a
gradual fashion. :ith regards to anesthetic technique, a welcome
addition has been the introduction of an apparatus that delivers
50 oxygen and 50 nitrous oxide by patient demand through
a mouthpiece the patient holds (Pro-1ox, Carestream Medical,
Altamonte Springs, FL). This is weaker than the 70 nitrous oxide
commonly used by dentists and is mainly an anxiolytic rather
than an anesthetic. Using dilute phenol as a first pass, the initial
short-lived stinging is nicely abated by the nitrous oxide, making
this extremely useful in an office setting. If a patient requests a
procedure with a quicker recovery, a lighter peel can be done and
repeated in the future with additive effect. In a real sense, the
lower eyelid can be peeled to the patient’s satisfaction. Treatment
of the lower lids is a good option for chemical peeling because of
its safety and predictability; it is a good starting point for patients
(and surgeons) who are reluctant to begin with a full-face peel.
Regardless of the technique chosen, the wise surgeon will avoid
serious problems by accepting that wrinkles cannot be completely
removed with a peel procedure alone.
A novel use of these procedures is to perform a lighter peel in
younger individuals to improve early imperfections while pro-
viding an easier recovery. These peels successfully improve early
wrinkling and solar damage, restoring a brightness or lucency to
the skin that evokes a look of youth. The aim of peels is to keep up
with aging; they can be an excellent adjunct to many facial pro-
cedures, except surgeries in which major skin flaps are elevated
(Fig. 18.17).
18.9 Posttreatment Care
For 15 years after Hetter’s description, I had used bacitracin/
polymyxin B ointment (Polysporin; -ohnson -ohnson, 1ew
Brunswick, 1-) and one tube of lidocaine jelly evenly mixed
together and applied to the peeled skin. This worked well (and
can still be used), but over time some deficiencies became appar-
ent. It required active participation of the patient, who had to
apply ointment frequently on a weeping, swollen, scary-looking
face. Sensitization to the antibiotic was not infrequent, and
breakouts, milia, and troublesome pruritus were seen. These,
and occasional intense erythema, led me to seek an alternative.
Once the peel is completed, the patient is observed until all
frosting subsides. The peeled area is then covered with zinc oxide
pink tape, creating a mask. If the upper lids are peeled, the tape
may interfere with opening the eye well, and with swelling, vision
may be impaired the first night. Utilizing the anesthetic technique
previously described, patients are usually comfortable once the
tape is applied (Fig. 18.18).
The patient returns the next day and the tape mask is removed
(Fig. 18.19). If one remembers to apply petroleum jelly to brow and
hairline, removal is not uncomfortable. This may be hard to believe,
Fig. 18.15 (a) In selected individuals with isolated upper lip lines,
(b) peeling of the mustache area can produce excellent results.
Fig. 18.16 Considerable improvement was achieved after a segmental
peel in this 42-year-old man, whose wrinkled lower eyelid skin was
incongruent with his otherwise youthful looks.
a
b

 &KemiFDO 3eeOV
187
but the entire skin is quite anesthetic, and touch-ups of remaining
lines can be done at this time. The skin is then gently cleansed
with poloxamer 188 (Shur-Clens; ConvaTech, Bridgewater, 1-)
or saline. Poloxamer 188 is an industrial surfactant that is very
healing and stabilizes cell membranes. Plastic surgeons may be
familiar with Shur Clens due to its use for washing out silicone
with ruptured implants.
The next step is mix poloxamer 188 or saline and bismuth subgal-
late powder into a smooth, even paste. Bismuth is a natural element
with well-known healing properties (as in Pepto-Bismol, Procter
Gamble, Cincinnati, OH, and Xeroform, Dynarex, Orangeburg, 1<).
A little ophthalmic gel adds to the creaminess. Once mixed, the
paste is applied to all peeled areas and allowed to harden, like a clay
mask. A hand-held fan aids in the process (Fig. 18.20).
From this point on, the patient does nothing and is strictly
instructed not to touch the face. The healing skin beneath will
gradually shed this mask in roughly 7 to 12 days. The patient is
seen on day 7 and adherence of the mask is assessed. The routine
is to gently apply petroleum jelly or another thick emollient on the
remaining crust, leave it on that day, and allow gentle showering
(no direct stream) the next day. The remaining mask will fall off in
the next 2 to 3 days. Our routine is to give the patient Epidermal
Repair (SkinCeuticals, Dallas, TX) to apply to the newly exposed
skin. It is imperative that neither patient nor surgeon pick at any
of the crust³it must be allowed to fall off on its own. Pruritus can
be a problem, for which diazepam has worked well. The healed
skin typically is less erythematous than when occlusive ointments
were used (Fig. 18.21; Fig. 18.22).
The net effect of the tape and bismuth mask has been dramatic.
If adequately educated, patients are very accepting of their bizarre,
green appearance and overall are in better spirits than with
previous techniques. One very tangible improvement is that it has
significantly cut down on office visits and worried calls (Fig. 18.23).
As previously mentioned, erythema is less intense, depending
on the depth of the peel, and can last 8 to 12 weeks. Makeup can
be used after the second week, which is a great help normalizing
life for the patient. If erythema is problematic, it can be improved
with judicious short-term use of topical steroids.
Management of the postpeel phase begins before the peel
with adequate information. Patients must fully understand what
the experience will be like and how they will look. Showing
photographs of the day-by-day recovery is valuable and ensures
that the patient will be a willing participant based on accurate
information. The early recovery can be challenging, but patients
do well if they are well prepared.
18.10 Problems and Complications
Complications from croton oil peels are the same as with any
other deep resurfacing technique. The main complications,
scarring and hypopigmentation, are largely preventable by
controlling the depth of peel. Delayed healing and thickening is
Fig. 18.17 This 45-year-old woman (a) exhibited generalized elastosis and etching of the chin. (b) Considerable improvement without loss of pigment
is seen at 1 year, and (c) her results remain stable after 6 years. Other than the original Baker peel, no other modality has been able to claim this kind
of longevity of results. (Reproduced with permission from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.18 Zinc oxide tape is applied to all peeled areas.
a
b
c

188
III Nonsurgical Cosmetic Treatments
evidence of peeling to the deep reticular dermis. This thickening
or mild scarring can progress to a full scar but can be arrested
and reversed by injecting triamcinolone acetonide 10 mg/mL and
5-fluorouracil (5-FU; off-label use) in a ratio of 3:2 or 1:1. Full-
strength 5-FU is also an option.
Both hyperpigmentation and hypopigmentation can occur as
blotchy areas or homogeneous abnormalities. They are less likely
to occur in lighter-skinned patients. Hypopigmentation can occur
if the peel penetrates deep enough. Alteration in pigmentation is
more common in older patients; it seems to be related to decreased
melanocyte synthetic function. For individuals with pronounced
rhytids, adequate improvement may necessitate peeling to a
depth that will result in hypopigmentation. The improvement is
well worth it, and the porcelain look of the skin that was typical of
formerly used peels is not seen.
Prevention of hyperpigmentation relies on the pretreatment
skin care regimen, which acts to suppress the melanocytes.
Transient hyperpigmentation may be seen during the recovery
period; this responds well to prompt treatment with tretinoin
and hydroquinone 4 over several weeks. Sun protection must be
emphasized to the patient as an important factor in prevention of
hyperpigmentation.
Infection in peeled skin can be bacterial, viral, or fungal.
Bacterial infections tend to develop on postpeel days 2 to 5 and
Fig. 18.19 (a) Zinc oxide tape mask after removal. (b) Day 1 after tape
mask removal.
a
b
Fig. 18.20 (a) Bismuth subgallate paste. (b) Paste applied to peeled
areas.
a
b

 &KemiFDO 3eeOV
189
are usually caused by common pathogens such as Staphylococcus
aureus, streptococci, or Pseudomonas aeruginosa. Bacterial infec-
tions are heralded by pain, fever, and purulence and are treated
with topical wound care and appropriate antibiotics. Herpes
simplex virus (HSV), the most common viral infection, is often the
result of reactivation of a latent infection. It is usually heralded
by dysesthesia or intense pruritus. 1otably, as the epithelium is
disrupted, the presentation of HSV is atypical, with erythematous
Fig. 18.22 (a) Patient shown in Fig. 18.21 before and (b) 6 months after peel.
Fig. 18.21 Patient, aged 62 years, with bismuth paste. (a) Day 1 post peel. (b–d) Subsequent shedding of mask over next 7 days.
a
b
c
d
a
b

190
III Nonsurgical Cosmetic Treatments
erosions rather than vesicles being present. Treatment includes
doubling the dose of oral antiviral therapy and adding a topical
antiviral agent, which should be applied with a cotton-tipped
applicator to prevent spreading the infection. A herpes outbreak
can be very impressive but typically does not leave any perma-
nent scars. Fungal infections most commonly occur with Candida
albicans and present as painful ulcerations. Diagnosis is made
with a potassium hydroxide (.OH) smear, and treatment is with
oral antifungal agents such as fluconazole.
A possible objection to the bismuth mask is that it does not
allow direct observation of the skin. A definite advantage is that
the patient is not touching the face and therefore not contami-
nating the skin with the hands. Transference of genital herpes to
the peeled face results in a very virulent infection with possible
scarring. It is the expectation that this would be totally avoided
with the bismuth technique.
Hypertrophic scarring is perhaps the most feared complication
with chemical peeling and one of the most difficult to treat. It
most commonly occurs in areas of thinner skin such as around the
lids or skin overlying bony prominences (for example, the malar
region or chin). As with poor scarring in general, it often occurs in
areas where wound healing is delayed beyond 14 days. Treatment
is generally nonsurgical, involving the application of steroid
creams or topical silicone. If this therapy is ineffective, a course
of triamcinolone steroid injections or 5-FU is recommended.
However, given the difficulty in effectively treating postpeel
scarring, prevention is undoubtedly the best cure through the
judicious use of peeling agents, particularly while the physician is
learning the techniques of chemical peeling.
Ectropion can result from excessive peeling of the lower lids. As
with blepharoplasty, caution should be exercised in patients with
lid laxity. Sequential lighter peeling and temporary suspension
of the lower lid are helpful in preventing this complication. Mild
tension in the lower lids is not uncommon and responds promptly
to massage.
Milia are keratin-retaining cysts and can be seen early or late
in the healing process. They occur in up to 20 of patients 6 to 8
weeks after a deep peel. They sometimes respond to an increased
intensity of the skin treatment regimen, specifically increased
tretinoin. Failing that, gentle excision with a fine needle or elec-
trocautery may be required.
Erythema usually resolves in 10 to 12 weeks after the peel
procedure, but prolonged erythema (longer than 12 weeks) can
be troublesome for the patient. Some physicians routinely use a
steroid cream for the postpeel skin care regimen as a preventive
measure. If not used already, steroid should be added into the
regimen if erythema seems excessive and extended. Bleaching
creams such as hydroquinone can also contribute to erythema
and may need to be discontinued, or an alternative pigmentation
prevention treatment can be used, such as azelaic acid 20 cream.
18.11 Outcomes and Results
An invariable observation of the results obtained with croton
oil peels is the overall qualitative improvement of the skin. The
supposition is that there has been a fundamental change in the
skin anatomy that not only dramatically improves wrinkles but
also significantly ameliorates the effects of sun damage. The skin
reflects light differently and brightens the dull, ashen look of
older, actinically damaged skin. This is the critical factor that has
been missing in surgical facial rejuvenation.
A constant observation of the Baker peel is the long-lasting (if
indeed not permanent) results. This has been substantiated by
multiple histologic studies that have shown the deposition of a
significant layer of collagen in the dermis after a peel procedure
Fig. 18.23 (a) Husband, day of peel; wife, day 7 post peel. (b) Husband, day 1 of bismuth mask; wife, day 8 post peel. This couple demonstrates a
more light-hearted and accepting attitude toward the healing process.
a
b

 &KemiFDO 3eeOV
191
that is aligned in an orderly manner and is thought to be the
mechanism for the effacement of wrinkles. This layer remains
constant for years, even decades.
Since 2000, results with croton oil peels show remarkable
improvement in deep wrinkles and actinic damage without
depigmentation. These improvements are completely stable,
and rather than showing diminishing results, the skin appears to
improve with time (Fig. 18.24; Fig. 18.25; Fig. 18.26).
Although not yet confirmed histologically, it is reasonable to
expect that this stability is modulated by a similar deposition of col-
lagen in the dermis, without disrupting the function of the melano-
cytes. The fact that repeated peels produce additive effects suggests
that there is more deposition of collagen each time. The skin looks
younger because, in essence, younger skin is being created.
Histologic studies have also shown eradication of actinic
keratoses in deeply peeled skin. The anecdotal impression of
experienced practitioners has been that individuals who have
undergone peels do not develop facial basal cell cancer or squa-
mous cell cancer. In a recent study in the dermatology literature,
Hantash et al showed that laser resurfacing, fluorouracil, and 35
TCA peels were equally effective in keeping susceptible individ-
uals free of nonmelanoma cancers for the studied 5-year period.
The deeper croton oil peels are expected to have a similar or better
effect, further expanding the benefits and utility of this approach.
The qualitative degradation of skin with time is obvious, and
many patients consider textural changes to be at least as important
as structural changes. It could be argued that the qualitative and tex-
tural improvements achieved with a peel in the 61-year-old woman
shown in Fig. 18.27 had greater impact than surgery could have.
There are many advanced surgical techniques to deal with grav-
itational and volume changes, but surgery can improve textural
issues only minimally and indirectly and has no effect on the
Fig. 18.26 Note the periorbital details in the same patient before
treatment, with posttreatment improvement of texture after 1 year,
and evidence of further improvement after 4 years.
Fig. 18.27 4ualitative and textural improvements achieved with
a peel in a 61-year-old woman. (Reproduced with permission from
Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.24 (a) This 47-year-old woman had brittle, sun-damaged skin
and smoker’s lines. (b) Considerable qualitative improvement is seen
after a croton oil peel, with a stable result 4 years after treatment.
(Reproduced with permission from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008; 28:33-45.)
a
b
Fig. 18.25 (a) This 53-year-old woman is shown before a croton oil
peel treatment and (b) 4 years after the peel and a facelift. She also
had an endoscopic brow lift and upper and lower blepharoplasties.
(Reproduced with permission from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008; 28:33-45.)
a
b

192
III Nonsurgical Cosmetic Treatments
perioral area, where improvement is often needed most (Fig. 18.28;
Fig. 18.29; Fig. 18.30; Fig. 18.31; Fig. 18.32; Fig. 18.33; Fig. 18.34).
18.12 Concluding Thoughts
Hetter’s work and subsequent experience have greatly clarified
the earlier issues regarding deep chemical peels, which are
generally classified, possibly inaccurately, as phenol peels. A
weaker concentration of phenol does not penetrate more deeply
than a stronger one, refuting long-held beliefs. This allows
greater latitude in the preparation of solutions. Croton oil has
been identified as the critical peeling agent, and a high concen-
tration of phenol is not necessary to obtain a desired peel. This
knowledge also opens the door to investigate other solvents
that may act as carriers of the croton oil and avoid the use of
phenol altogether.
The ´all-or-noneµ phenomenon attributed to the Baker peel,
which was one of the main sources of intimidation for surgeons,
was simply because the croton oil concentration was so high that
the operator had little control over the application process. By
lowering the concentration of croton oil, application technique
and concentration choice now become the main factors that deter-
mine the depth of the peel. In this manner, the main complication
of the traditional peel can be avoided while still providing the
desired clinical result. The principal objections to deep ´phenolµ
peels were misconceptions based on the experience of older peels
that are now obsolete: hypopigmentation is largely avoidable by
controlling the depth and by exercising rudimentary precautions,
and cardiac toxicity is better understood and easily avoided.
Obagi’s work with TCA in the 1990s was also an important
addition to the field. Concentrations from 20 to 50 were found
to be effective at producing superficial to medium and deeper
peels, while largely avoiding the complications of scarring and
hypopigmentation. :ith multiple concentrations of croton oil and
TCA available as peeling agents, surgeons have significant control
and specificity. This fact makes chemical peeling available to any
age group and skin type. The possibility of doing weaker peels on
younger patients with the thought of keeping up with aging is an
exciting prospect that has the potential of greatly expanding the
patient base. :eaker concentrations of peeling agent can likewise
be used to great advantage on delicate eyelid skin. Precise deeper
peeling can be done on problem rhytids without adversely affect-
ing other sectors of the face. The potential use of these peels in the
prevention of basal cell and squamous cell carcinomas is a new
frontier ripe for investigation.
The main drawback of modern chemical peels is the difficult
recovery; the zinc oxide tape/bismuth mask technique is a signifi-
cant advancement that has simplified postpeel care and improved
the experience for patients.
Fig. 18.28 (a) This 59-year-old woman could certainly have benefited from
a facelift, but her pronounced perioral lines would have been unaltered
and a detriment to the results. (b) The overall qualitative improvement,
especially around the mouth, seen here 1 year after her peel, have had a
greater impact than surgery would have. (Reproduced with permission
from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.29 (a) The preoperative view of a 75-year-old woman shows
advanced structural and textural changes of aging. Neither surgery
nor resurfacing alone could provide a complete result. (b) The second
image shows the patient at age 81, 6 years after a facelift and 1 year
after a full-face peel. Croton oil peels provide a powerful and effective
tool to complement surgery and make comprehensive facial rejuvena-
tion a reality. (Reproduced with permission from Bensimon RH. Croton
oil peels. Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.30 (a) This 67-year-old woman had undergone two previous
facelifts and overresection of the lower eyelids with rounding of the
outer canthi. (b) A corrective facelift and internal suspension of the
orbicularis oculi muscles certainly improved the situation, but the
subsequent peel was critical in completing the look of youth.
a
a
b
b
a
b

 &KemiFDO 3eeOV
193
Fig. 18.31 (a,c,e,g,i,k,m) 61-year-old woman, active smoker, with widespread wrinkling, sun damage, and pigmentary changes. (b,d,f,h,j,l,n)
Dramatic improvement 6 months post croton oil peel alone.
a
i
k
m
g
h
c
e
b
j
l
n
d
f

194
III Nonsurgical Cosmetic Treatments
Fig. 18.32 (a) This patient had splotchy pigmentation from actinic exposure and upper lip rhytids. (b) Note the improvement after a 35% TCA peel
and upper lip dermabrasion.
Fig. 18.33 (a,c) This patient sought treatment for her fine facial wrinkles, particularly in the periorbital region. (b,d) She is shown 5 months after a
35% TCA peel.
Fig. 18.34 (a) This patient was displeased with her periorbital rhytids and lower lid pigmentation. (b) A 35% TCA peel was performed with good results.
a
a
b
b
c
a
d
b

 &KemiFDO 3eeOV
195
Clinical Caveats
• Modern croton oil peels are a cost-effective means to
achieve long-lasting results in facial resurfacing without
hypopigmentation.
• Skin pretreatment and patient education are important
aspects of the process to decrease postpeel erythema and
assist the patient in dealing with the postpeel recovery
period.
• The recognition of croton oil as the critical peeling agent
allows the formulation of solutions with different croton oil
concentrations.
• Choice of concentration and control of the application tech-
nique allow the surgeon to choose the depth of peel desired.
• The depth of peel is determined by the appearance and
quality of frosting. This is a predictable and easily recognized
phenomenon.
• The preceding points afford the surgeon great control and
specificity. This enables treatment of a large range of ages
and skin types.
• The novice can approach the learning curve by peeling more
lightly with the option of repeeling. This is a safe way to gain
experience.
• Repeated peels provide additive effect. This is especially
valuable in the effective treatment of lower eyelid skin.
• Modern chemical peels are an important option for resur-
facing. Surgery can deal with the gravitational and volume
changes associated with aging, while chemical peels are an
excellent adjunct to treat the textural and pigmentary skin
changes that result from age and solar damage. Through a
combined approach, the goal of facial rejuvenation can be
attained.
Suggested Reading
>1@ Baker T-. Is the phenol-croton oil peel safe" Plast Reconstr Surg
2003;112(1):353–354
>2@ Baker T-, Stuzin -M, Baker TM. Facial Skin Resurfacing. St Louis, MO: 4uality
Medical Publishing; 1998
>3@ Baker T-. Chemical face peeling and rhytidectomy for facial rejuvenation. Plast
Reconstr Surg 1962;29:199–207
>4@ Bensimon RH. Croton oil peels. Aesthet Surg J 2008;28(1):33–45
>5@ Demas P1, Bridenstine -B. Diagnosis and treatment of postoperative complica-
tions after skin resurfacing. J Oral Maxillofac Surg 1999;57(7):837–841
>6@ Demas P1, Bridenstine -B, Braun T:. Pharmacology of agents used in the
management of patients having skin resurfacing. J Oral Maxillofac Surg
1997;55(11):1255–1258
>7@ De Rossi-Fattaccioli D. Histologic comparison between deep chemical peels
(modified Litton’s formulae) and extreme pulsed laser CO2 resurfacing [in Span-
ish@. Dermatol Peru 2005;15:181–184
>8@ Dinner MI, Artz -S. The art of the trichloroacetic acid chemical peel. Clin Plast
Surg 1998;25(1):53–62
>9@ Edison RB. Lighter phenol peel allows faster recovery and less discomfort. Aesthet
Surg J 1996;16(4):239–240
>10@ Hantash BM, Stewart DB, Cooper =A, Rehmus :E, .och R-, Swetter SM.
Facial resurfacing for nonmelanoma skin cancer prophylaxis. Arch Dermatol
2006;142(8):976–982
>11@ Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the
formula. Plast Reconstr Surg 2000;105(1):227–239, discussion 249–251
>12@ Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers
and their croton oil formulas. Plast Reconstr Surg 2000;105(1):240–248, discus-
sion 249–251
>13@ Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic
surgeons’ role. Plast Reconstr Surg 2000;105(2):752–763
>14@ Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel
results with different concentrations of phenol and croton oil. Plast Reconstr Surg
2000;105(3):1061–1083, discussion 1084–1087
>15@ -ohnson -B, Ichinose H, Obagi =E, Laub DR. Obagi’s modified trichloroacetic acid
(TCA)-controlled variable-depth peel: a study of clinical signs correlating with
histological findings. Ann Plast Surg 1996;36(3):225–237
>16@ .ligman AM, Baker T-, Gordon HL. Long-term histologic follow-up of phenol face
peels. Plast Reconstr Surg 1985;75(5):652–659
>17@ Landau M. Cardiac complications in deep chemical peels. Dermatol Surg
2007;33(2):190–193
>18@ Obagi =E. Obagi Skin Health Restoration and Rejuvenation. 1ew Springer-Verlag; 2000
>19@ Rubin MG. 0DQXDO Rf &KHPLFDO 3HHOV 6XSHUfiFLDO DQG 0HGLXP 'HSWK. Philadelphia,
PA: Lippincott :illiams :illiams; 1995
>20@ Stagnone --, Stagnone G-. A second look at chemabrasion. J Dermatol Surg Oncol
1982;8(8):701–705
>21@ Stegman S-. A comparative histologic study of the effects of three peeling
agents and dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg
1982;6(3):123–135
>22@ Tonnard PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. 1ew 1<: Thieme Medical Publishers, 2018
>23@ Truppman ES, Ellenby -D. Major electrocardiographic changes during chemical
face peeling. Plast Reconstr Surg 1979;63(1):44–48

196
III Nonsurgical Cosmetic Treatments
19 Lasers and Light-Based Devices in Plastic Surgery
Noelani E. González and David J. Goldberg
Abstract
Cosmetic surgeons and specialists have a range of options when
it comes to patient care, including surgical and nonsurgical
procedures. The popularity of less invasive cosmetic procedures
continues to grow among patients. Plastic and cosmetic surgeons
who do not offer these procedures might find themselves at a dis-
advantage. Aside from the latest surge in patient demand, these
less invasive options can also be performed as a complement to
surgical procedures. Careful patient selection and knowledge
of the different laser devices is vital in order to obtain worthy
outcomes. This chapter will review laser and light-based devices
that are currently available for the treatment of vascular lesions,
pigment abnormalities, skin tightening, and skin resurfacing. It
will also detail other less common uses for these devices, possi-
ble side effects, and postprocedure care.
Keywords
laser devices, radiofrequency, skin tightening, skin resurfacing,
rejuvenation, intense pulsed light, vascular lasers
19.1 Introduction
Lights and laser devices have experienced a boom in popularity
among patients seeking noninvasive, nonsurgical cosmetic pro-
cedures during recent years. As a consequence, cosmetic surgeons
and physicians are continuously expanding their practices to
include such procedures and devices. A 2017 American Society
of Dermatologic Surgery (ASDS) consumer survey on noninvasive
cosmetic dermatologic procedures found that the four most popu-
lar procedures patients are considering are body sculpting; treat-
ments to tighten skin or smooth wrinkles using ultrasound, laser,
light or radiofrequency devices; microdermabrasion; and laser
hair removal. Aside from the demand patients are exhibiting for
noninvasive procedures, these procedures can also be performed
as adjuncts of more invasive surgical procedures. For example,
radiofrequency and other tightening devices are being used more
frequently after blepharoplasty, liposuction, and ´tummy tucks,µ
among other body contouring surgeries. There are many devices
available that can complement the plastic surgery practice, among
which are resurfacing lasers, vascular lasers, and skin-tightening
devices. The nature of the device to be purchased depends on the
scope of practice of the particular surgeon and how that device
might complement his or her own practice.
19.2 Laser Resurfacing
There are many devices used for skin resurfacing. These can be
classified largely into ablative and nonablative devices. Ablative
devices remove the entire topmost layer of the skin, the epider-
mis, and produce damage to the dermis. 1onablative lasers, on
the other hand, deliver energy to the dermis and cause damage
at this level without removing the epidermis. Furthermore,
these devices can be classified into fractional and nonfractional
or fXOOfiHOG laser devices. Fractional devices create microscopic
treatment zones (MT=) of injury in a columnar array, whereas
full-field devices do not discriminate and treat the entire
selected area. Tighter skin and an improvement in rhytids are
achieved by damage to collagen bundles and stimulation of
dermal fibroblasts. In order to produce this damage, energy
needs to be delivered to the skin’s dermis at a minimum of 65ƒC,
which is the temperature required to damage collagen. Ablative
lasers require a great amount of recovery time, in comparison to
nonablative or fractional lasers, which do not require as much
downtime but do require more treatment sessions to achieve the
desired results.
19.2.1 Full-Field and Fractional
Resurfacing Devices
Ablative Full-Field Lasers
The first laser invention used in treatment was the carbon
dioxide (CO2) laser by Bell Laboratories, which is used for skin
pigmentation, texture, warts, scars, and rhytids and remained
the only energy-based device until the mid-1990s. Subsequently
a surge in innovation took place and continues to this day in the
revolutionary field of laser technology. Ablative lasers, such as the
CO2 laser, heat tissue to temperatures higher than 100ƒC, causing
vaporization of the epidermis and coagulation of the underlying
tissue and dermis. This creates damage to collagen, which stim-
ulates dermal fibroblasts and collagen production. This damage
in the skin and re-epithelialization in turn result in improvement
in skin texture, laxity, and dyspigmentation. Currently, there are
three ablative full-field laser platforms available: the CO2 laser,
the erbium:yttrium aluminum garnet (Er:and the yttrium scandium gallium garnet (Table 19.1 breaks down the different types of resurfacing
devices and their wavelengths, as well as the type of resurfacing
that can be achieved with each.
The CO2 laser has a wavelength of 10,600 nm, and its active
chromophore is water. After being developed in 1964, its first
uses were cutting and vaporizing. It has since become the gold
standard for the treatment of medium to fine lines and rhytids,
as well as tightening of lax tissue. Healing time for this laser is
approximately 10 to 14 days, and patients could experience
prolonged erythema that could last for a few months. Prolonged
downtime, and cases of delayed hypopigmentation, among
other complications, have caused these lasers not to be used as
frequently. Although nonfractional ablative CO2 lasers produce
excellent improvement in skin texture, laxity, pigmentary issues,
and rhytids, their 2-week recovery period is not popular. During
this recovery time patients can experience edema, burning, and

 /DVerV Dnd /igKW-%DVed 'eYiFeV in 3ODVWiF Surgery
197
crusting and can experience an average of 4 months of treatment
site erythema. These platforms also carry a risk of permanent
hypopigmentation, herpes simplex virus outbreak, scarring, milia
formation, and acne flares.
The Er:tissue comparably to the CO2 laser. Overall it was created to pro-
duce similar results to the CO2 laser but provides more precise
ablation, causing less thermal damage. This platform was designed
to be able to modify the ablation depth as a change in energy is
made. :hereas CO2 lasers can ablate at a set depth of 75 —m and
cause thermal damage that can extend to the 100 —m range, the
Er:Consequently, this laser gives the provider the option of delivering
more or less energy to cause varying amounts of tissue removal
or ablation without the residual thermal damage that would be
incurred were one using the CO2 laser. Recovery time is 7 days and
can be followed by 3 to 6 weeks of erythema. The Er:can produce results similar to the CO2 laser but with less tissue
destruction and thus less downtime, shortening the patient’s
recovery period. Although the CO2 laser has been found to have
better results in various studies, the Er:option for dyspigmentation, rhytids, and skin textural changes
and presents less downtime and complications than the CO2 laser
(Fig. 19.1; Fig. 19.2).
The the same affinity for water as the CO2 and Er:downtime is only a few days. Because it does not have as much
affinity for water, deeper resurfacing cannot be done with this
laser.
Ablative, full-field lasers are overall great workhorses for skin
tightening, wrinkles, and skin texture. Patient selection and
an appropriate treatment approach are paramount. Skin type,
ethnicity, discussion of downtime, skin pathology, and even
patient finances should be taken into consideration. As mentioned
previously, the greatest issue with these lasers is the pronounced
downtime and recovery, as well as unwanted pigmentary problems
such as hypo- and hyperpigmentation, and even scarring. These
can be seen in any patient if treatment is not done correctly, but
most complications arise in patients with Fitzpatrick skin types
IV to VI. Therefore, we do not recommend treating patients with
these skin types. Other contraindications include active infection,
as well as relative contraindications such as keloid history, skin
grafts, history of cold sores, or previous laser resurfacing or deep
dermabrasion, since appendages may have been damaged in the
past and skin may not heal properly. Consumers and physicians
eventually opted for procedures with less downtime and risks,
thus the arrival of nonablative and fractional devices.
Nonablative Nonfractional Lasers
Ablative lasers, as mentioned previously, can produce remark-
able results and have been the gold standard for rejuvenation;
however, their prolonged recovery time and potential side
effects have made these lasers less appealing. The development
of nonablative nonfractional lasers provides an alternative to
these other devices.
1onablative nonfractional lasers provide heat that denatures
proteins in collagen without any vaporization or any removal of
skin tissue. These devices, which are in the mid-infrared range,
cause heating and thermal injury of the mid to upper dermal
matrix. The skin’s healing response, in turn, causes neocolla-
genesis, skin tightening, and improvement in mild wrinkles. In
comparison to ablative lasers, these nonablative counterparts
have drastically reduced downtimes, which can even be limited
to a single posttreatment afternoon. In turn, their results are
not as drastic, although still present. These lasers can be used to
treat fine lines and wrinkles; however, results can take time to be
appreciated, and in some cases multiple treatment sessions are
warranted.
Among these devices are the 1,450-nm diode (SmoothBeam;
Syneron Candela, :ayland, MA), 1,320-nm 1d:CoolTouch, Rosedale, CA; Harmony XL, Alma Lasers, Buffalo Grove,
IL), and 1,319-nm pulsed energy (ThermaScan, Sciton, Palo Alto,
CA). These devices have cooling systems that are used to minimize
side effects such as pigmentation changes and epidermal damage.
Various clinical studies have demonstrated mild improvement,
and results are not always reproducible. In a comparative study
of the 1,450-nm diode and the 1,320-nm 1d:treat atrophic facial scars, the 1,450-nm diode was shown to be
more efficient.
An added benefit of nonablative lasers is the decreased risk of
hypopigmentation in darker skin types (Fitzpatrick skin types
V and VI); therefore, these laser modalities can be used in this
patient population, but should always be approached with
caution. Furthermore, these modalities produce only dermal
changes; therefore, the patient who comes in with photodamage
Table 19.1 Resurfacing devices
1Dme
:DYeOengWK nm
AEODWiYe
1RnDEODWiYe
)uOO-)ieOd
)rDFWiRnDO
CO2
10,600
Yes
No
Yes
Yes
Erbium
2,940
Yes
No
Yes
Yes
YSGG
2,790
Yes
No
Yes
Yes
Thulium
1,927
No
Yes
No
Yes
Er:Glass
1,540
No
Yes
No
Yes
Nd:YAG
1,440
No
Yes
No
Yes
Nd:YAG
1,319
No
Yes
Yes
Yes
Nd:YAG
1,064
No
Yes
Yes
No
Abbreviations:

198
III Nonsurgical Cosmetic Treatments
that includes epidermal and dermal changes will need a multi-
modal approach. In conclusion, these modalities provide modest
although inconsistent results at time with significant less
downtime.
Nonablative Fractional Laser
In 2004 fractional thermolysis was introduced and provided yet
another treatment approach that was effective and that resulted
in significant less downtime than ablative modalities. Fractional
thermolysis involves the generation of targeted heated columns
or microscopic thermal zones (MT=s), which can be controlled
in their ablative depth and their columnar width. These MT=s
are one-tenth the width of a hair follicle. These heated columns
produce thermal damage to levels of the epidermis and dermis,
without producing any damage to overlying skin or stratum
corneum; thus they are nonablative. :ater is this laser’s targeted
chromophore. Because only a portion of the skin is resurfaced,
leaving some skin intact, downtime is minimal, spanning to an
average of about 3 days. To achieve desired outcomes, multiple
treatment sessions may be necessary. The nonablative fractional
laser (1AFL) has since become the go-to laser for acne scarring,
skin rejuvenation, and skin tightening.
The population of color continues to increase, and it is esti-
mated that by 2060, nearly 60 of the United States population
will have skin of color. :ith this continuous growth, the myriad of
laser options for this subset of patients also continues to advance.
1AFLs are safe for use in patients with skin types V through VI;
however, it is recommended that experienced hands treat this
subset of patients.
The first fractional laser that was developed was the Fraxel laser
(Solta Medical, Bothell, :A), a nonablative fractional device that
used an erbium-doped fiber laser with a wavelength of 1,550 nm.
The MT=s created by this laser were between 125 and 250 per
square centimeter. Multiple passes were performed, with a final
density of 1,000 to 3,000 zones per square centimeter, a small frac-
tion of the skin. Multiple sessions were performed (usually three
to five) spaced 2 to 4 weeks apart. Other manufacturers developed
nonablative fractional lasers with different wavelengths (1,319,
1,440, and 1,540 nm), energies, and spot sizes, including a 1,927-
nm thulium laser that was introduced to treat actinic keratosis.
Fig. 19.1 Photodamage and rhytides before erbium laser resurfacing.
Fig. 19.2 Results on the patient shown in Fig. 19.1, 6 months after
erbium laser resurfacing.

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199
1AFLs have been shown to be effective in treating photoaging.
Manstein et al first demonstrated an improvement in periorbital
wrinkles after performing four treatments in a 3-month span.
Acne scarring has also been treated with this modality, which has
become the treatment of choice. Both :eiss et al and Alster et al
demonstrated the effectiveness of this laser, with :eiss showing
a median of 50 to 75 improvement in acne scars and Alster
demonstrating between 51 and 75 improvement in mild to mod-
erate acne scarring, using the 1,550-nm fractional laser system.
Erbium-doped 1,550-nm nonablative lasers (Fraxel re:store Dual
1550-nm; Solta Medical, Bothell, :A) have been successful in
the treatment of acne scars in Fitzpatrick skin types I through VI,
but with a significant incidence of self-limited postinflammatory
hyperpigmentation among those with Fitzpatrick skin types
IV to VI. Preoperative treatment with hydroquinone does not
diminish this risk. In addition to atrophic acne scarring, other
types of scars, such as hypertrophic and hypopigmented scars,
can also be treated successfully with this modality. There have
been mixed reports and studies in terms of these lasers’ effective-
ness to treat melasma; however, many providers continue to use
these modalities. The same holds true for the treatment of striae.
1onablative facial remodeling (1AFR) has been FDA-approved for
the treatment of stretch marks; however, studies are lacking to
determine its true effectiveness.
To summarize, these lasers are mostly used to treat acne
scarring, fine lines, wrinkles, photodamage, and melasma among
other things. Postprocedure patients typically experience mild
bronzing of the skin and mild erythema. Downtime is minimal,
and results take a range of multiple treatments to achieve. :hat
distinguishes these types of lasers from others is the fact that they
can be safely used in patients with darker skin tones and also in
other parts of the body aside from the face. These types of devices
would be a great companion to plastic surgical procedures to
correct or minimize postoperative scars.
As in the rest of the aforementioned modalities, patient selec-
tion is the key to success. Expectations should be discussed, as
well as treatment time and desired goals of treatment. To achieve
a desired outcome, multiple treatment sessions spaced about 4
weeks apart are needed, and dramatic results will not be a true
outcome after their first treatment.
Ablative Fractional Lasers
Ablative fractional laser use began in 2007. Its development
increased efficacy over nonablative fractional lasers. Three wave-
lengths are currently used for fractional ablative resurfacing:
CO2, 10,600 nm; erbium, 2,940 nm; and differ in their amount of water absorption and in the resultant
amount of thermal damage created. These lasers create MT= as
does 1AFL, sparing tissue that surrounds these columns; tissue
within these columns is ablated or destroyed to the choice of
depth of the provider. They essentially cause dermal ´miniholesµ
or ablation holes. Postprocedure edema and/or erythema may
last for up to 3 days.
These devices are used to treat fine and deeper lines and wrin-
kles, acne scars, dyschromias, and photodamage. These devices
can create more skin tightening than 1AFLs. Downtime can vary
depending on ablation depth, density of treatment, and spot size
but, in general, is much less than for full-field ablation.
19.2.2 Postprocedure Care
For any of the aforementioned devices, a test spot should always
be performed in high-risk patients prior to actual treatment.
For full-field ablation, Aquaphor (Beiersdorf, :ilton, CT) or
petrolatum jelly ointment should be applied to skin until
re-epithelialization is complete, followed by a lighter nonocclu-
sive dressing. Silicone gels are another option; these gels form
a sheet that protects the underlying skin and decreases the
duration of erythema and healing time. Once epithelialization
is complete, a skin care regimen of the provider’s choice should
be instituted. Some providers opt for a lighter, noncomedogenic,
cream-based regimen for fractional and nonablative procedures.
As with any other procedure, sun avoidance and the use of
sunscreen are paramount and should be an integral part of the
patient’s skin care regimen. Other postprocedure care, such as
antibiotics for acneiform eruptions and pre- and/or post anti-
virals, will not be discussed in this chapter; however, these are
conditions that a laser surgeon must know how to treat.
19.3 Vascular Lasers and
Light-Based Treatments
19.3.1 Vascular Laser Devices
Initially, lasers such as copper vapor (578 nm), krypton (568 nm),
and argon dye (577 nm) were used to target vascular lesions,
but they were eventually abandoned because of unwanted side
effects such as scarring. Technology later developed to include
selective photothermolysis, which allowed for targeting of spe-
cific chromophores and minimizing damage to the surrounding
tissue. :hen targeting vascular lesions, the specific chromo-
phore targeted is oxyhemoglobin. Oxyhemoglobin has absorp-
tion peaks at the 410- to 429-nm, 541-nm and 577-nm ranges, as
well as between the 700-nm and 1,100-nm ranges, although less
significantly. These lower absorption peaks also compete with
melanin absorption, and can result in preventable side effects.
Care must also be taken when selecting treatment parameters,
as they can also cause purpura and ecchymoses when aggressive
settings are used.
Pulsed Dye Laser
The pulsed dye laser (PDL) is known as the gold standard for the
treatment of vascular lesions. The traditional 585-nm PDL was
popular until the newer 595-nm PDL was introduced. PDLs are
very effective in treating portwine stain (P:S), rosacea, telan-
giectasias, and postprocedure bruising, among other things.
Because of the short pulse durations and high fluences needed to
treat vessel structures, vessels rupture and subsequently hemor-
rhage into surrounding tissue, causing ecchymoses that can be
commonly observed. This resulting purpura or ecchymoses can
last between 1 and 2 weeks and decrease patient satisfaction.
Some patients can even suffer from postinflammatory hyperpig-
mentation due to the purpura caused. Other side effects, such as
scarring and pigmentary disturbances, are not commonly seen.
To prevent the unwanted associated purpura, providers can
lengthen the treatment’s pulse duration, use multiple passes,

200
III Nonsurgical Cosmetic Treatments
or can use lower fluences and incorporate pulse stacking to
achieve the intended outcome without producing any purpura.
Additionally, there are newer devices which emit multiple
subpulses as a way of preventing unwanted side effects. The
newest addition to this group of lasers is a solid state 589-nm
wavelength laser (ADVATx; AdvaLight, San Marcos, CA), which
delivers individual pulses of energy at a repetition rate of 12 kHz,
with shortening of individual pulse duration and pulse spacing,
thus minimizing trauma to surrounding tissue. This laser has
FDA clearance for the treatment of hemangiomas, rosacea,
venous lakes, P:S, and poikiloderma of Civatte.
Potassium Titanyl Phosphate
In contrast to the PDL, the potassium titanyl phosphate (.TP) laser
emits light at a wavelength of 532 nm. The .TP laser is a great
alternative for the treatment of vascular lesions and is mostly used
for superficial and finer vascular lesions such as finer blood ves-
sels, telangiectasia, leg veins, and cherry angiomas. These lesions
would typically be harder to treat with PDLs. Because the .TP
laser emits longer pulse durations, up to 100 ms, causing targets
to be heated slowly, the risk of purpura is greatly decreased,
which positions this laser at an advantage. However, because the
wavelength of this laser is close to the melanin absorption peak,
there is a greater risk of hypo- or hyperpigmentation. The .TP
laser should be used in lighter skin types, I to III, as unwanted side
effects are more commonly seen with darker skin types. Transient
erythema, edema, and crusting can be observed. There have also
been reports of atrophic scarring, particularly when treating small
perinasal telangiectasias using high fluences (Fig. 19.3; Fig. 19.4).
19.3.2 Near-Infrared Devices
Red and near-infrared lasers provide an option for patients of
skin of color and for larger vessels or deeper targets. Because of
their wavelengths, set around 700 to 1,200 nm, which are near
the absorption of oxyhemoglobin and far enough from melanin’s
absorption peak, these lasers allow deeper penetration and use
in darker skin types. Among these devices are the 755-nm alex-
andrite laser, the 800- to 980-nm diode lasers, and the 1,064-nm
neodymium-doped yttrium aluminum garnet (1d::e will concentrate on the 1d:Fig. 19.3 Telangiectases before potassium titanyl phosphate (KTP)
laser treatment.
Fig. 19.4 Results on the patient shown in Fig. 19.3, 3 months after
potassium titanyl phosphate (KTP) laser treatment.

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201
with the most applications, so it would be the vascular device
that would make most sense in a plastic surgery office setting.
The 1064-1d:tion, good water absorption, and almost no melanin absorption.
Because of its low hemoglobin absorption, higher fluences are
needed to destroy the selected target. These high energy levels
increase the risk of blistering and scarring, so treatments should
be exercised with care. Since these lasers have very low melanin
absorption, they are safe to use in all skin types. 1d:have been used to treat deeper and larger targets such as blue
varicose veins, resistant P:S, hemangiomas, and venous mal-
formations. They are the gold standard for laser hair removal in
persons with skin of color.
The latest 1d:duration technology. These have shown results in treating
facial erythema, telangiectasias, postsurgical Mohs scars, and
even acne. These newer models, in the 300- to 650-Ǿs range,
minimize the risk of damaging surrounding tissue and scarring
and are less painful than their conventional millisecond 1d:counterparts.
19.3.3 Pulsed-Light Devices
The intense pulsed light (IPL) system was designed in the 1990s.
It emits broadband light from 500 to 1,200 nm at varying ener-
gies and pulse duration. This system differs from other devices
previously mentioned in that in contrast to lasers, which have
a specific wavelength (emit monochromatic light), IPL devices
deliver multiple wavelengths of light simultaneously and target
different structures or chromophores. These devices have partic-
ular filters that restrict the emitted wavelengths. For example,
a 560-nm filter would allow passage of all wavelengths below
the 560-nm range. Additionally, there is a peak of energy at the
lowest cutoff, which in the previous example would be around
the 560-nm range. Care must be taken to choose the appro-
priate filter, since shorter wavelengths could cause potential
pigmentary problems in darker-skinned individuals due to the
absorption of melanin at these wavelengths. Most platforms
include a myriad of filter options, so that the provider can choose
shorter wavelengths for lighter-skinned patients or to treat
deeper targets such as deeper vessels and longer wavelengths
for more superficial targets, with longer pulse durations used for
darker-skinned individuals. Overly aggressive settings can cause
blistering and postinflammatory pigmentary alterations.
The most common indications for these devices are pigmentary
and vascular lesions. IPL devices allow for the treatment of a
wide range of skin conditions, including photoaging, wrinkles,
ephelides, solar lentigines, telangiectasias, hemangiomas, venous
malformations, P:Ss, and poikiloderma of Civatte.
Pigmentary lesions are mostly treated with the 500- to 560-nm
range of wavelengths due to the increase in melanin absorption
at these wavelengths. This is typically termed a ´photofacial.µ
These wavelengths are most commonly used on patients with
Fitzpatrick skin types I to III; however, these may be used with
darker skin types at lower fluences. Lesions will turn darker right
after treatment and should flake off eventually. Vascular lesions
in turn require filters in the 585- to 595-nm range, which is the
vascular absorption peak. Lesions will turn darker as well before
improvement is noted. Multiple handpieces can be used to achieve
the desired outcome, and multiple treatment sessions should be
expected (Fig. 19.5; Fig. 19.6).
These devices have incorporated contact cooling, which aids in
the prevention of epidermal injury. There are many IPL devices
available from different manufacturers, with differing filters and
cooling systems. Specifications from one system should not be
assumed in another or compared, since different manufacturers
have differing setting specifications and parameters.
Selecting a Vascular Treatment
Both the PDL and .TP lasers are great workhorses for the treat-
ment of vascular lesions, including malformations, angiomas,
and venous anomalies or varicosities. However, a PDL or .TP
laser would not necessarily be the go-to laser or a cost-effective
option in a plastic surgery setting. The 1,064-nm 1d:or an IPL system would be a more appropriate option, given its
wider range of treatment options, including vascular lesions,
pigmentary lesions, and finally hair removal (which is not dis-
cussed here, although further reading is provided at the end of
the chapter).
The various vascular devices available are detailed in Table 19.2.
19.3.4 Postprocedure Care
In order to minimize any side effects such as blistering, scarring,
or pigmentary disturbances, epidermal cooling should be applied
immediately postprocedure after any vascular lesion is treated.
This should be strictly enforced in darker skin types. Moreover,
we recommend the use of light-emitting diode (LED) lights post-
procedure in darker-skinned patients, to minimize inflammation
and prevent any unwanted hyperpigmentation or scarring.
19.4 Noninvasive Skin Tightening
Increasing demand for noninvasive procedures has led to the
development of many devices that can be used to treat skin
laxity. 1oninvasive skin tightening of the face, neck, and abdo-
men is commonly sought after; furthermore, skin tightening of
the arms, knees, dpcolletage, and chin has started to increase in
popularity as well. Although more invasive surgical options such
as facelifts and rhytidectomy still remain the optimum treatment
for skin laxity, these newer devices provide the patient with less
invasive options and less to even no downtime. As mentioned
Table 19.2 Devices used to treat vascular lesions
'eYiFe
:DYeOengWK nm
SNin WySeV
Tan
Pulsed dye
585–595
I–III
No
Diode
589
I–III?
No
KTP
532
I–III
No
Nd:YAG
1,064
1–VI
Yes
IPL/BBL
585+
1–III
No
Abbreviations: BBL, broadband light; KTP, potassium titanyl phosphate; IPL,
intense pulsed light.

202
III Nonsurgical Cosmetic Treatments
before in this chapter, ablative resurfacing is considered the gold
standard for laser skin tightening and rejuvenation; however,
with the invention of newer skin-tightening devices, the surgeon
has a wide range of tools to choose from to reduce skin laxity.
This tightening effect can be achieved with various modalities;
the most commonly used devices are radiofrequency devices
and ultrasound devices. Most recently, needle-based devices and
picosecond lasers are starting to be used for this purpose. Patient
selection is crucial in obtaining optimum results.
All skin-tightening devices function by delivering heat in
the form of energy to the underlying skin and structures. This
heat in turn damages these structures, causing contraction of
collagen, neocollagenesis, and eventual tightening through the
wound-healing process. These devices are mainly indicated for
mild to moderate skin laxity.
19.4.1 Microfocused Ultrasound
Microfocused ultrasound (MFUS), with or without visualization,
targets deep to superficial subcutaneous and dermal tissues. This
technology works by heating tissue secondary to the absorption
of acoustic energy. Cellular friction caused by acoustic energy
causes precise heating. This then leads to tissue contraction,
destruction, and collagen synthesis and remodeling, avoiding
gross necrosis or affecting surrounding tissues. Research done on
human cadavers showed that this technology was able to target
the superficial musculoaponeurotic system (SMAS) without
causing injury to nontargeted adjacent structures.
Ultherapy (Ulthera, Inc., Merz Device Innovation Center, Mesa,
A=) is the first and only major MFUS system available that has
FDA clearance for the indications of lifting skin on the brows,
submental, and neck tissue and improving the rhytids of the chest
and dpcolletage area. It received its first FDA approval in 2009 for
the indication of brow lift. This device uses different transducers
at varying frequencies. The transducers operate at 4 or 7 MHz and
at fixed depths of 1.5 mm, targeting the superficial dermis; 3.0
mm, targeting the deep dermis; or 4.5 mm, targeting the SMAS.
The higher the frequency, the more superficial the tissue that is
targeted, such as the neck and periorbital areas, and it can be
used for tightening of skin crepiness. In contrast, lower frequen-
cies target deeper tissue and thicker skin, such as the cheeks,
and provide more of a lift of structures. Treatments usually last
Fig. 19.5 Photodamage before intense pulsed light (IPL) treatment.
Fig. 19.6 Improvement of photodamage in the patient shown in Fig.
19.5, 6 months after four intense pulsed light (IPL) treatments.

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203
between 30 and 90 minutes depending on the treatment areas,
and there is no patient downtime. Topical anesthetic is typically
applied prior to treatment to enhance patient comfort. Alam et
al carried one of the first clinical trials and showed significant
improvement in brow elevation in more than 83 of patients. The
average increase in brow elevation was between 1.7 and 1.9 mm;
these results were still present at 10-month follow up. Suh et al
treated 22 Asian patients with a single treatment with an average
of 200 lines. These patients reported a 77 and 73 subjective
improvement in their nasolabial folds and jaw line, respectively.
Histologic analysis showed increased dermal collagen and thick-
ness and straightening of elastic fibers in the dermis. Similarly,
noticeable improvement was noted when treating the dpcolletage
area, and over 60 patient satisfaction was observed. The thighs,
knees, and arms have also been studied. Patients’ knees and arms
demonstrated better results than their thighs did. Additionally, a
study on the buttocks done on 19 patients showed 89.5 subject
global assessment improvement at 180 days.
19.4.2 Radiofrequency Devices
Unlike ultrasound devices, radiofrequency (RF) devices function
by heating a broad, nonspecific area to target temperatures of
40 to 45ƒC. Energy is transmitted via radio waves. Initially, due to
the heat, collagen fibers thicken and denature, and an immediate
tightening effect can be seen; however, this is only temporary.
Once the healing process begins and new collagen is produced,
true tightening is observed. These devices have been shown
to produce neocollagenesis and neoelastogenensis. There are
currently many radiofrequency devices on the market; these can
be divided into bipolar, monopolar, and unipolar devices. Bipolar
devices have both electrodes at the patient’s treatment site.
Monopolar and unipolar devices have one treatment probe on
the treatment site, with the returning probe placed at a distant
location. Only a few will be discussed in this section.
Monopolar RF
Monopolar RF utilizes a grounding pad to pass electrodes or an
electric current back and forth between it and target tissues,
which heats the dermis, subdermis, and even subcutaneous fat
below it. Monopolar RF can reach the highest treatment depth in
comparison with other RF systems, and depth increases with the
diameter of the treatment electrode.
The first system of its kind was Thermage ThermaCool TC (Solta
Medical, Bothell, :A), which uses a stamping grid treatment
with epidermal cooling. It has FDA indications for the nonin-
vasive treatment of periorbital wrinkles and rhytids including
the upper and lower eyelids, noninvasive treatment of wrinkles
and rhytids, and temporary improvement in the appearance of
cellulite. It is the first and only system to receive FDA clearance
for noninvasive, energy-based eyelid treatments. Fitzpatrick et
al treated 86 patients in their periorbital areas with high-energy
fluences, resulting in 92.8 of treated areas being improved or
remaining the same at 6 months. The average brow lift was 1.30
to 1.49 mm, and 50 of patients were satisfied with the results. It
was noted, however, that treatment at higher fluences resulted in
scarring and other adverse effects. A subsequent study treating
patients with lower fluences and multiple treatments resolved
this difficulty. 1eck and cheek laxity was also studied, resulting in
objective improvement in 93 of patients.
ThermiSmooth 250 (ThermiGen, South Lake, TX) is another
monopolar RF indicated for the temporary reduction in the
appearance of cellulite and used as well for tightening of the face
and neck, among other bodily locations. Providers place a probe in
constant contact with the patient’s skin and in constant motion,
and the system provides real-time temperature feedback. Similar
to ThermiSmooth, Pellevp MRF system (Cynosure, :estford, MA)
requires a handpiece in constant motion over the skin, and it has
demonstrated an improvement in skin laxity of the face and neck,
among many other bodily areas.
Unipolar RF
Unipolar RF differs from monopolar RF in that it uses high-fre-
quency electromagnetic radiation instead of electrical currents
to produce heat. This heat can penetrate up to 20 mm in depth.
The RF device Accent Prime (Alma Lasers, Buffalo Grove, IL) is
indicated for the noninvasive treatment of wrinkles and rhytids
and demonstrates a reduction in cellulite and thigh circumfer-
ence of 2.45 cm (Fig. 19.7; Fig. 19.8).
Bipolar RF
Bipolar RF is typically used in combination with other devices or
can be included in different platforms. It has been suggested that
energy penetration is half the distance between the two probes,
to a maximum depth of 4 mm. In addition, these can be combined
with IPL devices, diodes, or even mechanical massage suction
devices such as the Velashape (Syneron Candela, :ayland, MA),
which has proven to improve the appearance of cellulite and to
result in reduction in circumference of the postpartum abdomen
and arms.
Multipolar RF
These devices use three electrodes or more to produce skin tight-
ening. The Apollo (Pollogen Ltd, Tel Aviv, Israel) is FDA-approved
for the noninvasive treatment of mild to moderate facial
wrinkles and rhytids and has been used for cellulite reduction
and to decrease body circumference areas. This RF system
requires constant contact with the treatment area and constant
motion. Another one of these devices is the 3DEEPtechnology by
EndyMed, or the EndyMed Pro (EndyMed Medical Ltd, Caesarea,
Israel), which is indicated for the noninvasive treatment of mild
to moderate facial wrinkles and rhytids. It has shown efficacy
in treating facial laxity as well as clinical benefit treating the
abdomen and thighs, cellulite, and body circumference.
Other RF technologies that have been shown to produce skin
tightening and correction of laxity are fractionated bipolar RF
devices and microneedling fractional bipolar RF. The latter devices
have needles that penetrate into the skin and deliver their energy
at the penetrating level, thus being more selective in their thermal
damage, avoiding any adjacent epidermal injury, and potentially
producing a greater tightening effect.
In general, results observed from RF devices can be unpredict-
able and rely heavily on patient selection. Patient expectations and
potential results should be discussed extensively. Most require
local anesthetic. These devices have an advantage over others in

204
III Nonsurgical Cosmetic Treatments
that they have minimal side effects, have little to no downtime,
and are safe to use on all skin types. to moderate laxity are more likely to receive better results than
are older patients with extreme skin laxity. Both ultrasound and
RF devices are good potential adjuncts to any surgical skin laxity
procedures, where the patient might desire some additional skin
tightening, or they can be an option for those patients looking for
less invasive options.
Picosecond Lasers
Among the latest devices currently being studied for skin reju-
venation and tightening are picosecond lasers. Various studies
have been carried out using an alexandrite picosecond laser with
a diffractive array, which has shown improvement in patients’
wrinkles, skin texture, and photoaging. However it is not clear
whether these results are maintained over time, as long-term
studies have not been done. In one of these studies, results were
not maintained at 3-month follow-up.
19.5 Concluding Thoughts
The number of patients seeking noninvasive and nonsurgical
options, including laser and laser-like devices, continues to grow.
Currently, the cosmetic surgeon has many treatment options to
choose from, many of which are nonsurgical, while others can
be used to complement surgical treatments. Every plastic and
cosmetic surgeon should have at least a basic knowledge of these
devices. Depending on the patient’s condition and needs, com-
bination treatments frequently yield increasingly better results
than monotherapy. As technology progresses, these devices will
become more advanced, perhaps competing one day with many
surgical procedures and even providing similar results. Light
energy–based devices are ever changing, just as the field of plas-
tic surgery is. The plastic surgeon will continuously be tasked
with being a part of this change and innovation.
Clinical Caveats
• Combination laser treatments yield the best results.
• Laser resurfacing can be classified into ablative or nonablative.
• Skin resurfacing can be performed as either fractional or full-
field resurfacing; fractional resurfacing poses less downtime
for the patient.
• Nonablative lasers have a decreased risk of pigmentary
changes in patients of darker skin types.
• Skin tightening can be achieved with radiofrequency and/or
ultrasound devices.
• Pulsed-light devices can be used to treat vascular lesions and
pigmentary irregularities, and even for hair removal.
• With any type of laser device, patient selection is crucial, and
adequate postprocedure care is vital.
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Fig. 19.7 Cellulite before treatment with monopolar radiofrequency.
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our experience and a review of the literature. Dermatol Surg 2014;40(Suppl
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>7@ Ciocon DH, Doshi D, Goldberg D-. 1on-ablative lasers. Curr Probl Dermatol
2011;42:48–55 10.1159/000328249
>8@ Clementoni MT, Gilardino P, Muti GF, et al. Intense pulsed light treatment of
1,000 consecutive patients with facial vascular marks. Aesthetic Plast Surg
2006;30(2):226–232 10.1007/s00266-005-0086-0
>9@ DeHoratius DM, Dover -S. 1onablative tissue remodeling and photorejuvenation.
Clin Dermatol 2007;25(5):474–479 10.1016/j.clindermatol.2007.05.006
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>11@ Elsaie ML, Choudhary S, Leiva A, 1ouri .. 1onablative radiofrequency for
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jaad.2013.06.045
>13@ Fitzpatrick R, Geronemus R, Goldberg D, .aminer M, .ilmer S, Ruiz-Esparza -.
Multicenter study of noninvasive radiofrequency for periorbital tissue tighten-
ing. Lasers Surg Med 2003;33(4):232–242 10.1002/lsm.10225
>14@ Garden -M, Tan OT, .erschmann R, et al. Effect of dye laser pulse duration on
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206
III Nonsurgical Cosmetic Treatments
20 Sclerotherapy and Laser Vein Treatment
Gilly Munavalli, Mitchel P. Goldman, and Robert A. Weiss
Abstract
Venous disease encompasses a wide spectrum of clinical manifes-
tations, including medical and cosmetic concerns. A knowledge
of the lower-leg venous anatomy is helpful for translating clinical
symptoms and signs into localized and diagnosable venous
disease. The zones of influence of the great saphenous and short
saphenous veins can determine whether new-onset or persistent
telangiectasia (spider veins) are associated with saphenous
reflux. Cosmetically sensitive telangiectasias/venulectasias and
reticular veins can be treated with either sclerotherapy or laser.
There are several sclerosing agents to choose from, depending
on the vessel size and location. Laser, specifically the 1,064-nm
wavelength, can be useful for treating telangectasia in situations
where needle injection is not desirable. Sclerotherapy can also
be used for treating other cosmetically undesirable veins in areas
such as the chest and dorsal hands.
Keywords
sclerotherapy, varicose, veins, spider veins, saphenous reflux,
laser, 1064 nm
20.1 Introduction
Venous disease encompasses a wide spectrum of clinical man-
ifestations, including asymptomatic unwanted small red, blue
reticular, and larger varicosities; intermittently bulging branches
of the great saphenous vein (GSV) that course down the medial
thigh and calf as well as extend across the thigh, knee, and calf
with terminal blue veins both large and small on the ankle and
feet; dull, achy pain in the posterior calf after prolonged standing
and, in the most advanced cases, golden-brown pigmentation of
the skin of the lower legs; ulcerations secondary to minor trauma
that are very slow to heal; and veins that are inflamed with the
potential progression of blood clots into the deep venous system.
The science of treatment of venous disease, phlebology, has roots
dating to 400 BC: the ancient Greeks recognized venous disease
as an undesirable and unsightly condition. Procedures involving
the use of instrumentation to traumatize veins were described
by Hippocrates in the fourth century BC, and procedures such
as cauterizing veins with a hot iron or surgically removing them
in pieces or in long segments (vein stripping) were routinely
practiced in the years that followed.
Today venous disease still presents a formidable challenge to
diagnose and treat. It affects 40 to 55 of the population, with
common symptoms of leg pain, swelling, and skin changes. Upward
of 80 of people aged 80 will have signs and/or symptoms of
venous disease. Venous insufficiency, which is caused by valvular
incompetence and a reversal of blood flow in the deep or superfi-
cial venous system, is the most common form of venous disease.
Deep venous insufficiency occurs when valves are damaged by
thrombosis and is beyond the scope of this chapter. Superficial
venous insufficiency occurs when high-pressure leakage develops
between the deep and superficial systems or within the superficial
system itself. This elevated venous pressure results in sequential
failure of the more distal venous valves in superficial veins. Venous
insufficiency allows venous blood to ´escapeµ from its normal
flow to the heart and flow in a retrograde direction down into an
already congested leg, thus increasing lower-leg venous pressure.
Over time, this elevated pressure and valvular-incompetent super-
ficial veins acquire the typical dilated and tortuous appearance
of varicosities. Furthermore, insufficiency can lead to chronic
morbidity of the skin as a result of compromised deoxygenated
skin, with subsequent fibrosis manifesting as stasis dermatitis,
lipodermatosclerosis, atrophie blanche, or edematous skin changes
eventuating in cutaneous nonhealing ulceration.
Farther downstream, changes involving the smaller branching
vessels, such as unsightly or symptomatic venulectasis and/or
telangiectasias, are a major consequence of superficial venous
valvular insufficiency. These entities occur in 29 to 41 of women
and 6 to 15 of men in the United States. Although up to 53 of
patients with leg telangiectasias have associated symptoms, the
most common reason patients seek consultation is cosmetic.
In the upper extremity, the forearm and dorsal hand veins rep-
resent the equivalent of varicose veins of the lower extremities.
Sunlight, gravity, and other environmental exposures subject the
hands to unique combinations of physiologic and environmental
stress. :ith the passage of time, the hands lose volume as a result
of muscle atrophy, bone demineralization, and loss of adipose
tissue. Elasticity is lost, and skin texture dramatically changes.
This process is accelerated by solar-induced damage, which
results in wrinkled, dyschromic skin and prominent and tortuous
varicosities of the superficial veins of the hand and forearms, such
as the cephalic vein and the basilic vein.
20.2 Pretreatment Assessment
20.2.1 Lower Extremity
Careful patient assessment is essential for patients seeking
amelioration of the symptoms of venous disease. Evaluation and
treatment in the lower extremity should be directed in a system-
atic fashion toward the size and type of vessel, starting with the
proximal, larger vessels and working down to the distal, smaller
vessels (Fig. 20.1). Vessel types classified in the superficial venous
system (from largest size to smallest) include the following:
• The GSV and small saphenous vein (SSV) with their respective
direct tributaries
• 1onsaphenous vein varicosities (often visibly bulging veins)
• Reticular or feeder veins (often bluish colored)
• Spider veins or telangiectasia (located just below the
epidermis)

 SFOerRWKerDSy Dnd /DVer Vein 7reDWmenW
207
The majority of symptomatic lower-extremity venous insuf-
ficiency is attributable to the superficial venous system and
specifically includes reflux of the GSV. Reflux of the SSV accounts
for approximately 5 of superficial venous disease, whereas the
remaining division of the superficial system is called the lateral
subdermic venous system. Younger patients, in their twenties
and thirties, usually present with telangiectatic webs on the
lateral thigh originating from reticular vein reverse flow or reflux
in the lateral venous system. :hen there is a family history of
large varicose veins, reflux originating from the GSV or SSV
must be suspected. A duplex ultrasound study in patients who
presented for ´cosmeticµ treatment of leg veins has been shown
to demonstrate a relatively high incidence of early associated axial
or truncal reflux in the GSV.
During an initial consultation, reflux in the GSV is first sus-
pected based on active symptoms elicited during a thorough
history and physical examination. Often these patients have a
strong family history of venous disease, especially the presence
of varicose veins in immediate family members. Symptoms of
venous disease are most often localized to the medial surface
of the leg and exacerbated by prolonged standing, or during the
premenstrual period in women, and are typically relieved by cold,
ambulation, or rest with leg elevation or by wearing graduated
compression stockings. Characteristics of venous pain can include
a dull ache; burning, heavy legs; throbbing; leg cramping; or
pruritus that worsens at the end of the day. Generally speaking,
abnormalities on physical examination of the lower extremities
such as pain, bulging veins, or skin findings such as discoloration
or ulceration located on the medial thigh and ankle correspond
with the GSV distribution, whereas those located on the posterior
calf and lateral ankle correspond to the SSV distribution.
Unlike the symptomatology associated with reflux in the larger
vessels, telangiectatic lesions more often present as a cosmetic
concern. The term telangiectasia was first used in the early 1800s
to describe a superficial vessel of the skin visible to the human
eye. These typically measure 0.1 to 1 mm in diameter and can be
either a distended arteriole or a venule. A host of conditions can
precipitate telangiectasia formation (see Table 20.1). Varicose
veins most likely lead to the formation of telangiectasias through
either associated venous hypertension with resulting angiogen-
esis or vascular dilation. These varicose veins may or may not be
clinically evident at the time of telangiectasia presentation but
should trigger the systematic proximal-to-distal vein evaluation
Table 20.1 Select conditions precipitating telangiectasia formation
Hormonal factors:
• Pregnancy
• Estrogen therapy
• Topical corticosteroid preparations
Physical factors:
• Age
• Trauma (contusion, surgical incision, lacerations)
• Infection
• Radiation dermatitis
• Erythema ab igne (chronic thermal injury)
• Actinic neovascularization
Component of a primary cutaneous disease:
• Varicose veins
• Necrobiosis lipoidica diabeticorum
• Capillaritis (progressive pigmentary purpura)
Fig. 20.1 An algorithm for evaluation of lower-extremity venous disease.

208
III Nonsurgical Cosmetic Treatments
of the affected extremity in efforts to unmask subclinical venous
disease.
Normal Venous Anatomy of the Lower
Extremity
.nowledge of superficial venous anatomy and the location of
important perforating vessels is fundamental to recognition of
normal patterns of varicose veins (Fig. 20.2).
The GSV is of primary concern when treating venous problems
in the lower extremity. The saphenous vein originates on the
dorsum of the foot in the dorsal venous arch, passes anterior to the
medial malleolus, progresses through the medial calf across the
posteromedial aspect of the popliteal space, ascends in the medial
thigh, and terminates in the femoral vein at the saphenofemoral
junction. It dominates the anteromedial superficial drainage
system. As the saphenous vein reaches its termination, it receives
important tributaries medially and laterally. Duplex ultrasound
examination may identify reflux in one or more of these vessels.
The anatomy of the GSV is relatively constant. It is understood
that this vein lies on the deep fascia of the leg and thigh, but it is
less well recognized that it lies below or deep to the superficial
fascia. Current descriptions of the anatomy of the lower-extremity
vasculature do not always make this distinction, yet this fact is
crucial to understanding the development of varicosities.
In varicose venous anatomy, the important tributaries to the
GSV extending upward from below are the posterior arch vein
(vein of Michelangelo), which receives the three Cockett perfo-
rating veins (posterior tibial perforators); the anterior tributary
vein to the saphenous system, which lies below the patella and
collects blood from the anterior and lateral surface of the leg; and
the posterior tributary vein, which also empties into the GSV in
the upper anteromedial calf. Other tributaries that may terminate
high in the saphenous system near the groin are the posterior
medial thigh vein and the anterior lateral thigh vein. Either or
both of these veins may become the site of varicose clusters.
Less common in primary varicosities, and more important in
recurrent varicose veins after treatment, are other tributaries
to the GSV as it terminates in the fossa ovalis. These include the
superior external pudendal vein, the superior epigastric vein, and
the superficial circumflex iliac vein.
Leg varicose veins could be the result of retrograde flow from
pelvic vein varicosities from the connection of pelvic veins, the
external pudendal vein, and the saphenofemoral junction. The
findings of varicose veins of the medial groin, medial buttocks,
and pubic area in patients with chronic pelvic pain should lead
one to suspect pelvic congestion syndrome.
The 34-year-old woman in Fig. 20.3 presented with recurrent
varicose veins of the left groin and thigh 2 years after she under-
went endovenous laser ablation for left GSV reflux. She reported
having felt heaviness and intermittent pain of the left pelvic area
and groin for the past several years; her symptoms worsened with
prolonged standing and during menstruation. Physical examina-
tion revealed reticular veins and bulging varicose veins of the left
medial groin in addition to a varicose vein of the left thigh.
Duplex ultrasound showed several dilated veins in the left
groin that continued proximally to the pelvic area. Her magnetic
resonance imaging (MRI)/magnetic resonance venography (MRV)
Fig. 20.2 Illustration of the superficial venous anatomy of the anterior
lower extremity that is important for evaluation of varicose veins.
Fig. 20.3 A patient with medial thigh and groin varicose veins 2 years
after endovenous laser ablation of the great saphenous vein. Magnetic
resonance imaging (MRI)/magnetic resonance venography (MRV) revealed
an enlarged left gonadal and pelvic vein associated with pelvic conges-
tion syndrome. (Reproduced with permission from Alam M, Silapunt S,
eds. Treatment of Leg Veins, 2nd ed. Elsevier; 2010.)

 SFOerRWKerDSy Dnd /DVer Vein 7reDWmenW
209
showed an enlarged left gonadal and pelvic vein. She was diag-
nosed with pelvic congestion syndrome and was treated, with no
subsequent recurrence of varicose veins.
Posteriorly, the most important of the axial veins is the SSV. This
vein originates on the lateral aspect of the foot in the dorsal venous
arch and ascends virtually in the midline of the calf, between the
bellies of the gastrocnemius muscle. Unlike the GSV, the SSV may
penetrate the deep fascia at any point from the middle third of
the calf upward. This fact explains its segmental rather than total
nature of reflux.
Important tributaries to the saphenous vein are variable in
location or existence but may include the posterolateral trib-
utary vein. Superiorly, this tributary may be associated with a
lateral thigh vein called the DQWHURODWHUDO VXSHUfiFLDO WKLJK YHLQ
Another important and frequently encountered vein is the vein
of Giacomini, which connects the lesser and greater saphenous
veins. It may originate from the SSV or from its thigh extension
and ends in the GSV or its posterior accessory.
The value of knowing the gross anatomy of the superficial veins
of the lower extremity is that any one of the systems may be the
site of the growth of clusters of varicosities (Fig. 20.4).
SigniÀFDnW 3erIRrDWing 9einV
The perforating veins connect the superficial venous system to
the deep venous system and penetrate the fascia. Any one of
these veins, alone or in combination, may be the source of hydro-
dynamic forces of venous hypertension that produce superficial
varicosities. It is the abnormally high pulses of hydrodynamic
pressure transmitted through incompetent valves that affect rel-
atively unsupported superficial veins. Such pulses of increased
fluid force originate to some extent from increased abdominal
pressure and to a greater extent from increased compartmental
pressure during muscular contraction.
The best-recognized connections between the superficial venous
system and the deep venous system are the saphenofemoral and
saphenopopliteal junctions. Incompetence of the check valves at
their termination has been suggested as the cause of distal vari-
cosities from gravitational reflux. This reverse flow is said to dilate
veins in a progressive fashion, from proximal to distal.
Because it is frequently the site of the first varicose veins or
the first reticular veins that become varicose, Boyd’s perforating
vein in the anteromedial calf has come to receive great attention
by physicians who treat venous problems. Experience with the
duplex scanner reveals that venous incompetence at this level
may be isolated and may be the first reflux to appear. Such incom-
petence may be asymptomatic; however, when the incompetence
is symptomatic, it produces aching pain, fatigue, and even a throb-
bing discomfort as mentioned previously. These symptoms can be
relieved by firm local pressure. Progressing proximally from Boyd’s
communicating vein are the perforating veins in the distal third of
the thigh. These veins are named for English surgeon Harold Dodd
and may be found in any location along the saphenous pathway in
the distal third of the thigh. The third important series of commu-
nicating veins, the Hunterian (midthigh) perforators, are named
for Scottish surgeon and anatomist -ohn Hunter (Fig. 20.5).
Recognizing the normal anatomy and the most common perfo-
rating vein sources of varicosities makes identification of patterns
of varicosities relatively easy.
Telangiectatic Leg Veins
Telangiectatic leg veins may be described as venous spiders,
spider veins, sunburst veins, starburst veins, venous plexuses,
dilated venules, venous blemishes, venulectasias, superficial or
minor varicosities, essential cutaneous telangiectasias, vanity
veins, and cosmetic veins (Fig. 20.6). All of these terms describe
the type of telangiectatic networks that may cause physical
symptoms of pain and discomfort. More than 50 of patients
presenting for treatment of these ´spider veinsµ express aching
associated with them. These symptomatic veins are best catego-
rized as arborizing networks (according to the Redisch and Pelzer
classification). They are actually combinations or networks of
telangiectasias (0.1–1 mm) and venulectases (1–2 mm). Painful
telangiectasias on the leg are usually grouped; they are rarely
present as isolated telangiectatic vessels or spider angiomas with
a central arteriole. More important, symptomatic telangiectasias
Fig.20.4 Illustration of the superficial venous anatomy of the posterior
lower extremity.

210
III Nonsurgical Cosmetic Treatments
and venulectases commonly are associated with slightly larger
blue veins, which have been called ´feederµ veins, reticular veins,
or minor varicose veins. These small subdermal blue veins may
be tributaries of the saphenous system. Reticular veins are most
commonly part of a superficial venous system that is separate
from either of the saphenous systems, originally described as the
´lateral subdermic venous systemµ by Albanese et al.
To diagnose and treat painful telangiectasias in a logical way,
a precise classification is helpful and is given in Table 20.2. This
includes telangiectasias (type I), venulectases (type II), associated
blue reticular veins (type III), and reflux from primary varicose
veins (types IV and V).
A disturbance of normal venous physiology with back pressure
and reverse flow or reflux through incompetent valves results
in transmission of pressure through reticular veins into venules,
causing their expansion into telangiectasias and venulectases.
Telangiectasias located on the anterior aspect of the thigh could
occur as a consequence of reflux in the following vessels: anterolat-
eral tributary of the GSV, inguinal fold reticular veins, incompetent
saphenofemoral junction, superficial axial branches of the GSV, or
anterior branches of the lateral subdermic venous system. Although
painful telangiectasias and venulectases may appear anywhere on
the leg, they are most likely to occur near the knee.
Regions in which painful groups of telangiectasias and venulec-
tases are most likely to occur are shown by the shaded areas in Fig.
20.7. Patients most often complain of focal burning, throbbing,
and aching in these areas.
20.2.2 Upper Extremity
The veins of the upper extremities, primarily the cephalic and
basilic veins, are analogous to the great and small saphenous veins
Fig. 20.5 Illustration of the superficial venous anatomy of the medial
lower extremity.
Fig. 20.6 Illustration of telangiectatic leg veins of the lower extremity.

 SFOerRWKerDSy Dnd /DVer Vein 7reDWmenW
211
of the superficial venous system in the lower extremities (Fig. 20.8).
Because of the proximity of these veins to the radial and ulnar veins,
they are commonly used as bypass routes for procedures such as
arteriovenous shunts in patients with renal disease. Sclerotherapy
of upper-extremity veins is not commonly performed for several
reasons. Because these veins are not subject to the same hydrostatic
pressures as the lower-extremity veins, valves in cephalic and basilic
veins do not commonly exhibit reflux and associated symptomatol-
ogy. These veins usually do not appear overly distended or tortuous,
and varicosities/telangiectasias do not generally develop in the
upper extremities. A noted exception occurs with upper-extremity
exercisers, such as weight lifters, who perform frequent Valsalva
maneuvers during exercise. Prolonged increase in intrathoracic
pressure will increase flow through upper-extremity veins and can
result in clinically noticeable vein distention. This is a normal phys-
iologic response and not considered pathologic. In our experience,
branches of the cephalic vein in the forearm and dorsal hand are the
most common areas treated with sclerotherapy. Detailed upper-ex-
tremity venous anatomy is beyond the scope of this chapter.
20.3 Treatment Options
Ideally, treatment for unwanted leg veins would be performed
in one session, cause no pain, and be 100 effective in clearing
vessels, with no associated side effects. Unfortunately, the
variations in vessel size, flow, depth, and type preclude the pos-
sibility of a single effective treatment modality. However, there
are a number of effective treatments that can produce excellent
results, including conventional and duplex-guided sclerotherapy
for the treatment of larger vessels and telangiectasias and laser
treatment of reticular and spider veins.
20.3.1 Conventional (Visual) and
Duplex-Guided Sclerotherapy
Conventional sclerotherapy is indicated for the elimination
of unwanted reticular veins and telangiectasias (Table 20.3).
Table 20.2 Revised vessel classification (eliminating the mixed telangiectasia/varicose category)
Type I
Telangiectasia, spider veins
0.1–1 mm diameter
Usually red (rarely, may be cyanotic)
n Type IA
Telangiectatic matting
< 0.2 mm diameter network, bright red
Type II
Venulectasis (usually protrudes above skin surface; distinguished from telangiectasia by deeper color and larger diameter)
1–2 mm diameter
Violaceous, cyanotic
Type III
Reticular veins (“minor” varicose veins, “feeder” veins)
2–4 mm diameter
Cyanotic to blue
Type IV
Nonsaphenous varicose veins (primary varicosity of saphenous tributary usually related to incompetent perforator)
3–8 mm diameter
Blue to green
Type V
Saphenous varicose veins (varicosities associated with reflux at saphenofemoral or saphenopopliteal junction or major perforators of
saphenous system causing enlargement of great or small saphenous vein)
Usually > 8 mm diameter
Blue to bluish-green
Because most patients have a combination of multiple varicose vein types, a description of type I in association with type II or type III varicosities is simpler. Classifying varicose
veins in this way facilitates a more straightforward treatment plan.
Note: Data from Goldman MP. Sclerotherapy treatment for varicose and telangiectatic leg veins. In: Coleman WP, Hanke CW, Alt TH, et al, eds. Cosmetic Surgery of
the Skin. Philadelphia: BC Dekker; 1991: 197-211; and Duffy DM. Small vessel sclerotherapy: an overview. Adv Dermatol. 1988; 3:221-242.
Fig. 20.7 The shaded regions are most likely to be effected by groups of
telangiectasias and venulectases causing burning, throbbing, and aching.

212
III Nonsurgical Cosmetic Treatments
:hen leg veins are managed in a systematic approach, feeder
vessels or larger varicose veins are first eliminated surgically
or with radiofrequency or laser ablation, and sclerotherapy
proceeds from largest to smallest vessels, with 80 to 90 of ves-
sels responding to one or two treatments. As with endovenous
ablation, sclerotherapy is performed in patients of all age groups,
ranging from patients in their late twenties to early seventies.
If treatment is initiated early in the course of the disease and
with proper proximal-to-distal treatment techniques, patients
can expect to achieve excellent results. Although hypertonic
saline solution is the sclerosant most widely available and
used in the United States, it is approved by the Food and Drug
Administration (FDA) only as an abortifacient and is the most
painful of sclerosing solutions, with the highest risk for causing
cutaneous necrosis if extravasated into soft tissue. Two FDA-
approved sclerosing solutions, polidocanol (Asclera; Merz, Mesa,
A=) and sodium tetradecyl sulfate (STS; Sotradecol; Mylan,
Institutional LLC, Cannonsburg, PA) are less painful to inject and
less ulcerogenic if extravasated. Vessel size and, to some extent,
location are two of the most important factors to consider when
choosing a sclerosant.
In expert hands, nearly any vessel can be treated with traditional
sclerotherapy techniques. It is more difficult to treat larger vessels,
vessels with a high-grade source of reflux, vessels with a complex
pattern of reflux, and vessels that lie deeper beneath the surface
of the skin. Failures can be caused by incorrect assumptions about
the patterns of flow, incomplete understanding of the anatomy, or
incorrect placement of the delivery catheter or needle.
Direct duplex ultrasound visualization offers an alternative to
´blindµ sclerotherapy that has one very important advantage³
after a treatment under direct visualization, there can be no doubt
that sclerosant has been delivered where it was intended and that
all areas of reflux have been exposed to the sclerosing solution.
An important secondary benefit is that observable spasm is a
predictor of vessel closure.
Common indications for injection with duplex ultrasound
visualization include the following:
• Great saphenous vein without junctional incompetence
• Small saphenous vein without junctional incompetence
• Truncal or tributary vessels with large failed perforating veins
• Varicosities with saphenofemoral incompetence
• Varicosities with saphenopopliteal incompetence
• Resistance to other techniques of sclerotherapy
• 1ontruncal varicosities larger than 5 mm in diameter
• Venous component of arteriovenous malformations
• Varicosities eroding into soft tissues
• Vulvar or scrotal varices
• Varicosities with large open connections to the deep venous
system
Although sclerotherapy is generally safe and effective, situa-
tions do arise in which it is contraindicated. Any patient with a
medical history significant for deep venous thrombosis should be
Fig. 20.8 The venous system of the upper extremity is illustrated here.

 SFOerRWKerDSy Dnd /DVer Vein 7reDWmenW
213
thoroughly evaluated with duplex examination of the deep and
superficial venous systems before treatment. If sclerotherapy is
to be performed, these patients must be anticoagulated. Patients
with a history of arterial insufficiency or hypercoagulable states
should not be considered candidates for treatment. Additionally,
sclerotherapy should not be performed on patients who are preg-
nant, bedridden, or severely diabetic.
20.3.2 Laser Treatment of Reticular
Vessels and Telangiectasias
Although sclerotherapy remains the mainstay of treatment
of varicose and reticular veins, lasers may play a role in the
treatment of lower-extremity telangiectasias, especially those
that remain after effective treatment of feeding reticular veins.
Upper-extremity or dorsal hand varicose veins are best treated
with sclerotherapy. Lasers typically have no role in the treatment
of upper-extremity varicosities.
In general, treatment with lasers and light sources is more
expensive, is more painful, require more treatment sessions, and
has less predictable results, and the risk of side effects is at least
as high as with sclerotherapy. Candidates suitable for laser or light
source treatment are those who are needle phobic, have failed
sclerotherapy, or have developed untoward side effects from
sclerotherapy. Others suited for laser treatment are fair-skinned
individuals who have either vessels smaller than the caliber of
Table 20.3 Indications for sclerosant usage
SROuWiRn e̥eFWiYe
concentrations)
7rDde nDmeV
0eFKDniVm
AdYDnWDgeV
'iVDdYDnWDgeV
Reticular veins
Polidocanol
(0.5–1%)*
Asclera
Detergent
(emulsifier)
Always painless
Cutaneous necrosis low
Effective at low concentrations
Urticaria (immediate) at injection site
Skin necrosis from painless
arteriolar injection
Expensive
Sodium tetradecyl
sulfate (0.2–5%)
Sotradecol
Detergent
(emulsifier)
Painless intravascular
Painful extravascular
Strong for varicose veins
Effective at low concentrations
Skin necrosis with extravasation of
concentrations 1.0%
Expensive
Dissolves rubber; must use latex-
free syringes to avoid allergic
response
Hypertonic saline
solution (20–23.4%)
None
Hyperosmolar
Low risk of allergic reaction
Readily available
Rapid action
Painful stinging and cramping
Highly ulcerogenic—high risk for
skin necrosis if extravasation occurs
Saline and dextrose
(25% dextrose and
10% sodium chloride
phenethyl alcohol)*
Sclerodex
Hyperosmolar
High viscosity; remains in treated
veins
Low risk of allergic reaction
Low risk of necrosis
Too weak for larger varicosities
Slight stinging
One concentration only
Telangiectasias
Polidocanol
(0.25–0.6%)*
Asclera
Detergent (emulsifier)
Always painless
Cutaneous necrosis low
Effective at low concentrations
Urticaria (immediate) at injection site
Skin necrosis from painless
arteriolar injection
Sodium tetradecyl
sulfate (0.1–0.5%)
Sotradecol, Fibrovein,
Thrombovar
Detergent (emulsifier)
Painless intravascular
Painful extravascular
Strong for varicose veins
Effective at low concentrations
Skin necrosis with extravasation of
concentrations > 0.25%
Expensive
Hyperpigmentation postsclerosis
Dissolves rubber; must use latex-
free syringes to avoid allergic
response
Hypertonic saline
solution (11.7–23.4%)
None
Hyperosmolar
Low risk of allergic reaction
Readily available
Rapid action
Painful stinging and cramping
Highly ulcerogenic—high risk for
skin necrosis if extravasation occurs
Saline and dextrose
(25% dextrose and
10% sodium chloride
phenethyl alcohol)
Sclerodex
Hyperosmolar
High viscosity; remains in treated
veins
Low risk of allergic reaction
Low risk of necrosis
Too weak for larger varicosities
Slight stinging
One concentration only
Not FDA-approved
Glycerin (72% solution
mixed 2:1 with 1%
lidocaine with or
without epinephrine
1:100,000)
None
Osmotic
Relatively painless
Lower potential to cause
hyperpigmentation
Cutaneous necrosis low
Lower potential to cause telangiectatic
matting
Can cause hematuria at high
volumes (>10 mL per treatment
session)
High viscosity
Cannot be used with lidocaine- or
epinephrine-sensitive patients
Off-label use in United States
*Now FDA-approved.
Note: Modified from Weiss RA, Dover JS. Leg vein management: sclerotherapy, ambulatory phlebectomy, and laser surgery. In Kaminer MS, Dover JS, Arndt KA, eds.
Atlas of Cosmetic Surgery. Philadelphia: WB Saunders; 2002: 309-328.

214
III Nonsurgical Cosmetic Treatments
a 30-gauge needle or foot and ankle vessels that are notoriously
difficult to treat with sclerotherapy.
Lasers are typically reserved for the smallest telangiectasias
of the leg, but newer long-wavelength lasers can be useful for
reticular veins up to 2 mm in diameter, especially in the lateral
orbital region of the face.
Despite the fact that sclerotherapy has a long list of potential
side effects, including pain, swelling, urticaria, systemic allergic
reaction, hyperpigmentation, telangiectatic matting, skin necro-
sis, and phlebitis, it remains the treatment of choice for most leg
veins less than 4 mm in diameter.
20.4 Overview of Sclerotherapy
Treatment Regimen
The usual number of treatments is two to five per region, with
a typical interval between treatments of 4 to 8 weeks. After a
series of successful treatments, a rest period of 6 months is
preferred to observe for second-generation vessels and to allow
venous pressure to normalize. Reevaluation is done at 6 months
if new or recurrent vessels appear (Fig. 20.9).
20.4.1 Patient Education
Before treatment is initiated, the patient is asked to view a sclero-
therapy consultation video that explains the pathophysiology of
spider veins, treatment options, preoperative and postoperative
care, and the need for compression therapy, among other issues.
After the test treatment and before the next treatment session,
the patient is instructed to eat beforehand to avoid a vasovagal
response. Female patients are told not to shave their legs or use
moisturizers on the night before and the day of treatment, to
wear shorts during treatment sessions, and to bring properly
fitted medical graduated compression stockings to the visit.
:e highly recommend stocking these compression stockings in
the clinic so that accurate leg measurements and fittings occur,
since an improperly fitted stocking can produce a tourniquet
effect.
Graduated compression therapy is very important to improve
and maximize the results following sclerotherapy. External
compression collapses and decreases blood flow in the treated
veins, allowing maximal sclerosant effects on the vessel walls
and minimizing intravascular thrombosis. To achieve adequate
compression, different posttreatment regimens are utilized. In
one of the authors’ posttreatment protocols, it is recommended
that patients use class II (30–40 mm Hg) compression stockings
24 hours a day for the first 7 days and then class I (20–30 mm Hg)
stockings for at least 2 weeks while standing.
It is not uncommon for patients to present for a treatment
session and request that lasers be used in place of sclerotherapy.
Patients must be counseled that lasers are a second-line treat-
ment for spider and varicose veins. They are not as effective as
conventional sclerotherapy. Treatment with currently available
Fig. 20.9 An algorithm for treatment of lower-extremity venous disease. STS: sodium tetradecyl sulfate.

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215
lasers requires longer sessions, is generally more painful, and
poses more risk of causing harm.
20.4.2 Technique
Glycerin Sclerotherapy
Glycerin is usually supplied in 100 or 72 solutions. Because
glycerin injected at 100 is painful and too viscous to inject
through a 30-gauge needle, it is usually diluted 2:1 volume/
volume with 1 lidocaine with 1:100,000 epinephrine. It acts as
an osmotic corrosive agent, causing damage to the vessel wall
directly, and works very well on vessels 0.5 mm or smaller. To
minimize the risk of hematuria, the use of less than 10 mL of
glycerin per treatment session is recommended.
Lateral Thigh Telangiectasias
The 35-year-old woman shown in Fig. 20.10 presented with
concerns about a spider vein on her right thigh (arrow). The veins
had appeared after the birth of her first child 4 years earlier and
persisted without worsening.
A clustering of 0.5- to 0.8-mm bluish-colored telangiectasias
was evident on the right anterior thigh. These vessels were
associated with a 2-mm reticular vein, which was injected. These
associated telangiectasias were not located in the typical distribu-
tion for the GSV.
The patient underwent a test treatment with two different
sclerosants, 72 glycerin solution (compounded by the University
Compounding Pharmacy, San Diego, CA) and 0.1 STS (Mylan
Pharmaceuticals, USA), and wore compression stockings, 20 to 30
mm Hg, during waking hours for the next 2 weeks to ensure the
best results.
The patient returned for a full sclerotherapy session 4 to 5
weeks after the test treatment. The previously treated areas
were evaluated and showed good resolution of vessels, without
evidence of hyperpigmentation.
The patient was placed in the supine position on a surgical
table with a sclerotherapy tray (Fig. 20.11; Table 20.4) nearby.
After wiping with isopropyl alcohol, a disposable 30-gauge needle
connected to a 3-mL syringe filled with 1 mL of the 72 glycerin
solution was used to cannulate the vein. The needle was bent
at a 30ƒ angle to facilitate cannulation. The solution was slowly
injected into several places in the vein.
On withdrawal of the needle, immediate but transient blanch-
ing of the telangiectasias was noted (Fig. 20.12). After treatment,
mild erythema and urtication were noted along the course of the
treated vessels.
Foamed Sodium Tetradecyl Sulfate or
Polidocanol Sclerotherapy
Foamed sclerosant is an alternative to traditional liquid sclero-
sant; it offers several advantages:
• Better displacement of the venous blood to allow intimate and
prolonged contact with the vessel wall
• Ability to maintain its concentration better than liquid sclero-
sant, which is diluted by venous blood
• Ability to travel farther along the vessel than liquid sclerosant
• Doubling of potency of the sclerosing solution with dilution
4-fold
Currently, foam sclerotherapy is an off-label use. Foamed STS is
generally prepared using the Tessari technique, in which 0.5 mL
of the sclerosant in a latex-free syringe is mixed with 2 mL of air
in an empty syringe connected to the other using a Baxa RapidFill
connector (Baxter; Deerfield, IL) .
Fig. 20.10 Patient undergoing sclerosing agent injections for treat-
ment of lateral thigh spider veins (arrow).
Fig. 20.11 The components of a standard tray used for sclerotherapy,
listed in Table 20.4.
Table 20.4 Standard sclerotherapy tray contents
• Cotton balls, dry and soaked with 70% isopropyl alcohol
• Protective nonsterile gloves
• 30-gauge and 32-guage, 0.5-inch disposable plastic-hub needles
• Clearly labeled sclerosing solutions in 0.5-mL aliquots in 3-mL
disposable latex-free syringes
• Disposable latex-free syringes

216
III Nonsurgical Cosmetic Treatments
3RSOiWeDO )RVVD %uOging 5eWiFuODr VeinV
Foamed sclerosant was used to treat the patient shown in Fig.
20.13, who complained of bulging varicose veins, approximately
2.5 mm, located on the posterior leg, in the popliteal fossa.
The patient was placed in the supine position on a surgical table
with a sclerotherapy tray nearby. A disposable 30-gauge needle
connected to a 3-mL latex-free syringe was used to canalize the
vessels. After flashback was visualized, the sclerosant solution,
0.5 mL of 0.2 foamed STS (prepared using the Tessari technique),
was slowly injected into the reticular veins. On withdrawal of
the needle, the areas treated were gently massaged in a proximal
direction (Fig. 20.14).
Dorsal Hand Veins
A foamed sclerosant is also used for hand sclerotherapy in
patients who have cosmetic problems with enlarged dorsal hand
veins.
Careful consideration during the medical examination includes
any history of hand trauma, weakness, carpal tunnel syndrome,
need for frequent intravenous medications, and foreseeable need
to canalize hand veins. Consent must include the fact that the
treated vein will no longer be usable in the future for intravenous
access. During the physical examination, the brachial and ante-
cubital veins need to be identified, which can be accessible in the
event of a future need for intravenous access.
The patient is placed in the supine position, and the arm and
forearm on the side to be treated should be placed along the
bedside. A disposable 30-gauge needle connected to a 3-mL
latex-free syringe is used to canalize the vessels. The sclerosant
solution, 0.25 to 0.5 foamed STS, is commonly used for hand
sclerotherapy. Alternatively, 0.5 to 1.0 polidocanol (Asclera) can
also be used, foamed. Vein distention and mild blanching occurs
while the foam is being injected (Fig. 20.15).
The 49-year-old woman shown in Fig. 20.16 presented with
cosmetic concerns about her hands. She thought they looked old
and ´worn down.µ She inquired about any treatments that could
revitalize the appearance of her hands. She was distressed about
the dorsal hand veins, which were especially prominent and
had become more noticeable over the past 5 years. On physical
examination, a bluish superficial varicose vein of approximately 5
Fig. 20.12 Telangiectasias (arrow) will blanch immediately after
injection and withdrawal of the needle.
Fig. 20.13 Patient with varicose veins located on the posterior leg in
the popliteal fossa.
Fig. 20.14 (a) Patient in Fig. 20.13 being shown having her varicose
veins injected with 1% foamed sodium tetradecyl sulfate solution
starting proximal and moving distal every 4 to 5 cm. (b) The area is
massaged after each injection. (c) The patient after treatment.
a
b
c

 SFOerRWKerDSy Dnd /DVer Vein 7reDWmenW
217
mm was noted on the dorsal aspect of the left hand. One year later,
marked reduction of dorsal hand veins was seen on the left hand
compared with the untreated right hand (Fig. 20.17).
The patient should elevate the treated hand immediately after
injection to minimize dilution of the foam sclerosant with venous
blood and to maximize the contact of the sclerosant with the vein
walls. Compression wrapping or a gauntlet is placed on the treated
hand while the entire upper extremity is still elevated. The patient
is instructed to monitor carefully for any changes in sensation, tem-
perature, color, and decreased motion in the fingers on the treated
hand. If these symptoms occur, the patient should loosen the
compression bandage; otherwise, it should be kept on overnight.
Foamed Sodium Tetradecyl Sulfate
Sclerotherapy
%Oue 5uEEer %OeE 1eYuV SyndrRme
Blue rubber bleb nevus syndrome (BRB1S) is a rare vascular
anomaly syndrome consisting of multifocal venous malforma-
tions (VM). The malformations are most prominent in the skin,
soft tissues, and gastrointestinal (GI) tract but may occur in
any tissue. The cutaneous lesions of BRB1S are generally small,
measuring less than 1 to 2 cm, and blue to purple. They are often
very tender to the touch or external trauma and can occasionally
engorge with blood. Patients may have from several to hundreds
of cutaneous lesions. GI lesions of this syndrome are more clin-
ically relevant than the skin and soft tissue lesions. Therefore,
workup should include imaging of the GI tract. Most cases are
sporadic in nature and not hereditary.
The 58-year-old man shown in Fig. 20.18 was seen for evalu-
ation and treatment of longstanding, intermittently tender blue
nodules on the volar aspect of his left arm. He had been diagnosed
with BRB1S 20 years prior and had a negative GI exam at that
time. He had since been followed with regular colonoscopy and
imaging, with no visceral involvement. Multiple spongy 6- to
12-mm, bluish-purple papules and nodules were noted on the
flexor aspect of the left arm (Fig. 20.18a).
The patient underwent a duplex ultrasound examination of
these lesions on his left wrist, which revealed superficial, thin-
walled nodules as vascular lesions with no communication to
deeper structures. Indeed, the vascular lesions of BRB1S are con-
sistent with congenital VMs rather than proliferative tumors (Fig.
20.18b). The patient was willing to undergo foam sclerotherapy
injections to debulk and treat these lesions.
A solution of 0.5 foamed STS was slowly injected with a
30-gauge 0.5-inch needle after withdrawing slightly to visualize
blood flashback in the needle hub. A total of 2.0 mL of foamed STS,
prepared using the Tessari technique, was injected during the first
Fig. 20.15 Patient being injected to treat veins on the dorsum of the hand with 1% foamed sodium tetradecyl sulfate solution.
Fig. 20.16 Patient presenting with concerns of prominent veins on the
dorsum of her hand, which have become more noticeable over the past
5 years.
Fig. 20.17 One year post sclerotherapy, marked reduction of dorsal
hand veins is seen on the left hand of the patient in Fig. 20.16
compared with the untreated right hand.

218
III 1RnVurgiFDO &RVmeWiF 7reDWmenWV
visit. Immediate blanching and slight spasm of the lesions were
noted after treatment. The patient had no complaints of pain at
the conclusion of the treatment (Fig. 20.19a).
At the follow-up visit 4 weeks later, the patient noted a decrease
in the lesion size and was treated again, resulting in the improve-
ment shown (Fig. 20.19b).
In the immediate postoperative period, the patient’s arm was
elevated. A compression dressing was placed on the area and
secured with Coban wrap (3M, St. Paul, M1). The patient was told
to remove this dressing the following day. 1o further care was
needed.
Long-Pulse Laser Therapy
Long-pulse neodymium:yttrium aluminum garnet (1d:1,064-nm lasers have been developed in an eff ort to target deep,
relatively large-caliber cutaneous vessels. The primary benefi t of
this wavelength is its capacity for relatively deep penetration to
approximately 0.75 mm in human skin, allowing targeting of ves-
sels in the mid-dermis. The wavelength is well absorbed by water
and hemoglobin but not by melanin, thus allowing treatment
even in deeply pigmented individuals. However, high energies
must be used for adequate penetration in these individuals. Only
with suffi cient fl uence and facilitation of heat dissipation can the
posterior wall of a larger-diameter (1- to 2-mm) vessel fi lled with
deoxygenated hemoglobin be reached and heated.
The newer pulsed 1,064-nm lasers have pulse durations
between 1 and 200 msec and are capable of more than 350 -/cm2
at small spot sizes. In general, treatment with long-pulse 1,064-
nm laser light is relatively painful and requires cooling and topical
anesthesia. Large-caliber vessels, greater than 0.5 mm in diameter,
respond best. Vessels up to 3 mm can be treated with long-pulse
1d:be addressed by treating these larger vessels, although the pain
experienced by patients signifi cantly increases beyond a 2-mm
vessel. Recent data suggest that with use of smaller spots and even
higher fl uences, even small vessels respond (Fig. 20.20).
It is likely that the 1,064-nm laser achieves its vasodestructive
eff ects by penetrating deeply enough to cause complete, circum-
ferential thermal damage to the vessel wall. For patient comfort
and epidermal sparing, some type of cooling must be employed,
Fig. 20.18 (a) Patient presents with long-standing blue-colored nodules on the fl exor aspect of the left arm. (b) Duplex ultrasound showing a venous
malformation with incompetent, refl uxing perforator communicating between the radial vein and the more superfi cial cephalic vein.
a
b
Fig. 20.19 (a) The nodules of the patient in Fig. 20.18 were injected with foamed sodium tetradecyl sulfate (STS). (b) Postprocedure photos show
improvement after STS injections 4 weeks later.
a
b

 SFOerRWKerDSy Dnd /DVer Vein 7reDWmenW
219
whether in the form of contact cooling, cryogen cooling, or ice-
cold gel.
Anterior Thigh Telangiectasias
This 41-year-old woman in Fig. 20.21 presented with a 5-year
history of anterior right thigh telangiectatic vessels. She had long
wished to be rid of the unsightly, asymptomatic veins but had
an overriding fear of needles, which prevented her from seeking
treatment.
She agreed to undergo a series of test pulses with the long-
pulsed 1d::ayland, MA; Fig. 20.22) to a small segment of the veins. She
underwent a duplex examination of the right GSV and right
saphenofemoral junction, which revealed no abnormalities.
Duplex examination did reveal enlarged anterosuperior branches
of the lateral subdermic venous system. The patient was unwilling
to undergo duplex-guided sclerotherapy for the reflux and instead
opted for 1,064-nm laser treatment of her spider veins. She was
informed that the results of this treatment would likely not be
permanent.
A grouping of telangiectasias on the patient’s thigh were
selected and treated at a constant fluence of 120 -/cm2 with a spot
size of 2.5 mm and varying pulse durations from 10 to 40 msec.
Ice-cold gel was applied to the skin before laser treatment. A pulse
duration of 30 msec produced the best immediate contraction, as
illustrated by hand-held digital microscopy (Fig. 20.23).
Postoperatively the patient requires minimal care. He or she
should be made aware of the potential for posttreatment hyper-
pigmentation, which results from the hemosiderin degradation
Fig. 20.20 The long-pulse 1,064-nm lasers penetrate more deeply and
cause circumferential thermal damage to the vessel wall.
Fig. 20.21 Patient presenting with telangiectatic vessels on the
anterior right thigh.
Fig. 20.22 Candela Vbeam Prima dual wavelength 595 nm pulsed
dye and long-pulsed neodymium:yttrium aluminum garnet (Nd:YAG)
1,064-nm laser.

220
III Nonsurgical Cosmetic Treatments
products of blood trapped in the vessel during and after treat-
ment. The larger the treated vessel, the more likely the chance that
hyperpigmentation will occur. Most hyperpigmentation resolves
spontaneously within 3 to 6 months.
20.5 Concluding Thoughts
Sclerotherapy is a safe, effective treatment for leg and hand
varicosities. The surgeon must recognize various patterns of var-
icose veins, thoroughly understand the pertinent anatomy, and
be familiar with sclerosants, injection techniques, and the use of
compression therapy; these are the keys to successful treatment.
Underlying superficial or deep venous insufficiency requires
management before one attempts to treat clinically apparent
reticular or spider veins, to avoid failure of the sclerotherapy and
potential complications.
Clinical Caveats
• Sclerotherapy:
̑ Be aware of your body position; avoid neck and back strain.
̑ Avoid halogen surgical lighting—indirect lighting is best.
̑ Use magnification (1.5–33).
̑ For smaller matting, use double-polarized light.
̑ Apply alcohol to decrease white scale reflection.
̑ Stretch the skin taut for easier cannulation.
̑ Bend the needle 30°.
̑ Obtain 30-gauge disposable needles with a plastic hub;
the needle should be changed frequently if it dulls.
̑ Do not attempt to withdraw blood into the hub with
vessels less than 0.55 mm in diameter; intravascular place-
ment cannot be confirmed except by the smooth flow of
solution.
̑ Before solution is injected, producing a tiny air bubble
(approximately the volume in the hub) may be helpful to
clear the existing blood.
̑ Inject very slowly, with little pressure, 0.1 to 0.3 mL at each
site.
̑ Advise the patient to wear graduated compression hose,
30 to 40 mm Hg, 24 hrs a day for 7 days, then 20 to 30 mm
Hg while standing for the 2 weeks after treatment.
• Foam sclerotherapy:
̑ Be aware of the anatomy and orientation of each individual
patient.
̑ Use latex-free syringes when using STS.
̑ Produce a small bolus of air or foam preceding injection of
the sclerosant when possible.
̑ Visualize the initial injection of foam or sclerosant.
̑ Stop if distention or bulging around the vein occurs.
̑ Stop if the patient complains of discomfort at the first
moment of injection.
̑ Note immediate vessel contraction as a treatment
endpoint.
• Duplex-guided sclerotherapy:
̑ Try to identify reticular veins, which may be difficult to
appreciate clinically but feed smaller vessels; if they are
identified, treat those first.
̑ Draw venous blood (low pressure and darker) freely back
into the syringe before injection.
̑ Visualize the initial injection of several drops of foam or
sclerosant.
Fig. 20.23 (a) Pretreatment hand-held digital microscopic view of
telangiectasias. (b) Response of telangiectasias treated at a constant
fluence and spot size with varying pulse durations from 10 to 40 msec.
The 30-msec pulse duration produced the best immediate contraction.
a
b

 SFOerRWKerDSy Dnd /DVer Vein 7reDWmenW
221
̑ Stop if distention around the vein is seen on ultrasound.
̑ Stop if the patient complains of discomfort at the first
moment of injection.
̑ The proper endpoint is total contraction.
̑ Foam resting in the vein is often seen on duplex imaging.
• Long-pulse laser therapy:
̑ Use 1,064-nm laser for treatment of leg telangiectasias.
̑ Always check that safety glasses are in use by all.
̑ Target only superficial reticular and telangiectatic vessels.
̑ Use long-pulse laser therapy for vessels larger than 0.5 mm.
̑ If the vessel is 0.5 mm or larger, start with a modest flu-
ence of 60 to 80 J/cm2 at a pulse duration of 30 msec (given
a 2.5-cm spot size) and gradually increase the fluence.
̑ If the vessel is 0.5 mm or smaller, start with a pulse dura-
tion of 15 to 16 msec.
̑ Have ice-cold gel on hand to decrease the sensation of
pain and avoid epidermal injury.
̑ Strongly avoid double-pulsing or pulse-stacking the laser
at these settings; vessels can be re-treated after several
minutes if the settings need to be modified.
̑ After successful treatment, note the vessel contraction,
perivessel erythema, and edema.
Suggested Reading
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of the legs. Its surgical treatment by the chiseling tube method. Vasc Surg
1969;3(2):81–89
>2@ Bergan --, :eiss RA, Goldman MP. Extensive tissue necrosis follow-
ing high-concentration sclerotherapy for varicose veins. Dermatol Surg
2000;26(6):535–541, discussion 541–542
>3@ Bowes LE, Goldman MP. Sclerotherapy of reticular and telangiectatic veins of the
face, hands, and chest. Dermatol Surg 2002;28(1):46–51
>4@ :right AD, .inmonth -B, et al. Discussion on primary treatment of varicose
veins. Proc R Soc Med 1948;41(9):631–639
>5@ Cabrera -, Cabrera - -r, Garcia-Olmedo MA, Redondo P. Treatment of ve-
nous malformations with sclerosant in microfoam form. Arch Dermatol
2003;139(11):1409–1416
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222
III Nonsurgical Cosmetic Treatments
21 Nonsurgical Treatment of the Face and Neck
Michael P. Ogilvie and Julius W. Few Jr.
Abstract
Facial plastic surgery has undergone tremendous change as the
paradigm for facial rejuvenation has shifted away from invasive,
surgical techniques. Facial rejuvenation has been revolutionized
by the rapid innovation of noninvasive or minimally invasive
procedures, which has been fueled by patients’ desires for
near-surgical results without significant risk and minimal recov-
ery time.
Facial aging is defined by decreased skin quality, predictable
volume loss, and skin ptosis. In addition to the signs of facial
aging, one issue that concerns many facial rejuvenation patients
is excess fat. This chapter discusses several noninvasive or min-
imally invasive techniques, used either alone or in combination,
aimed at alleviating the telltale signs of aging and reducing excess
fat, helping provide near-surgical facial rejuvenation results. In
particular, we discuss deoxycholic acid (.ybella, Allergen, Irvine,
CA) injections as well as cryolipolysis (CoolSculpting, =eltiq
Aesthetics, Pleasanton, CA) directed at volume reduction. The
use of energy-based modalities such as microfocused ultrasound
(Ultherapy, Ulthera, Mesa, A=) or radiofrequency devices (Pellevp,
Cynosure, :estford, MA; Venus Freeze/Legacy, Venus Concept,
:eston, FL; and ThermiRF, ThermiGen, South Lake, TX) as well
as the latest technology in thread lifting (Silhouette InstaLift,
Sinclair Pharma, Irvine, CA) to improve skin ptosis are discussed.
Last, we discuss laser therapy (Halo Hybrid Fractional Laser,
Sciton, Palo Alto, CA) for facial skin resurfacing and describe our
techniques to combine these modalities to achieve near-surgical
results.
Keywords
facial rejuvenation, nonsurgical techniques, fat reduction,
microfocused ultrasound, radiofrequency, thread lifting, laser
resurfacing, stackable therapies
21.1 Introduction
Surgical rejuvenation of the face has been the gold standard of
therapy for many years, but with noninvasive and minimally
invasive cosmetic medicine applications undergoing rapid
innovation and development, current procedures have already
revolutionized the treatment paradigm for facial rejuvenation
and may be some of the most significant changes in the recent
history of facial plastic surgery.
As patients have become younger, busier, and less tolerant of
surgical complications or longer recovery times, nonsurgical or
minimally invasive procedures have been on the rise. Data from
the American Society for Aesthetic and Plastic Surgery (ASAPS)
collected yearly since 1997 have shown the rapid rise of non-
surgical options (Table 21.1). These therapies may be used as an
adjunct to surgery, or, as introduced in 2012 with the concept of
stackable therapies or using multiple nonsurgical therapies in a
single setting, near-surgical results may often be obtained.
1onsurgical or minimally invasive procedures typically follow
the same core principles of surgical facial rejuvenation, namely
to replenish lost volume, remove excess, and lift and/or tighten
where indicated, which are often directed at the key elements of
aging. Facial aging is the result of several physiologic processes,
including decreased skin quality from photodamage, fat atrophy
and subsequent loss of facial volume, and loss of elasticity result-
ing in ptotic skin.
In this chapter, we discuss specific nonsurgical modalities
focused on fat reduction, namely lipolytic therapy with deoxycho-
lic acid injections, submental cryolipolysis, as well as nonsurgical
devices or techniques to improve ptotic skin, namely energy-based
therapies such as microfocused ultrasound and radiofrequency
(RF) as well as the minimally invasive technique of thread lifting.
:e briefly discuss the lasers we use in our practice to improve
skin quality; however, nonsurgical therapies for volume replace-
ment (e.g., dermal fillers) and for skin quality improvement (e.g.,
lasers and other devices in plastic surgery) are covered in more
detail in other chapters.
21.2 Volume Reduction
1onsurgical removal of unwanted fat, namely submental fat, is
a common theme among cosmetic facial rejuvenation patients.
Previously, submental liposuction was the only tool available in the
Table 21.1 American Society for Aesthetic and Plastic Surgery top ten
procedures for 2015
5DnN
Nonsurgical procedure
1umEer RI
procedures
Percent increase
 YV 
1
Botulinum toxin injection
4,267,038
18.9
2
Hyaluronic acid filler
injection
2,148,326
26.6
3
Hair removal (laser or
pulsed light)
1,136,834
37.2
4
Chemical peel
603,305
24.6
5
Microdermabrasion
557,690
33.7
6
Photorejuvenation
(intense pulsed light)
483.792
30.3
7
Nonsurgical skin
tightening
471,759
58.2
8
Full-field ablative laser
skin resurfacing
326,120
−20.2
9
Sclerotherapy
322,170
2.0
10
Nonsurgical fat reduction
160,763
18.7
Data from American Society for Aesthetic Plastic Surgery. 2015 Cosmetic Surgery
National Data Bank Statistics.
Stats2015.pdf. Accessed October 9, 2019.