Atlas Phẫu Thuật Thẩm Mỹ (Tập 2) – Atlas of Cosmetic Surgery

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Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
Subcision
Preoperative considerations
Subcision is a form of minimally invasive surgery for depressed
rolling scars. Scars most responsive to this technique are those
scars that improve when the skin is stretched at the time of
examination. It is believed that subcision has two mechanisms
of action: (1) the surgical release of fibrotic bands results in
scar elevation, and (2) the controlled trauma promotes new
connective tissue formation under the defect, further elevating
the scarred areas.
Techniques
The rolling scars to be treated are marked with the patient in
the upright or sitting position. Anesthesia is obtained with in­
jectable 1% lidocaine with 1:100  000 epinephrine and 15–30
minutes are allowed to elapse for maximum ­vasoconstriction.
A
B
Fig. 23-6  Woman with boxcar acne scarring
on cheeks. (A) Preoperative appearance.
(B) At 6 months after punch excisions followed
by carbon dioxide full-face resurfacing.
A
B
Fig. 23-7  Woman with severe box­
car scarring on face. (A) Preoperative
­appearance. (B) At 1 year after treatment
with punch and linear excisions, followed
by erbium and carbon dioxide full-face
resurfacing.

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The patient is prepped and draped in the usual sterile
fashion.
A sterile NoKor (Becton Dickinson, Franklin Lakes, NJ)
hypodermic 18-gauge needle is inserted through a needle
puncture into the skin. The needle is inserted at an acute
angle, with the blade oriented parallel to the skin surface.
The free, nondominant hand is used to stretch and stabilize
the treatment site. Various maneuvers are used to release
the subcutaneous fibrotic strands (Fig. 23-8). Lancing is a
technique involving a linear inserting-withdrawing needle
motion similar to piston-like liposuction cannula move­
ment to subcise very fibrotic scars. Fanning involves needle
movement, in side-to-side and back-and-forth motions,
while withdrawing the needle in a fanlike motion, similar
to cutting the bands. A combination of these techniques
may be applied, approaching the scar via multiple punc­
ture sites to maximize release of the fibrotic strands. During
treatment of bound-down scars, the needle is inserted into
the superficial subcutaneous plane and, in some cases, the
deep dermis. The final result should be a scar that appears
smooth and is elevated from its preoperative bound-down ­
appearance (Fig. 23-9).
Postoperative considerations
Firm, direct pressure is applied to the treated sites for sev­
eral minutes after the procedure to obtain hemostasis. The
patient is instructed to wash the treatment sites twice daily
with soap and water, followed by antibiotic ointment until the
needle entrance sites are healed. Camouflage makeup may be
applied to cover the bruised areas. Side effects include local­
ized bruising, hypertrophic scarring, discoloration, and scar
­recurrence. If hypertrophic scarring is noted during healing,
the affected sites may be treated with monthly injections of
intralesional triamcinolone acetonide, 3.3–10  mg/mL until
flattening ­occurs.
Dermabrasion
Dermabrasion has been available for many years as an ­effective
treatment for acne and post-traumatic scarring but is highly
technique dependent. Dermabrasion acts to ­ mechanically
eliminate the sharp edges of acne scars as well as reduce the
A
B
C
Fig. 23-8  Young man with rolling scars on cheek. (A) Areas to be subcised marked with ‘X.’ (B) Correct placement of NoKor needle with blade
oriented to skin surface. (C) Tenting with fanning to release fibrotic bands.
• Scars that respond best to subcision are those
that improve with gentle stretching of the skin.
• A combination of both the lancing and the fanning
techniques may work better than either alone.
Pearls
• Scars that appear to have responded to
­subcision may contract down again in time.
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Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
crateriform appearance of these scars. With wound healing,
collagen synthesis further smoothes the treated areas via der­
mal thickening and contracture. Therefore, dermabrasion is
most effective in the treatment of rolling scars and very super­
ficial boxcar scars. Deeper boxcar scars may be substantially
improved utilizing this treatment.
Preoperative considerations
A prophylactic antiviral medication is initiated 2 days before
the procedure, and a prophylactic antibiotic medication is
­initiated 1 day before the procedure.
Techniques
Patients generally require sedation and local anesthesia. Most
procedures can be accomplished with low doses of preopera­
tive meperidine (25–50  mg i.m.), hydroxyzine (25  mg i.m.),
and diazepam (5–10  mg p.o.). Facial anesthesia is achieved
with local anesthesia using 1% lidocaine with or without
epinephrine (1:100  000) or regional nerve blocks. Skin turgor
is achieved via the use of tumescent anesthesia or spray re­
frigerants. The operating room staff must be protected from
airborne and aerosolized particles during the procedure. Ap­
propriate protective measures include gloves, gowns, masks,
and protective eyewear.
The area is sterilely prepped and draped. Great care is
taken to avoid free gauze, hair, and towels within the surgical
field in order to avoid interaction of these materials with the
treatment device. Vaseline and gauze pads are used to protect
the patient’s eyes, ears, and nose. The treatment areas are out­
lined with gentian violet or surgical ink.
Dermabraders are hand engines with an attached diamond
fraise that may vary from fine to coarse. Treatment is performed
by spraying and abrading one area at a time, moving from the
outermost and dependent areas toward the central and upper
areas of the face. The skin is placed under gentle, spreading
tension between the thumb and index finger of the nonoperat­
ing hand. The plane of the rotating head is held parallel to
the skin’s surface while light, brushing strokes are performed.
The handpiece is kept in motion at all times in order to avoid
heat conduction to the underlying tissue and to produce a more
uniform wound depth. At the periphery of the field the pres­
sure and number of strokes are decreased to produce a gradual
feathering between treated and nontreated areas. The derma­
brasion is usually carried to the end of natural folds of the face
(i.e. nasolabial fold, hairline, and under the jawline) to avoid vis­
ible demarcation lines that can occur with spot dermabrasion.
Recognition and control of the proper depth of wounding
are the most important concepts of dermabrasion. Derma­
brasion is normally performed to the level of the papillary
(sebaceous glands visible) or superficial reticular (white col­
lagen visible) dermis. Generally, two cycles of spraying and
abrading are necessary to achieve the desired effect. Under­
treatment may result in persistent lines and overtreatment
may result in permanent scarring. Chemical exfoliation with
30–50% trichloroacetic acid may be applied to adjacent una­
braded areas (i.e. lower eyelids and upper lip) for additional
blending. Care must be taken when combining the two proce­
dures to prevent pigmentary alterations.
Postoperative considerations
Application of compresses saturated with 1% lidocaine with
epinephrine (1:100  000) are applied to the treated areas to assist
in vasoconstriction and control bleeding. An occlusive ointment
such as Aquaphor is then applied to the face and a biologic
dressing such as Vigilon (Bard Home Health Div­ision, C.R.
Bard, Murray Hill, NJ) placed directly on the abraded sites, fol­
lowed by a Telfa dressing (Kendall Hospital Products, Boston,
MA), sterile gauze pads, and wrap. The dressing is changed at
24-hour intervals. After 2–4 days the dressings are discontinued
and an antibiotic ointment is applied to prevent crusting. Mild
soap can be introduced 5 or 6 days postoperatively. Gentle
soaking and antibiotic ointment application is performed until
reepithelialization occurs, generally within 5–7 days. Postpro­
cedure erythema may persist for 2–3 months Box 23-4).
B
A
Fig. 23-9  Woman with depressed scar on lower chin. (A) Preoperative appearance. (B) At 1 year after subcision.

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Dermasanding
Preoperative considerations
Dermasanding is a form of manual dermabrasion typically
applied to localized areas or scars. It is safer, without aero­
solized particles or blood splatter, and typically easier to per­
form than true dermabrasion.47
Techniques
Treatment areas are anesthetized with injectable 1% lidocaine
with 1:100  000 epinephrine and 15–20 minutes are allowed to
elapse for vasoconstriction. The patient is prepped and draped
in the usual sterile fashion. Sterile strips of waterproof silicone
carbide sandpaper are wrapped around the surgeon’s finger
or the barrel of a 3  cc syringe and used to gently abrade the
scar. Coarser, 200 grit sandpaper is used first until pinpoint
bleeding is achieved, followed by 400 grit paper for smooth­
ing/finishing. As with dermabrasion, hemostasis is achieved
via topical application of 1% lidocaine with epinephrine and
pressure.
Postoperative considerations
An occlusive ointment such as Aquaphor and a pressure
dressing are applied for at least 24 hours postoperatively.
Thereafter, the patient begins daily dressing changes for
1–2 weeks. Postoperative hyperpigmentation may be
managed with the use of topical hydroquinone.
Laser surgery
Carbon dioxide laser
The use of high-energy, short-pulsed, or scanned carbon di­
oxide 10  600  nm lasers in the treatment of acne scarring has
proven successful in improving or eliminating mild to moder­
ately severe, superficial rolling or boxcar acne scars and very
superficial ice pick scars. Ice pick and deep scarring have dem­
onstrated poor responses to laser resurfacing and may worsen
with treatment. Scar improvement is achieved by precise, con­
trolled, layer-by-layer tissue vaporization with minimal ther­
mal damage to the underlying normal skin. In general, laser
resurfacing of the entire face is recommended in the manage­
ment of acne scarring to ensure even coloration and texture.
Preoperative considerations  Patients are given prophy­
lactic antiviral medications (500  mg valacyclovir p.o. b.i.d. or
400  mg acyclovir t.i.d.) initiated 2 days prior to the procedure
and continued for 10–14 days until complete reepithelializa­
tion has occurred. Antibiotics (500  mg cephalexin p.o. b.i.d.)
are administered 1 day prior to the procedure and are con­
tinued for 7–10 days postoperatively. The patient is made
aware that approximately 1–2 weeks at home will be needed
for recovery. A facial scrub should be performed prior to the
procedure. Avoidance of all flammable materials, including
alcohol swabs, is vital. Hair-bearing areas are covered with
wet towels and a nonflammable lubricant. Nonreflective eye
shields or protective eye goggles are worn throughout the pro­
cedure to prevent eye injury.
Techniques  For full-face resurfacing, a combination of topi­
cal, local, regional nerve blocks, and intravenous (i.v.) anesthe­
sia can be employed to achieve an adequate level of comfort
during the procedure. For resurfacing of localized areas, local
anesthesia is administered intralesionally or via a nerve block.
Typically, i.v. anesthesia is achieved with propofol, fentanyl,
midazolam, or ketamine. Appropriate monitoring equipment,
including a blood pressure monitor, electrocardiogram, and
oxygen saturation monitor are required. An emergency cart
should be present and kept up to date. Tumescent anesthesia
may be utilized. If so, treatment areas should be highlighted
with a marker prior to infiltration, as subtle variations in skin
topography may be obscured.
• Freeze and abrade only one area at a time,
moving from the outermost and dependent
areas to the central and superior areas.
• Keep the handpiece moving at a constant rate
to produce a more uniform wound depth.
• Use gauze soaked with lidocaine containing
epinephrine to aide in hemostasis.
PEARLS
• Pigmentary alteration (hyperpigmentation
or hypopigmentation)
• Hypertrophic scar or keloid
• Infection (bacterial, fungal, or viral)
• Persistent erythema
• Demarcation lines or patches
• Milia development
• Acne flare
• Ectropion formation
• Scar recurrence
• Incomplete removal
• Treatment failure
Box 23-4  Side effects of dermabrasion
• Dermabrasion is highly technique dependent.
• Prophylactic antibiotics and antivirals must be
given prior to the procedure and continued for
10–14 days afterwards to minimize the risk of
infection.
• Significant protective wear must be used by all
those in the operating room to minimize risk of
infection from airborne and aerosolized particles.
• If combining dermabrasion with chemical peel­
ing, perform the chemical peel first so as not to
accidentally apply a chemical peel to an already
dermabraded area and create a wound that is
much deeper than intended.
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Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
When using the UltraPulse laser system (Lumenis, Santa
Clara, CA), the 3  mm collimated handpiece is used at ener­
gies of 350–500  mJ, with a power of 3–7 watts. One to three
passes are performed over the cosmetic unit or full face with­
out overlapping treatment spots. The treated skin is gently
wiped with saline-soaked gauze between laser passes. After
the first laser pass, the scars will become more evident as
white, slightly depressed scars. Once the face or cosmetic unit
has been treated, further laser passes can be made around
the scar edges first, then across the scar to even the texture.
Care must be taken to avoid overtreatment of the scar, as
this may result in a more visible scar once healed. The CPG
handpiece may also be used at an energy of 300  mJ, power
of 60 watts, a density of 4–6, and a size setting of 6–8  mm.
Generally one or two passes are first made with the CPG,
and the fine tracing is performed with the 3  mm collimated
handpiece.
When using the SilkTouch laser (Sharplan/Lumenis, Santa
Clara, CA), a power of 5–7 watts is employed with a 0.2  s
pulse duration for spot sizes 2–4  mm and a power of 15 watts
with a 0.2  s duration for the 6  mm spot size. Treatment is per­
formed as for the UltraPulse laser. Other carbon dioxide la­
sers available include the NovaPulse (Luxar, Bothell, WA) and
TruPulse (Tissue Technologies, Albuquerque, NM).
The erbium:YAG laser is often employed as additional
treatment before or following carbon dioxide resurfacing (see
the following discussion).
Postoperative considerations  Immediate postoperative
care includes the continuous use of ice packs or cool com­
presses every 1–2 hours. This is followed by the application
of Aquaphor ointment (Biersdorf, Wilton, CT) or similar
emollient that provides hydration. The authors recommend
the postoperative application of a bio-occlusive dressing
such as Silon TSR (BioMed Sciences, Bethlehem, PA) over
the treatment sites for the first 24–72 hours, as this results
in more rapid reepithelialization and decreased patient dis­
comfort.48 Once the dressing is removed, soaks are initiated
every 1–2 hours until reepithelialization is noted. Postopera­
tive pain control is achieved by administration of oral anal­
gesics and nighttime sedatives. Close follow-up is required for
the first few weeks postoperatively to ensure that the patient
is able to care for the treated areas properly and that the
desired healing is evident. Common side effects are listed in
Box 23-5. Camouflage makeup may be used after the crust­
ing and oozing have subsided. Optimal results are generally
observed 6–12 months after full-face resurfacing.
Erbium:YAG laser
Preoperative considerations  The pulsed erbium:YAG (Er:
YAG) laser is employed singly or in combination with carbon
dioxide laser resurfacing in the treatment of depressed scars.
A study using the Er:YAG laser alone to treat pitted acne scars
and pox scars revealed an average of 50% improvement of
acne scars and 55% improvement of pox scars.49
Laser treatment utilizing sequential carbon dioxide la­
ser and Er:YAG laser treatments has been performed for
additive scar improvement with minimal surrounding skin
damage. Advantages of combination treatment include the
ability to remodel collagen followed by precise ablation of tis­
sue, leading to a reduction in thermal damage to the surround­
ing skin. This leads to decreased healing times and a reduction
in postoperative side effects. Preoperative measures are the
same whether single or combination ablative lasers are used.
Techniques  Most Er:YAG lasers generate repetition rates
from 1 to 10 pulses per second and spot sizes of 3–7 mm.
Treatment is performed by overlapping pulses by approxi­
mately 10% across the treatment area. Approximately 4  μm
of tissue is affected for each joule per square centimeter of
energy. Settings are adjusted according to the depth of tissue
one desires to ablate with each pass. A setting of 5  J/cm2
will ablate the epidermis in four passes. Care must be taken
to limit the extent of tissue ablation for the best treatment
control. In general, a range of two to six passes of the Er:
YAG laser may be necessary to achieve scar effacement. If
scarring is limited, spot laser ­resurfacing may be employed.
The area around and over the scar is resurfaced first, fol­
lowed by resurfacing of the scar edges until it is completely
effaced. If scarring is extensive, the entire face should be re­
surfaced to obtain more consistent color and textural change.
Frequently the Er:YAG laser will be utilized immediately fol­
lowing carbon dioxide laser resurfacing to remove the zone
of thermal necrosis left by the carbon dioxide laser as well
as to produce additional contouring. In these cases, much
more conservative settings and a smaller number of passes
should be performed in order to limit the risk of scarring and
­depigmentation.
Postoperative considerations  Postoperative care measures
are similar to those described for carbon dioxide laser resur­
facing. Reepithelialization generally occurs over 3–10 days.
• Persistent erythema (temporary erythema lasting
2–4 months is expected)
• Hypertrophic scarring (rare)
• Infection (bacterial, viral, fungal)
• Pigmentary alteration (hyperpigmentation or
hypopigmentation)
• Demarcation lines or patches
• Milia development
• Acne flare
• Ectropion formation
• Scar recurrence
• Incomplete removal
• Treatment failure
Box 23-5  Side effects of carbon dioxide laser ­resurfacing

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Plasma skin resurfacing
In contrast to the above lasers, plasma resurfacing utilizes
radiofrequency pulses into nitrogen gas to create plasma
(the fourth state of matter) that induces a thermally medi­
ated tissue ablation. Plasma resurfacing can be adjusted to
induce injury at a variety of depths and therefore may be
performed as a single high-energy treatment with significant
downtime (comparable to an Er:YAG laser treatment) or
with multiple low-energy treatments that have minimal to
no downtime. A recent study demonstrated a 35% reduc­
tion in depth of acne scarring after plasma skin resurfacing
without any pigmentary alteration.50 With further study, this
new technique may hold significant promise for the treat­
ment of atrophic scars.
Fractional resurfacing
The 1550  nm erbium-fiber fractional laser (Fraxel, Reliant
Technologies, Palo Alto, CA) and the fractionated handpiece
of the Star Lux (Palomar, Burlington, MA) target water as its
chromophore. It differs from the above ablative lasers in that
fractional treatment areas, or microthermal zones of tissue
coagulation, are produced without tissue vaporization. The
stratum corneum remains intact, minimizing downtime. His­
tologically, neocollagenesis and collagen remodeling result.51 A
recent study published by Alster et al. showed an average clini­
cal improvement of 51–75% in nearly 90% of patients with
atrophic scars after 3 monthly fractional laser treatments.52
Preoperative considerations  Topical anesthetics such as
LMX-5 (Ferndale Laboraties, Inc, Ferndale, Michigan), EMLA
(AstraZeneca, Wilmington, DE), or other lidocaine/tetracaine
formulations, such as 7% lidocaine/7% tetracaine (S-Caine,
ZARS Pharma, Salt Lake City, UT) should be applied for 30–
60 minutes prior to procedure.
Techniques  For atrophic scars, high energies should be used.
Forced air cooling (Zimmer Cryo 5, Simmer Medizin Systems,
Irvine, CA) during treatment can increase patient comfort.
Treatments may be spaced 2–4 weeks apart and at least five
treatments are necessary.
Postoperative considerations  Sunscreen application is
mandatory after treatment. Most patients experience ery­
thema for 2–7 days. Some patients experience desquamation,
scale, or crust following aggressive treatments as well as ede­
ma. Edema can be minimized by cold pack or ice application
at intervals for the first 24 hours after treatment.
Nonablative lasers
Preoperative considerations  Nonablative laser therapy
causes spatially selective thermal injury of the dermis (100–
400  μm in depth) without significant injury to the epidermis
and results in gradual and subtle improvement in skin texture
with minimal to no downtime. Multiple lasers can be used
nonablatively for atrophic scarring, such as the 585  nm and
595  nm pulsed dye lasers, the 532  nm KTP laser, and the
infrared lasers: 1064  nm Q-switched Nd:YAG, 1320  nm Nd:
YAG, 1540  nm Er:glass, and the 1450  nm diode laser. The
infrared lasers all target water and, by cooling the epidermis
during treatment with a cryogen spray, create a thermal injury
to the dermis. The injury heals like other wounds by going
through inflammation, proliferation, and remodeling phases.
The release of heat shock proteins at the point of injury starts
the whole cascade of events that lead to angiogenesis, fibroblast
migration, and the deposition of granulation tissue and then
collagen. Overall, mild to moderate improvement in atrophic
scars (40–45%) with the use of nonablative lasers has been
reported in the literature.52 Topical anesthetic may be applied
for 30–60 minutes to treatment areas prior to the procedure.
Techniques  The Nd:YAG 1320  nm (CoolTouch Corp.,
Auburn, CA) is used at fluences of 13–18  J/cm2 with two to
three passes. Treatments are typically monthly with a total
of four to six treatments. The diode 1450  nm laser (Smooth­
Beam, Candela Corp., Wayland, MA) is used at a fluence
of 9–14  J/cm2 for a single pass. Similarly, treatments are
monthly for four to six treatments.
Postoperative considerations  Patients may experience
erythema for up to 24 hours after treatment. Sun avoid­
ance should be recommended. New collagen formation may
be detected 6 months after treatment. Rare complications
include blistering, crusting, or hyperpigmentation. In case of
blister or crust formation, a bland ointment should be applied
and treatment postponed until reepithelialization occurs.
• Treatment areas should be marked with the
patient in an upright position and before
infiltration of the local anesthetic.
• Scar edges/shoulders should be treated with an
additional pass using a small spot size to help
soften the transition into the scar.
• Combining CO2 and Er:YAG lasers may reduce
residual thermal damage and shorten the
healing phase that patients must endure.
• Plasma resurfacing may be performed at a
­variety of settings which correspond to the
depth of thermal injury.
• Nonablative lasers improve scars with minimal to
no downtime.
Pearls
• Prophylactic antibiotics and antivirals must be
given prior to the procedure and continued for
10–14 days afterwards to minimize the risk of
infection.
• Strict sun avoidance must be exercised by any
patient undergoing treatment with a resurfacing
laser.
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Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
Autologous fat transplantation
Preoperative considerations
Autologous fat transplantation has proven successful in the
treatment of rolling acne scars and trauma-induced lipoatro­
phy; however, an average of 50% of transplanted fat may be
resorbed after 1 year. Ice pick acne scars and deep boxcar scars
do not respond to this treatment. Optimal donor sites for ob­
taining adipose tissue are the thighs, abdomen, and ­buttocks.
Techniques
The patient is given an anxiolytic sedative (e.g. diazepam, lo­
razepam) approximately 15 minutes before the procedure. The
selected donor site is sterilely prepped and draped. Cannula
insertion sites are selected and anesthetized with a small bolus
of 0.1% tumescent lidocaine anesthesia. Small incisions only
large enough to allow introduction of an infusion cannula
are made with a No. 11 blade at these sites. Tumescent 0.1%
anesthesia is introduced to the donor site subcutaneously via
a blunt sprinkler tip infusion cannula attached to a 20–60  cc
syringe. Anesthesia is allowed to sit for 30–45 minutes to ob­
tain maximum anesthesia and hemostatic effect. The fat is re­
moved using a 12-gauge Klein cannula attached to 10, 20, 30,
or 60  cc Luer-Lok syringes (Becton-Dickinson, Franklin Lakes,
NJ). The cannula is introduced subcutaneously, and once it is in
place, the syringe plunger is pulled back to create negative pres­
sure. The cannula is then moved in a piston-like motion, with
the cannula parallel to the skin. The filled syringes are capped
and placed standing in an upright position for 10 minutes to
allow for separation of the infranate from the intact adipocytes
by gravitational pooling. The infranate is discarded to leave
blood-free, yellow adipose tissue. If significant blood remains,
normal saline solution may be added to the adipocytes, mixed,
and allow to settle. The infranate can again be discarded. The
adipocytes are transferred to 3  cc syringes using a female-to-
female adapter.
A variation of this technique, lipocytic dermal augmen­
tation, involves mechanical disruption of harvested adipose
tissue. The harvested fat is allowed to stand for 5 minutes, al­
lowing for separation of the fat from the infranate. The fluid
infranate is decanted and the remaining fat is centrifuged at
1000  rpm for 1 minute. After centrifugation, the remaining
infranate is discarded and the fat transferred into 3  cc syringes
via a bi-Luer-Lok adapter. The fat is manipulated back and
forth through two 3  cc syringes in a sterile fashion to disrupt
the adipocytes and connective tissue septa. One milliliter of
sterile, distilled water may be added before centrifugation to
facilitate this separation. This disrupted fat may be used for
dermal augmentation.
The recipient area is sterilely prepped and draped. A small
amount of 1% lidocaine with epinephrine is injected subder­
mally into the defect, with care not to substantially elevate the
depressed treatment areas. A tract can be created by advanc­
ing a NoKor needle into the depressed scar. Lipoinjection is
then performed with a 16- or 18-gauge needle. The needle
is advanced into the depressed scar, and adipose tissue is
injected while the needle is withdrawn. Control of fat deposi­
tion is obtained by applying manual pressure along the edges
of the defect. Lipoinjection is continued until an overcor­
rection of 20–30% is achieved. When complete, the graft is
­gently molded for precise localization.
Postoperative considerations
Antibiotic ointment and a pressure bandage are placed on the
donor site, and antibiotic ointment is applied to the graft sites.
The patient is instructed not to shower for 24 hours and to limit
facial motion as much as possible, including extensive chew­
ing, over a 24-hour period to limit graft movement. Ice should
be applied by the patient intermittently throughout the day.
The incision sites are cleaned daily, followed by the application
of antibiotic ointment to avoid scab formation and decrease
infection risk. Scarring is uncommon (Box 23-6). Repeat in­
jections may be performed at 6–8-week intervals. Fat can be
stored for up to 18 months at −4°C and reused for subsequent
injections.
Fillers
The work of Knapp et al.54 in 1977 with bovine collagen be­
gan a new era in the treatment of soft tissue irregularities. Fill­
ers are utilized for sauceriform atrophic scars, concave defects
in the dermis, or easily distensible scars. More mature and sup­
ple scars will achieve better results with fillers. Injection of the
filler also creates localized trauma with resultant neocollagen­
esis; therefore, with repeated filler injections, the defect may
become shallower. Numerous fillers with various viscosities
and durations are currently available. These include bovine
collagen (Zyderm, Zyplast, Inamed Corp., Santa Barbara,
CA); human collagen (Cosmoderm, Cosmoplast, Inamed
Corp., Santa Barbara, CA); and hyaluronic acid (Restylane,
Medicis Aesthetics, Scottsdale, AZ; Hylaform, Inamed Corp.,
Santa Barbara, CA; Captique, Inamed Corp., Santa Barbara,
CA; Juvederm, Allergan Inc., Irvine, CA). Longer lasting fill­
ers may contain particles that stimulate greater fibrosis. At the
time of publication, several of these fillers may not be FDA
approved in the United States or their use for scars may be
considered off label. These fillers include partly denatured
bovine collagen with polymethylmethacrylate microspheres
Box 23-6  Side effects of autologous fat transplantation
• Minimal bruising
• Temporary edema and erythema
• Minimal pain of the donor site
• Temporary drainage of the donor site
• Infection
• Scarring (extremely rare)
• Unilateral blindness (extremely rare) when used in glabella,
periorbital areas55

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Cosmetic surgery procedures and techniques
(Artecoll and Artefill, Artes Medical Inc., San Diego CA);
poly-L-lactic acid (Sculptra, Aventis Pharmeceuticals, Bridge­
water, NJ); calcium hydroxyapatite (Radiesse, Bioform Inc.,
San Mateo, CA); and medical grade silicone (Silikon 1000,
Alkon Laboratories Inc., Fort Worth, TX).
Preoperative considerations
Skin testing is mandatory prior to the injection of bovine colla­
gen since allergic reaction is seen in 3% of patients. Testing is ad­
ministered as an intradermal injection in the forearm of 0.1  mL
of collagen administered on two occasions 4 weeks apart.
Patients should understand the temporary nature of fillers,
with augmentation lasting between 3 and 12 months. They
should also be made aware of the temporary discomfort
­incurred during treatment.
Techniques
The treatment area is cleansed with alcohol. Injection is usually
performed with a 30-gauge needle with the needle bevel up.
The more viscous the injection material, typically the deeper
in the dermis it is placed. Multiple different fillers may be lay­
ered (e.g. Cosmoderm and Cosmoplast). Injections should be
performed very slowly and should be stopped ­immediately if
any distention of the surrounding area is noted. Care should
also be taken to avoid intravascular injection, which can lead
to necrosis.
Postoperative considerations
Patients are given an ice pack, which may be applied to the
treatment areas intermittently throughout the day. No further
care is required.
• The type of scars that respond best to fillers
include sauceriform atrophic scars, concave
defects in the dermis, or easily distensible scars.
• Injection of fillers creates a localized trauma
resulting in neocollagenesis which helps fill
scars in the long term. Most scars never return
to their initial depth after even a single injection
with a temporary filler substance.
• More viscous fillers are generally injected more
deeply.
• Injections should be performed slowly and the
physician should watch very closely for any dis­
tention of the scar edge, signifying filler material
going out of the desired area.
PEARLS
REFERENCES
  1. Ketchum LD, Cohen IK, Masters FW. Hypertrophic scars and keloids:
a collective review. Plast Reconstr Surg 1974; 53:140–154.
  2. Breasted JH. The Edwin Smith Surgical Papyrus: hieroglyphic
transaction and commentary. Chicago: University of Chicago Press;
1970; I:403-406.
  3. Addison T. On the keloid of Alibert and on true keloids. Mediocochir
Trans 1835; 19:19.
  4. Cohen IK, McCoy BJ. The biology and control of surface overhealing.
World J Surg 1980; 4:289–295.
  5. Cosman B, Crikelair GF, Ju DM. The surgical treatment of keloids.
Plast Reconstr Surg 1961; 27:335–358.
  6. Crockett DJ. Regional keloid susceptibility. Br J Plast Surg 1964;
17:245–253.
  7. Muir IFK. On the nature of keloids and hypertrophic scars. Br J Plast
Surg 1990; 43:61–69.
  8. Blackburn WR, Cosman B. Histologic basis of keloid and hypertrophic
scar differentiation. Arch Pathol 1966; 82:65.
  9. Diegelmann RF, Cohen IK, McCoy B. Growth kinetics and collagen
synthesis of normal skin, scar and keloid fibroblasts in vitro. J Cell
Physiol 1979; 98:341–346.
10. Cohen IK, Keiser HR, Sjoerdsmo A. Collagen synthesis in human
keloid and hypertrophic scars. Surg Forum 1971; 22:488.
11. Linares HA, Lasron DL. Proteoglycans and collagenases in hypertrophic
scar formation. Plast Reconstr Surg 1978; 62:589–593.
12. Diegelmann RF, Bryant CP, Cohen IK. Tissue alpha globulins in keloid
formation. Plast Reconstr Surg 1977; 59:418–423.
13. Murray JC, Pollack SV, Pinnell SR. Keloids: a review. J Am Acad
Dermatol 1981; 4:461–470.
14. Bloom D. Heredity of keloids: a review of the literature and report of
a family with multiple keloids in five generations. NY State J Med 1956;
56:511–519.
15. Castagnoli C, Pervecci OD, Stella M. The HLA-DR beta 116
allogenotype constitutes a risk factor for hypertrophic scarring. Hum
Immunol 1990; 24:229–232.
16. Castagnoli C, Stella M, Magliacani G. Anomalous expression of HLA
class II molecules on keratinocytes and fibroblasts in hypertrophic scars
consequent to thermal injury. Clin Exp Immunol 1990; 82:350–354.
17. Laurentaci G, Diguardi D. HLA antigens in keloids and hypertrophic
scars. Arch Dermatol 1977; 113:1726.
18. Ramakrishnan KM, Thomas KP, Sundararjan CR. Study of 1,000
patients with keloids in South India. Plast Reconstr Surg 1974; 53:
276–280.
19. Peacock EEJ, Madden JW, Trier WC. Biologic basis for the treatment of
keloids and hypertrophic scars. South Med J 1970; 63:755–760.
20. Roenigk HH Jr, Pinski JB, Robinson JK, et al. Acne, retinoids, and
dermabrasion. J Dermatol Surg Oncol 1985; 11:396.
21. Friedman SJ, Butler DR, Pittelkow MR. Perilesional linear atrophy and
hypopigmentation after intralesional corticosteroid therapy. J Am Acad
Dermatol 1988; 19:537–541.
22. Ceilley RI, Barin RW. The combined use of cryosurgery
and intralesional injections of suspension of fluorinated
adrenocorticosteroids for reducing keloids and hypertrophic scars.
J Dermatol Surg Oncol 1979; 5:54.
23. Fitzpatrick RE. Treatment of inflamed hypertrophic scars using
intralesional 5-FU. Dermatol Surg 1999; 25:224–232.
24. Pollack SV, Gosler JB. The surgical treatment of keloids. J Dermatol
Surg Oncol 1982; 8:1045–1049.
25. Nouri K, Rivas MP, Ballard CJ. Treatment of scars with lasers and
other energy sources. Arndt, KA, ed. Scar revision. Philadelphia:
Saunders; 2006:67–88.
26. Alster TS. Alteration of argon laser-induced scars by the pulsed dye
laser. Lasers Surg Med 1993; 13:368–373.
27. Reiken SR, Wolfort SF, Berthiaume F. Control of hypertrophic scar
growth using selective photothermolysis. Lasers Surg Med 1997; 21:
7–12.
28. Mancini RE, Quaife JV. Histogenesis of experimentally produced
keloids. J Invest Dermatol 1962; 38:143.
• Skin testing is mandatory for any filler containing
bovine collagen, and testing a second time is
strongly recommended.
• If filler material is injected or filters out to the scar
edge or beyond, the scar may appear deeper
than in did prior to injection.
pitfalls

417
Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
29. Darzi MA, Chowdi NA, Kaul SK. Evaluation of various methods of
treating keloids and hypertrophic scars: a 10-year follow-up study. Br J
Plast Surg 1992; 45:374.
30. Apfelberg DB, Maser MR, Lash H. The use of epidermis over a keloid
as an autograft after resection of the keloid. J Dermatol Surg Oncol
1976; 2:409.
31. Weimar VM, Ceilley RI. Treatment of keloids on earlobes. J Dermatol
Surg Oncol 1979; 5:522.
32. Murray RD. Kenalog and the treatment of hypertrophied scars and
keloids in Negroes and whites. Plast Reconstr Surg 1963; 31:275.
33. Linares HA, Larson DL, Willis-Galstaun BA. Historical notes on the
use of pressure in the treatment of hypertrophic scars or keloids. Burns
1993; 19:17–21.
34. Kischer CW, Shetlar MR, Shetlar CC. Alteration of hypertrophic scars
induced by mechanical pressure. Arch Dermatol 1975; 11:60–64.
35. Davies DM. Scars, hypertrophic scars and keloids. Br Med J 1985;
19:733–743.
36. Dockery GL, Nilson RZ. Treatment of hypertrophic and keloid scars
with Silastic gel sheeting. J Foot Ankle Surg 1994; 33:110–119.
37. Wong T, Chiu H, Chen J. Symptomatic keloids in two children. Arch
Dermatol 1995; 131:775–776.
38. Rusciani L, Rosse G, Bono R. Use of cryotherapy in the treatment of
keloids. J Dermatol Surg Oncol 1993; 19:529–534.
39. Ceilley RI, Barin RW. The combined use of cryosurgery
and intralesional injections of suspension of fluorinated
adrenocorticosteroids for reducing keloids and hypertrophic scars.
J Dermatol Surg Oncol 1979; 5:54.
40. Jimenez SA, Freundlich B, Rosenbloom J. Selective inhibition of human
diploid fibroblast collagen synthesis by interferons. J Clin Invest 1984;
74:1112–1116.
41. Janssen de Limpens AMP. The local treatment of hypertrophic scars and
keloids with topical retinoic acid. Br J Dermatol 1980; 103:319–323.
42. Lee RC, Ping JA. Calcium antagonists retard extracellular matrix
production in connective tissue equivalent. J Surg Res 1990;
49:463–466.
43. Berman B, Kaufman J. Pilot study of the effect of postoperative
imiquimod 5% cream on the recurrence rate of excised keloids. J Am
Acad Dermatol 2002; 47:S209–S211.
44. Martin-Garcia RF, Busquets AC. Postsurgical use of imiquimod 5%
cream in the prevention of earlobe keloid recurrences: results of an
open-label, pilot study. Dermatol Surg 2005; 31:1394–1398.
45. Kim A, DiCarlo J, Cohen C, et al. Are keloids really ‘gli-loids’?: High-
level expression of gli-1 oncogene in keloids. J Am Acad Dermatol 2001;
45:707–711.
46. Berman B, Zell D. Medical treatment of scarring. In: Arndt KA, ed.
Scar revision, Philadelphia; Saunders; 2006:17–44.
47. Choi JM, Rohrer TE, Kaminer MK, et al. Surgical approaches to
patients with scarring. In: Arndt KA, ed. Scar revision, Philadelphia;
Saunders; 2006:45–66.
48. Batra RS, Ort RJ, Jacob C, et al. Evaluation of a silicone occlusive
dressing after laser skin resurfacing. Arch Dermatol 2001;
137:1317–1321.
49. Kye YC. Resurfacing of pitted facial scars with a pulsed Er:YAG laser.
Dermatol Surg 1997; 23:880–883.
50. Potter M, Harrison R, Ramsden A, et al. Facial acne and fine lines:
transforming patient outcomes with plasma skin resurfacing. Lasers Surg
Med 2005; 36:23.
51. Manstein D, Herron GS, Sink RK, et al. Fractional photothermolysis:
a new concept for cutaneous remodeling using microscopic patterns of
thermal injury. Lasers Surg Med 2004; 34:426–438.
52. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser
photothermolysis for the treatment of atrophic scars. Dermatol Surg
2007; 33:295–2999.
53. Tanzi EL, Alster TS. Comparison of 1450  nm diode laser and 1320  nm
Nd:YAG laser in the treatment of atrophic facial scars: a prospective
clinical and histological study. Dermatol Surg 2004; 30:152–157.
54. Knapp TR, Kaplan EN, Daniels JR. Injectable collagen for soft tissue
augmentation. Plast Reconstr Surg 1977; 60:398.
55. Temouria B. Blindness following fat injections. Correspondence and
brief communications. Plast Reconstr Surg 1988; 80:361.

History and Science
History
Evidence of surgical reconstruction appears in the Egyptian
papyri from approximately 3000 BC. As delineated in the
Samhita, or encyclopaedia, of the Hindu author Sushruta
Samita, physicians in India as early as 600 BC were recon­
structing defects of the face in order to restore a human’s aes­
thetic, not simply functional, form using both flap and graft
reconstruction techniques.1 It was not until World War I and
the advancement of sterile technique and surgical anesthe­
sia that reconstruction for both functional and aesthetic goals
Aesthetic Surgical Closures
Andrew Kaufman
Wendy Long and
Thomas E. Rohrer
C H A P T E R
24
p a r t 2
Key Points
n Match the repair with both the defect and the
patient
n Reconstruction of ���g���l ������������������������y
surgical defects ����������������y
is an opportunity
to improve patient appearance
n Minimize wound tension.
n Flap and graft contouring.
n Ensuring flap and graft viability
n Perioperative patient education
n Intraoperative techniques to improve cosmetic
outcomes
n Wound care tips to ensure optimal healing
n Aesthetic surgical closure pearls and pitfall s
by facial region
n Postoperative tools to refine the surgical result
became a realistic objective of surgical repair.2 As dermato­
logic surgeons, we have the opportunity to use our extensive
background in the biology of the integument and our surgi­
cal training to cure cutaneous carcinoma and execute elegant,
functional, and aesthetic repairs.3
Science
In order to achieve an aesthetically pleasing closure, local
anatomy, tension vectors, cosmetic units, relaxed skin tension
lines, and free margins must be considered. Once the closure
is planned, the repair must then be executed with precise
­surgical technique. Even when all these parameters are met,
the final scar can still require postoperative revision.4
After removing benign or malignant lesions, dermatologic
surgeons are left with a wound. These wounds are frequently
round in shape and may be allowed to heal by secondary in­
tention, closed with a side-to-side repair, or reconstructed with
a flap or graft. In general, wounds that are superficial and in
concave areas such as the inner canthus, alar crease, and tem­
ple tend to heal well by secondary intention. Zitelli described
these areas as NEET: concave areas of the nose (N), ears (E),
eyes (E), and temple (T) that heal well by secondary intention
(Fig. 24-1).5
Whenever possible, primary linear closures should be
oriented along relaxed skin tension lines (RSTLs) or along
cosmetic unit junctions to maximize aesthetic appearance
(Fig. 24-2).6 Closure should also avoid tension on mobile free
margins or anatomical landmarks. The classic ellipse is de­
signed with a length three times its maximal width and with
30-degree angles at each end to minimize the formation of
redundant tissue cones (‘tricones’). Over convex surfaces and
sebaceous skin it is generally helpful to lengthen the ellipse to
greater than a 3:1 ratio in order to avoid these tricones.
The standard ellipse can also be taken out in a more
­arciform shape or in an ‘S’ shape (S-plasty) to better match
the natural curvature of the skin in the area. An S-plasty is
particularly helpful over convex areas such as the extremities.
By creating an ‘S’ shape, the forces of contraction that occur
along the long axis of a closure during wound healing occur

420
Chapter 24
Cosmetic surgery procedures and techniques
in more than one direction. This reduces the likelihood of the
final scar pinching down over the convex surface and creating
an indentation. Another modification of ellipses is shortening
or incorporating an M-plasty at one or both ends (Fig. 24-3).
This technique is often used to prevent an incision from cross­
ing into a second cosmetic unit or into an important anatomic
structure or free margin.
When a wound cannot be closed in a simple primary fash­
ion, skin flaps or grafts are employed. Skin flaps are composed
of skin and subcutaneous tissue with an attached vascular
pedicle that is moved from a donor site into the surgical de­
fect. There are many ways to classify flaps used in reconstruc­
tion; the most common are blood supply and direction of
movement.
Arterial or axial flaps have a large named artery in their
pedicle. The artery generally lies in the deep subcutaneous
layer superficial to the muscular fascia and supplies the entire
flap. The most commonly used axial flap in facial reconstruc­
tion is the paramedian forehead flap, which has the supra­
trochlear artery in it. Fasciocutaneous flaps include only the
fascial covering of the muscle in the pedicle whereas muscu­
locutaneous flaps actually include muscle in the base of the
flap. The most commonly used musculocutaneous flap in der­
matologic surgery is the myocutaneous island pedicle flap em­
ployed in nasal reconstruction. The most frequently used flaps
Cosmetic result
Excellent (NEET area)
Satisfactory (fair area)
Variable (noch area)
Fig. 24-1  Optimal areas for healing by second intension are gener­
ally concave and include the nasal alar groove, conchal bowl, helical
sulcus, inner canthus, and temple.
Fig. 24-2  Relaxed skin tension lines of the face.
Primary defect
Fig. 24-3  M-plasty design.

421
Aesthetic surgical closures  •  Chapter 24
in dermatologic surgery are classified as random. Random
flaps depend on a small unnamed perfusion plexus of highly
anastomotic vessels in the dermis to perfuse the flap. Since the
vascular input of random-pattern flaps is not as predictable as
axial flaps, proper flap design and execution is crucial for flap
survival. Inadequate blood supply or excessive closure tension
(which in turn reduces blood flow) creates an environment
that has insufficient nutrient supply to the distal aspect of the
flap and may lead to partial- or full-thickness flap necrosis.
The vascular perfusion pressure, the force of blood flow
through a vessel, is greatest at the proximal end of a vessel and
decreases steadily as it travels more distal into the flap. To en­
sure flap survival, the perfusion pressure must be great enough
to keep the distal capillaries of the flap open. If the pressure
falls below a certain critical level, the capillaries close and
­insufficient blood is supplied to the distal end of the flap.7
For years it was believed that the viable length of a flap
was directly proportional to the width of the pedicle. In 1970,
Milton discovered that axial flaps in a pig model under the
same conditions of blood supply survive to the same length
regardless of width.8 Daniel and Williams, as well as Stell
confirmed Milton’s findings and concluded that there was
an upper limit of flap length that cannot be increased by
­increasing the pedicle width.9,10 The maximal flap length is
determined by vascular supply, not simply pedicle width. The
greater the perfusion pressure in the flap pedicle, the longer
the flap can be without undergoing necrosis.11 In addition, the
greater the perfusion pressure in the pedicle, the narrower the
pedicle may be. Axial-pattern flaps have the highest perfusion
pressure at the base and therefore can support very narrow,
long flaps (generally greater than 4:1 length to width ratio).
Musculocutaneous flaps have the next greatest vascular per­
fusion pressure, followed by fasciocutaneous flaps, and finally
random-pattern flaps. Stell discovered the greatest length of
a viable axial flap was 60% greater than that of a random-
pattern flap.10 In general, random-pattern flaps on the face
should have a maximal length to width ratio of 3:1.12–14 This
is, however, only a rough guideline and individual patient
characteristics such as tobacco use, sebaceous nature of skin,
prior radiation or surgical procedures, and precise location all
affect vascular perfusion.
Random-pattern flaps, the most widely used in dermato­
logic surgery, are supported by the small arterioles and capil­
laries of the subdermal vascular plexus found in the mid to
superficial fat (Fig. 24-4). Therefore, undermining and flap
mobilization must be done at or below this level to ensure ad­
equate blood supply. If undermining occurs too superficially,
the intradermal vasculature alone will often not be able to
support a flap.15 In areas off the face, the perfusion pressure
of even the subdermal vascular plexus is often not sufficient to
support a random-pattern flap. This is why random-pattern
flaps are rarely performed off the face. Fortunately, the blood
supply of the face is rich, estimated to be ten times greater
than necessary to support the skin’s basic metabolic needs,
and can support a wide variety of random-pattern flaps.16–18
Random-pattern flaps may also be classified by their move­
ment. The three basic categories of movement are advance­
ment, rotation, and transposition. Classic advancement flaps
move tissue in a single direction directed towards the primary
defect and do not alter the vector of tension during closure.
They instead allow the surgeon to place the incision lines in
a different direction and orientation than would be achieved
with a primary linear closure. To a small extent, advancement
flaps also tap into adjacent tissue laxity. Rotation flaps also
slide tissue towards the primary defect, but do so in an arci­
form manner around a pivot point. The large arc of rotation
allows a sharing of the tension vectors of closure and can tap
into skin laxity in the surrounding area. Transposition flaps
lift the tissue (the flap) over intervening skin and rotate it into
the surgical defect. In addition to tapping into adjacent tissue
laxity, the vector of tension may be altered up to 90 degrees or
greater with transpositions flaps.19
There are two basic types of skin grafts: full-thickness skin
grafts (FTSGs) and split-thickness skin grafts (STSGs). FTSGs
are composed of epidermis and the full thickness of dermis
while STSGs are composed of the epidermis and only a small
part of the dermis. FTSGs generally have a superior aesthetic
result when compared to STSGs but also have higher nutri­
tional requirements and require a more robust vascular bed
for viability. Skin grafts follow a progression of stages during
wound healing that lead to graft survival. During the first 24
hours following placement, the graft undergoes an ischemic
phase of plasmatic imbibition, during which fibrin glue at­
taches the graft to its recipient bed. Vessel anastomoses occurs
over the next 48–78 hours. This is followed by vascular prolif­
eration. Full circulation is generally achieved in 4–7 days.20,21
Grafts are very tenuous during this initial week and all efforts to
minimize trauma to the area must be taken. Careful ­attention
Superficial and deep
intradermal plexus
Subdermal plexus
Subcutaneous and
intrafascial axial
vessels
Perforators
Dermis
Fat
Fascia
Fig. 24-4  Subdermal vascular plexus. Undermining should be
performed deep to this network of vessels to ensure good vascular
supply to a flap.

422
Chapter 24
Cosmetic surgery procedures and techniques
to matching the donor and recipient site in terms of skin color,
texture, photodamage, thickness, and sebaceous quality is
essential in achieving an optimal aesthetic result.22 Since skin
used in local random flaps is adjacent to the surgical defect,
it is much more likely to match the skin removed during the
excision and lead to an aesthetically pleasing closure. Adja­
cent-tissue skin grafts attempt to avoid this problem by using
tissue adjacent to the surgical defect as the graft donor site.23
One distinct advantage to skin grafts is the avoidance of
­additional incisions and resultant scars, in contradistinction
to flap reconstruction.
Procedures and Techniques
Preoperative clinical considerations­
A surgical defect on the face demands that the surgeon con­
sider many issues in order to design an aesthetic surgical clo­
sure. The definition of an aesthetic surgical closure is one that
produces a scar that is not visible at a social distance, and that
may even improve the patient’s appearance. The surgeon
must take into account characteristics of both the defect and
the patient. The defect’s location, size, and depth, the regional
facial anatomy, local skin laxity, adjacent free margins, and
anatomical landmarks must all be considered.
It is just as important to bear in mind the characteristics of
the patient. The patient’s age, potential for compliance with
wound care or a staged procedure, smoking status, and other
comorbidities are all factors that should affect a surgeon’s
­surgical closure plan. A large flap repair in a three pack a day
smoker, no matter how well executed, has a high likelihood
of necrosis and may not be the best option in this patient.24 A
staged procedure, no matter how elegantly it may reconstruct
the defect, may not result in an aesthetically pleasing result if
performed on a patient without the ability or inclination to per­
form adequate wound care or to follow up ­appropriately.25
When assessing a closure plan one must always consider
where the incision scars will lie. Surgical defects are best cam­
ouflaged on cosmetic unit junctions and/or parallel to relaxed
skin tension lines. When a wound is closed parallel to the
­relaxed skin tension lines the resultant scar is usually thinner
because the wound has healed under low tension. Avoidance
of crossing cosmetic unit junctions also helps to camouflage
the resultant scar.26
Occasionally, the surgeon is given the opportunity to make
a cosmetic improvement for the patient during the repair of a
surgical defect. Defects on the forehead may allow correction
of brow asymmetry. Nasolabial and melolabial folds are fre­
quently asymmetrical and may be amenable to improvement
during surgical closure. Nasal defects can offer the surgeon the
opportunity to reverse nasal tip ptosis or narrow the nose if
the patient supports the need for aesthetic improvement.
Remember to plan the closure before the antisepsis prepa­
ration obscures and/or local anesthetic infiltration distorts
the area.
Procedural techniques
General pearls and pitfall s
Even the most well-planned closure will not result in an aes­
thetic result if the procedure is not performed with meticulous
surgical technique. It is not within the realm of this textbook to
teach surgical technique; however, a few general points should
be kept in mind in order to allow the well-planned closure to
realize its potential. These intraoperative surgical pearls help
achieve the most aesthetically pleasing results and can pre­
clude the need to perform postoperative revisions.
Wounds under high tension heal with more noticeable
scars. The closure should be planned to keep local skin laxity
and mobility in mind to allow for low wound tension. In ad­
dition to an excellent closure design, to achieve optimal cos­
metic results it is essential to reduce the tension on the wound
edges intraoperatively. Buried vertical mattress sutures should
be placed to evert the wound and minimize wound edge ten­
sion, resulting in a finer scar (Fig. 24-5). In addition, a postop­
erative or perioperative hematoma can dramatically increase
wound tension with disastrous results, so it is also important to
achieve thorough intraoperative hemostasis.
Another intraoperative technique to decrease wound tension,
therefore improving the aesthetics of the final closure, is the in­
traoperative injection of botulinum toxin. Botulinum toxin can
be injected intraoperatively into the perioperative fields of fore­
head and lip closures to induce weakness or paralysis of regional
muscles, thereby decreasing tension across the closure.
It is beyond the scope of this chapter to detail the multitude
of closure techniques available to the dermatologic surgeon,
but the general tips below can help achieve optimal aesthetic
results.
Optimal aesthetic results may occur from simple, yet ele­
gant, linear closure or allowing the defect to heal by secondary
intention. The most technically challenging and complicated
reconstruction techniques do not guarantee the most aesthetic
result. Sometimes it is best to err on the side of a simple and
straightforward repair.
The use of flap reconstruction allows the dermatologic sur­
geon to tap into adjacent skin laxity to repair a defect. The most
obvious advantage to this closure technique is that it allows the
best matching of skin color, texture, and thickness. Defect size,
surrounding skin mobility, nearby free margins, and anatomi­
cal landmarks are factors that are considered when choosing
between flap and graft repair. In order to ensure optimal
cosmetic results when using flap or graft reconstruction it
is essential to plan and execute the repair appropriately.27
When using a flap to close a defect the size of the flap should
be neither too large nor too small for the defect. The pedicle

423
Aesthetic surgical closures  •  Chapter 24
of the flap determines the flap’s vascular supply and incision;
undermining and closure should ensure adequate perfusion
and flap viability. Both flaps and grafts should be designed so
that they correspond to the depth of the defect. Thinning of
flaps should be done judiciously and enough subcutaneous tis­
sue left to ensure adequate vascular supply. The distal ­portion
of a flap can be thinned or contoured to facilitate a better
cosmetic result, but in a patient with comorbidities affecting
circulation and/or wound healing, as in smokers and diabet­
ics, thinning should be performed with caution or delayed for
a second procedure to avoid flap necrosis.
It is essential to keep in mind the variables that allow for
flap and graft viability in order to realize the aesthetic poten­
tial of a planned repair. Flap and graft viability depend upon
adequate perfusion via existing blood vessels, imbibition, and/
or angiogenesis. Any factor that decreases the oxygen delivery
to a flap or graft will limit survival and, therefore, decrease
the likelihood of a cosmetically pleasing outcome. Excessive
wound edema, high wound tension, surgical wound infection,
postoperative hematoma, and tobacco use during healing all
decrease flap perfusion and, hence, viability.28
While many of these factors can be addressed during the
planning and execution of the reconstruction, as touched
upon above, patient education is essential to ensuring the best
possible aesthetic outcome. It is a wise investment of a few
minutes of one’s time to educate patients about postoperative
care. This small effort helps protect the investment of time
already made by so precisely and diligently designing and
­performing an elegant repair.
Patients undergoing dermatologic surgery should be in­
structed to discontinue the use of aspirin, nonsteroidal anti­
inflammatory drugs, alcohol, vitamin E, ginko, garlic, ginseng,
ginger, and feverfew 2 weeks prior to surgery to decrease the
risk of seroma or hematoma postoperatively. The use of these
substances can be reinitiated 1 week after surgery.29 If a pa­
tient has been put on aspirin, coumadin, or another antico­
agulant for primary prevention or for treatment of an existing
condition, the patient should continue this therapy regardless
of the increased risk of intra- and postoperative bleeding and
hematoma.
The use of topical antibiotic ointments by the pa­
tient, ­ including bacitracin, neomycin, and triple antibiotic
­preparations should be strongly discouraged. The incidence
of ­ allergic contact dermatitis to topical antibiotic prepara­
tions after ­cutaneous surgery has been recently quantified to
be as high as 5.3%.30 Allergic contact dermatitis can inhibit
good wound healing and increases the risk of scarring from
excoriation and increased wound tension from edema. The
wound infection rate in a study including more than 1000 pa­
tients with 530 undergoing Mohs’ micrographic surgery and
­reconstruction and 517 undergoing excision was only 2.29%
according to a recent study. The risk of contact dermatitis to
topical ­antibiotic preparations and its resultant negative effect
upon the ­cosmetic results of reconstruction outweighs the risk
of postoperative wound infection31 Patients should be told to
use bland ­petrolatum-based ointments during the postopera­
tive wound care period.
Patient education should also stress the importance of compli­
ance with wound care instructions. Inform and consent the pa­
tients to the risks of tobacco use and encourage, at the very least,
temporary tobacco cessation or reduction during the 2-week
A
B
Fig. 24-5  (A) Line drawing of a buried vertical mattress suture.
(B) Good wound eversion created by the use of buried vertical
­mattress sutures.

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Cosmetic surgery procedures and techniques
postoperative period. Discourage any form of exertional ­activity
in the immediate postoperative period, as it can threaten opti­
mal wound healing by increasing the risk of dehiscence, post­
operative hematoma and infection, and wound tension.
Regional pearls and pitfall s
It is useful when planning and executing a repair to conceive
of the face as separate regions, each with regional pitfalls or
obstacles to good cosmetic outcome and the surgical pearls to
avoid these pitfalls.
Periocular
Reconstruction of the eyelids may provide an excellent aes­
thetic result secondary to low wound tension and speed of
healing of eyelid skin; however, successful repair in this area
requires fulfillment of both cosmetic and functional con­
cerns. Cosmetic factors include maintenance of size and
symmetry and avoidance of ectropion and distortion of the
eyebrow. Functional factors require protection of the globe,
­preservation of the lacrimal system, and stability and mobility
of the lids and supporting structures to preserve vision.
Repair of the eyelids should be planned based on the ­thickness
of the surgical defect and the need to replace with like tissue.
For the eyelids, defects can be categorized based on whether
they involve the anterior lamella, posterior lamella, or both. The
­anterior lamella consists of the skin and ­orbicularis oculi muscle,
and the posterior lamella consists of the tarsus and conjunctiva.
Each component serves separate functions, ­ whether opening
or closing the lids, providing lubrication and protection to the
­cornea, and repair needs to address these ­specific functions.
Many small surgical defects on the eyelids or periorbital
area can be repaired with a side-to-side closure. Since relaxed
skin tension lines run parallel to the lid margin, one impor­
tant ­consideration is to orient the tension vectors perpendic­
ular to the eyelid margin as the incision approaches the lid
margin (i.e. the closure is perpendicular to the lid margin)
(Fig. 24-6). This decreases the possibility that wound closure
and ­ contracture will deviate the eyelid margin away from
the globe. This is ­especially true in older patients with pr­
eoperative senile ­ectropion and significant eyelid laxity. The
repair should structurally support the lower eyelid rather than
­exacerbate ectropion or lacrimal dysfunction.
Medial canthal defects that are superficial and balanced
above and below the medial canthal ligament may heal with
excellent results via secondary intention healing. Defects not
above and below the ligament or in close proximity to the eye­
lid margin are candidates for repair with a rhombic transposi­
tion flap or full-thickness skin graft.32 A key consideration in
this area is to avoid webbing of the medial canthus in design
and execution of the repair. A useful pearl in this area is to
avoid suturing of the flap or graft immediately adjacent to the
medial canthal lid margin if closure creates webbing.
For repair of the eyebrow and medial upper and lower eye­
lids, advancement flaps are capable of repair of fairly large
defects. These flaps utilize inherent elasticity in this area, help
to avoid ectropion, and incision lines can sometimes be cam­
ouflaged in pre-existing rhytides.33 For larger defects and de­
fects in the lateral periorbital area, island pedicle and rhombic
flaps are useful alternatives (Fig. 24-7).
Discussion of repair of larger defects is beyond the scope
of this chapter, but aesthetic repair requires application of the
principles discussed: replace anterior and/or posterior lamella
when involved, maintain symmetry, shape and function, and
avoid deviation of free margins.
A pitfall of lower eyelid reconstruction is the ­development of
persistent lymphedema. It can be unavoidable given certain de­
fects; however, if the surgeon attempts to incise and undermine
at the most superficial plane viable for repair and to attempt to
keep incisions in the lower lid medial to the lateral canthus, the
risk of persistent lymphedema can be minimized.
Finally, it is advisable to pull the drape back, ask the ­patient
to open his/her mouth, look up (the ‘yawn test’), and ­assess the
patient’s overall facial anatomy in order to preserve ­symmetry
and avoid ectropion. As with reconstruction in any cosmetic
unit, if one is not comfortable repairing a substantial ­eyelid
margin defect, consider referral to another dermatologic
­surgeon or oculoplastic surgeon.
• Anesthetic infiltration distortion of anatomic
­contour
• High wound tension
• Hematoma
• Patient noncompliance
• Contact dermatitis with topical antibiotic
­preparations
Pitfalls
• Keep it simple
• Wound eversion
• Thorough hemostasis
• Intraoperative botulinum toxin injections
• Patient education
Pearls
• Close perpendicular to free margins.
• Avoid deviation of eyelid margin from primary or
secondary tension ­vectors.
• Do not suture area immediately adjacent to lid
margin in medial canthus if those few sutures
exacerbate or cause webbing.
• Perform the yawn test.
Pearls
• Avoid exacerbation of senile ectropion and
­lacrimal ­dysfunction in older patients.
• Avoid persistent ly mphedema by undermining
­superficially and keeping incision medial to the
lateral canthus.
Pitfalls

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Aesthetic surgical closures  •  Chapter 24
A
B
C
D
Fig. 24-6  (A) Patient with basal cell carcinoma of the lower eyelid. (B) Surgical defect foll owing Mohs’ micrographic surgery is full -thickness
portion of eyelid at lid margin. (C) Side-to-side closure completed, keeping closure perpendicular to lid margin and hypereverting closure over
margin. (D) Eyelid complex repair healed. Healed result after aesthetic repair.

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Chapter 24
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Perioral
The lips’ malleable structure allows humans to express and
nourish themselves. These essential functions and the central
location make perioral reconstruction a significant challenge.
The lip region can be divided into five subunits, the right and
left lateral upper lip, the central philtrum, the vermilion lip,
and the lower lip. In order to achieve an optimal closure of
a defect in the perioral region the surgeon must respect the
junctions of these subunits, closing within cosmetic subunits
whenever possible and considering multiple repairs for defects
extending into multiple subunits.34
One key consideration when planning repair of the lip is to
mark out the vermilion border prior to anesthesia. Local anes­
thetic infiltration distorts the subunit junctions and the vermil­
ion, obscuring normal anatomy and relaxed skin tension lines
that ought to be used when planning a closure. Therefore, it
is crucial to mark the vermilion border, the subunits, and the
­relaxed skin tension lines with an indelible surgical marker
prior to local anesthetic infusion. Another tip is the use of nerve
blocks via intraoral approach that allow complete anesthesia
of the area while using much less anesthetic volume, thereby
­decreasing distortion.
Many surgical defects can be successfully repaired in a
side-to-side closure along the relaxed skin tension lines which
radiate from the lip. Crossing the vermilion border ­ during
­reconstruction design may have the best aesthetic result;
­however, as with any repair crossing into vermilion, it is essen­
tial to precisely realign the vermilion border. Some surgeons
might hesitate to cross the border or utilize an M-plasty repair,
but shortening of the incision line too much will push the lip
downward on the upper lip or upward on the lower lip.
Defects too large for side-to-side repair on the lateral cutane­
ous lip can be repaired using an advancement flap. Due to abun­
dant nearby lax tissue on the cheek and jowl, fairly large repairs
C
D
A
B
Fig. 24-7  (A) Patient with lentigo maligna of the lateral canthus and temple prior to surgical excision. (B) Surgical defect immediately after
Mohs’ micrographic surgery. (C) The inferior aspect of the wound was closed in a side-to-side fashion along relaxed skin tension lines. The
defect of the lateral canthus was reconstructed using an adjacent-tissue skin graft; the tricone removed during the side-to-side repair was used
to graft the remaining adjacent defect. The adjacent donor site is closely matched to the color, texture, and thickness of the skin lost in removal
of the cancer. (D) Cosmetic and functional result of repair when healed.

427
Aesthetic surgical closures  •  Chapter 24
can be safely completed. A key consideration here is to plan
repair so that incision lines are hidden at the junctions ­between
cosmetic units or subunits. This might necessitate ­sacrifice of
tissue between the surgical defect and the ­ vermilion border.
Burrow’s triangles or crescents are excised at the ­distal ends of
these flaps to facilitate movement medially. For upper lateral lip
defects, rotation flaps might also be useful for repair since the
arc of the incision can be concealed within the melolabial fold
(Fig. 24-8). Due to trapdoor risks, transposition flaps are usually
reserved for repair of defects where there is inadequate tissue
or mobility with an advancement or rotation repair.
For defects on the philtrum side-to-side repair successfully
repairs this subunit if the width of the defect is less than 50%
of the total philtral width. For larger defects, consideration
should be given to an island pedicle flap, keeping incision lines
along the philtral ridges, or bilateral rhombic transposition
flaps. While covering the defect, a full-thickness skin graft does
not aesthetically reconstruct the color, texture, thickness or, in
men, beard pattern.
Vermilion defects may be allowed to heal by secondary in­
tention if the defect is small and away from the vermilion bor­
der. Small defects can be repaired in a side-to-side fashion and
defects up to 40% of the vermilion width can be repaired with
a bilateral vermilion rotation flap, which utilizes adjacent ver­
milion for repair and maintains the anterior-posterior fullness
to the lip (Fig. 24-9). Larger defects or defects on vermilion
with significant residual actinic cheilitis are best reconstructed
using a mucosal advancement flap, but this repair decreases
the thickness of the lip and risks persistent hypoesthesia and
inward redirection of beard growth in men.
Reconstruction of the nose
Several factors make the nose one of the most challenging areas
in reconstructive surgery. It is a very visible and mobile struc­
ture composed of multiple balanced subunits that must be re­
stored and kept perfectly symmetric. Artists and reconstructive
surgeons do not view the nose as a single area, but rather break
it down into multiple subunits and approach it as an intricate
arrangement of contour and texture (Fig. 24-10). Any change
in nasal symmetry is apparent even to the casual observer. The
nasal tip and alae have only mobile cartilage supporting them
and are subject to deviation with even the slightest tension. Un­
less the surgeon is attempting to correct tip ptosis or a prior
nasal deviation, all efforts should be made to redirect the vec­
tors of tension away from the nasal tip and alae to minimize
the risk of nasal deviation and asymmetry. There are no hidden
imperfections in this area; it is served up for all to see.
When planning a closure of a nasal defect the surgeon must
also be mindful of the differences in texture, sebaceous gland
density, thickness, and mobility of the skin in various regions
of the nose. Skin on the nasal tip, supratip, and alae tends to
be thicker, more sebaceous, and less mobile than that found on
the nasal dorsum, nasal sidewalls, soft triangle, and columella.
It is important to replace the tissue of the surgical defect with
tissue having similar characteristics. If a local flap is used, it
should be comprised of similarly textured skin and thinned ap­
propriately to match thickness. Likewise, grafts should be taken
from skin with as similar characteristics as possible and avoided
if not closely matched. Thick sebaceous nasal skin can be very
difficult to work with and gives less predictable results. Its lower
vascular supply:demand ratio make it more likely to necrose
and more prone to heal with depressed scar lines. These zones
of transition from one type of skin to another vary from pa­
tient to patient and should be fully evaluated in the individual
before any reconstructive procedure is ­undertaken. As in other
areas of reconstruction, keeping ­incisions along cosmetic unit
junctions help minimize the appearance of scars.
As is always the case, it is critical to protect and/or re-
­establish the functionality of the area when repairing a defect.
Large defects on the alae often require cartilage grafts at the
wound base to give additional support and prevent nasal valve
dysfunction on inspiration. These cartilage grafts are generally
harvested from the conchal bowl, helix, or posterior ear, shaped
and thinned to match the defect and tacked to the base of the
defect with braided absorbable suture. If skin grafting is planned
over the cartilage graft, the cartilage should not be a single large
piece but comprised of thin battens that allow vascularization
to the skin graft from the base of the defect. Small pockets are
often made at each end of the defect and a slightly oversized
piece of cartilage is wedged into the pocket for added support.
Keeping the intricate arrangement of nasal subunits with
their variations in contour and texture in mind, the surgeon is
able to approach a nasal defect with the goal of aesthetically
restoring the nose to the point where a casual observer is un­
able to detect any surgical intervention and does not ask the
patient, ‘What happened there?’ Although complete ­textbooks
have been written solely on nasal reconstruction, a few gen­
eral guidelines and techniques go a long way to aesthetically
restoring the nose.
Small (<1 cm), shallow defects on concave ­ areas such as
the alar groove and medial canthus can often heal by ­second
­intention with a reasonably aesthetic result. ­ Similarly, very
shallow defects on sebaceous nasal tips and alae may be
• Mark the vermilion border, cosmetic subunits,
and planned repair before anesthesia.
• Most lax tissue is medial cheek and jowl.
• Do not fear crossing the vermilion border, but be
sure to realign it afterwards.
• Hide incisions and tricone excisions by ­enlarging
defect if necessary and keeping incisions at
junctions of cosmetic units and subunits.
Pearls
• Avoid flattening of the philtrum.
• Avoid distortion of the lip from too much tension
on the lip free margin.
• Decrease lip full ness and increased
­hypoesthesia with mucosal advancement flap.
Pitfalls

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Chapter 24
Cosmetic surgery procedures and techniques
C
D
A
B
Fig. 24-8  (A) Patient with basal cell carcinoma of the lateral upper lip. (B) Surgical defect after Mohs’ surgery to remove malignancy.
(C) ­Rotation flap completed to recruit lax tissue from oral commissure area, keeping the incision line along the melolabial fold. Tricone is
excised from inferior portion of Mohs’ defect and closed within relaxed skin tension lines. (D) Final healed result.

429
Aesthetic surgical closures  •  Chapter 24
­allowed to heal secondarily. Resurfacing (CO2 or Er:YAG laser,
­sandpaper, etc.) the surrounding tissue helps blend the area in
and significantly enhances the final ­appearance (Fig. 24-11).35
Small (<0.7 cm) defects on the nasal dorsum and side wall
can often be closed primarily along relaxed skin tension lines
(either angled towards the medial canthus or directed horizon­
tally across the nose). Small defects on the nasal dorsum, su­
pratip, and tip may also be closed primarily in a vertical ­fashion
in the midline. Primary closures on the nose should be designed
with a length to width ratio of at least 4:1 (they may even carry
over the apex of the nasal tip and down the columella if nec­
essary) and be widely undermined below the nasalis muscle
along the periosteum. For midline defects, the determining fac­
tor in whether to perform the closure in a vertical or horizontal
­direction generally depends on the shape of the nose. Broad
noses often benefit aesthetically from the slight narrowing that
occurs with a closure in the vertical direction and patients with
nasal tip ptosis often benefit cosmetically from the slight tip lift­
ing that occurs with closures in the horizontal plane.
Very small (<0.5 cm) defects in the alar groove may be
closed with an arciform linear closure along the groove. Care
must be taken not to elevate the ala during closure. If the
defect is too large to close in a curvilinear fashion, an alar
rotation flap may be employed. An incision is made laterally
around the ala along the groove and the entire alar unit is
rotated into the defect. A small cone of tissue redundancy is
then excised medially and inferiorly along the groove where it
travels into the nares (Fig. 24-12).
C
D
A
B
Fig. 24-9  (A) Young female with squamous cell carcinoma of the vermilion of the lower lip. (B) Surgical defect of vermilion after Mohs’
surgery. (C) Reconstructed with bilateral vermilion rotation flap. Incision is carried along vermilion borders to oral commissures, where back-cut
facilitates movement. Undermining deep to minor salivary glands on labial mucosa and flaps rotated centrally and sutured into place. Tricone
excised from posterior aspect of surgical wound. (D) Healed functional and aesthetic result, maintaining the anterior–posterior dimension of the
lower lip, preservation of remaining vermilion and avoidance of hypoesthesia (compared to mucosal advancement flap).

430
Chapter 24
Cosmetic surgery procedures and techniques
Although grafts may give an unnatural patchlike appear­
ance if the color, texture, and thickness is not well matched,
there are times when they can produce excellent results. Large
defects (1–2 cm) on the nasal sidewall that are not candidates
for flap repair may be repaired with full-thickness skin grafts.
Although results are generally better with local flaps, full-
thickness skin grafts offer the advantage of keeping the repair
localized to the one cosmetic unit. Full-thickness skin grafts
taken from the conchal bowl can also be used successfully to
repair shallow defects up to 1.5 cm on the nasal tip and ala.
The skin of the conchal bowl is generally more sebaceous
than other potential donor sites and can offer a reasonable
color and texture match (Fig. 24-13). The advantage of con­
chal bowl skin grafts in this area is that it does not extend the
wound and closure beyond the original defect created by the
tumor. This can be a very big advantage for certain patients.
If the defect is too deep or the surrounding tissue on the ala
or nasal tip is too sebaceous, the graft can have an unsightly
appearance.36 Other donor sites include the preauricular and
postauricular areas, the supraclavicular region, the melolabial
fold, and the forehead.
Superiorly based myocutaneous island pedicle flaps can
work very well to repair small to medium-sized defects on the
nasal dorsum, sidewall, supratip, and tip (Fig. 24-14). The ten­
sion vectors are in the horizontal plane and therefore do not
place significant tension on the mobile nasal tip or alae. These
flaps should be undermined both above and below the nasa­
lis muscle for optimal mobility. Inferiorly based island pedicle
flaps can be utilized for defects located more superiorly on
the nasal sidewall and nasal dorsum and laterally based island
pedicle flaps along the alar crease may be used for defects in
the inferior nasal sidewall and alar crease.
Rotation flaps with cutbacks (Hatchet flaps) can be used
for medium-sized defects (0.5–1.5 cm) of the nasal dorsum.
These flaps are designed to have one scar line cross the nose
in a horizontal direction (redundant tissue cone excision) and
the longer scar line traversing along the nasal sidewall or pref­
erably along the nasal sidewall–nasal dorsum cosmetic unit
junction and then extending into the glabellar crease (Fig. 24-
15). It is important to thin the thicker skin moved down from
the glabellar region to match the thinner skin of the medial
canthal region. It also important to monitor tension vectors
during closure to maintain symmetric brow position. Botu­
linum toxin injections can be used to help reduce motion on
the flaps during the healing stage and potentially allowing for
a thinner scar.
Laterally based crescentic advancement flaps are an excel­
lent reconstructive option for small to medium-sized defects
on the distal nasal sidewall. Incisions are placed along the alar
groove with a small crescent excised just superior or lateral to
the ala, and the cone of redundant tissue is excised superiorly
along the junction of the nasal sidewall and nasal dorsum.
These same very aesthetic closure lines may be used with
a superiorly based advancement flap. Any closure that falls
along the cosmetic unit junctions without distorting the ala
or nasal tip will reproducibly give a very aesthetic result.
Transposition flaps are often utilized in nasal reconstruc­
tion. Rhombic transposition flaps offer an excellent recon­
structive option for small to medium-sized defects on the nasal
sidewall and supratip. The Zitelli modification of the bilobed
flap has become a mainstay in the repair of distal nasal de­
fects up to 1.5 cm. Bilobed flaps are optimally designed to
have their redundant tissue cone lay in the alar groove and the
secondary lobe close along the cheek–nasal sidewall cosmetic
unit ­junction (Fig. 24-16). Closure of the tertiary defect is of­
ten tacked down to periosteum to maintain proper contour.
To minimize the risk of pincushioning, flaps should be widely
undermined, tacked down if going over a concavity, and not
be oversized.
Nasolabial (melolabial) transposition flaps may be used for
reconstruction of alar defects but carry with them a signifi­
cant risk of blunting the alar groove. If performed, these flaps
should be thinned and tacked down at the point where they
Fig. 24-10  The face may be viewed in terms of multiple cosmetic
units with subtle variations in contour and texture. Many of the facial
cosmetic units can be further broken down into cosmetic subunits.
Scar lines placed at the junction of two cosmetic units or subunits
tend to hide better than those crossing over these lines.

431
Aesthetic surgical closures  •  Chapter 24
cross the alar groove to recreate it. If the alar groove can be
recreated, the melolabial transposition flap can provide an ex­
cellent color and texture match for thick defects of the alae
(Fig. 24-17). If the alar defect is thick enough to create nasal
dysfunction, cartilaginous struts may be placed below the flap
for additional structural support.
Given the high risk of alar groove blunting with melolabial
transposition flaps, large alar and nasal tip defects are usually
best repaired with two staged interpolation flaps. Interpola­
tion flaps bring skin and subcutaneous tissue from either the
forehead or melolabial fold to repair the alar or nasal tip de­
fects. The obvious disadvantage of these flaps is the period of
several weeks the patient has to have an unsightly pedicle of
skin attached to the reconstructed area prior to its removal in
the second stage of the procedure.
Ear reconstruction
Since both ears are generally not visualized at the same time,
the most critical aspect of reconstructing defects on the ear
is maintaining the natural shape and contour of the ear.
­Preserving or recreating the natural shape and smooth curve
of the helix is far more important than the overall size of the
ear. Although auricular length varies somewhat based on eth­
nicity, the length to width should be slightly less than 2:1, and
the auricle protrudes from the scalp roughly 20–30 degrees.
The earlobe varies more than other areas of the ear, and tends
to elongate with age, but averages 2 cm in length and offers an
excellent reservoir of tissue for repair of lower ear defects.
Defects of almost any size in the generally concave areas
inside of the helix (scapha, triangular fossa, conchal bowl,
etc.) can be allowed to heal by second intention with excel­
lent cosmetic results. If significant amounts of cartilage are
­exposed, small punches are taken through the cartilage to ­allow
granulation to occur from the posterior ear. If a ­significant
amount of cartilage is missing from the scaphoid area and the
ear does not have a sturdy structural support, cartilage struts
may be harvested from the contralateral ear and sutured in
place to give a framework for reconstruction. Given that there
is a higher incidence of pseudomonas in this area, ­appropriate
antibiotic prophylaxis and acetic acid (diluted vinegar) soaks
help minimize the risk of infection. Tenderness of the ear is
often a significant problem for patients with wounds healing by
second intention in this area and some may go on to develop
a chondritis. Keeping the wound very moist with ­ occlusive
­ointment helps minimize this to some extent but patients
should be made aware of this before they leave the office.
Full-thickness skin grafts are an excellent option for many
defects on the ear (Fig. 24-18). Areas described above that
could be allowed to heal by second intention could also be
covered with a skin graft and have a shorter and less painful
healing time. Similarly, full-thickness skin grafts are useful to
reconstruct defects adjacent to the external auditory meatus,
where grafting decreases contracture and possible narrowing
of this aperture. In addition, superficial defects of the helix
(not involving perichondrium) are often best repaired with
a full-thickness skin graft. Common donor sites include the
preauricular and postauricular sulci. The preauricular skin is
generally thicker and more photoaged and therefore usually
gives a more aesthetic result.
Inferior and middle helix defects can be repaired with heli­
cal advancement flaps, taking advantage of the laxity of the
lobule. Incisions are made in the sulcus between the scapha
and helix anteriorly and then in the opposite area on the pos­
terior aspect of the ear. Alternatively, a cone of redundant
tissue is taken out of the posterior ear and the flap is advanced
more like an A-to-L type of advancement flap. Keeping the
flap as an A-to-L advancement enhances its blood supply
and increases its chance of survival. If there is just a little bit
too much tension on the flap at closure, the cartilage may be
shaved down in the same curvature as the helix to lessen the
distance the flap has to go, thus reducing tension.
Small defects on the helical rim can also be closed with
hinge flaps from the posterior aspect of the ear. Wound edge
eversion is critical along the helix. Placing good buried vertical
mattress sutures and cutaneous vertical mattress sutures help
evert the wound edges and reduce the risk of notching along
the helical rim.
Other than the lobule, the ear has little in terms of mo­
bile reservoirs of skin to be used for reconstruction with local
flaps. Larger defects on the superior helix may be closed with
banner-type transposition flaps from the postauricular sulcus,
bilobed flap from the same area, or two-stage flaps such as the
temporoparietal staged advancement flap or the tubed ­pedicle
flap from the preauricular sulcus. Larger defects of the middle
and lower helix may also be closed with staged ­retroauricular
advancement flaps. These flaps are extended well beyond the
postauricular sulcus (>4:1 length to width ratio) and a petro­
latum gauze is placed in the sulcus for the weeks preceding
flap division.
Medium to large defects of the helix that extend through
cartilage may also be closed with wedge excisions (Fig. 24-19).
It is important to take Burrow’s triangles out in the wedge to
• Dog-ears are especially noticeable on the nose.
• Be wary of highly sebaceous nasal skin.
• Pincushioned or trapdoor deformity.
Pitfalls
• Watch cosmetic subunits and maintain symmetry.
• Utilize cosmetic unit junctions when possible.
• Undermine widely at the level just above the
periosteum or perichondrium.
• Look for ways to cosmetically enhance the nose
during closure.
• Extend the length of primary closures.
• Undersize and judiciously thin flaps to match
contour.
Pearls

432
Chapter 24
Cosmetic surgery procedures and techniques
keep the cartilage from buckling forward. The size of these
­triangles is varied depending on the amount of curvature in
the area and the size mismatch that exists between the two sides
being brought together. The cartilage is reapproximated with
4-0 or 5-0 braided absorbable suture. Again, taking ­tension
off of wound edges with buried sutures and hypereversion
of the helical rim are important considerations for successful
aesthetic repair of the ear.37
Cheek and chin
The dermatologic surgeon will frequently find that the side-
to-side primary closure is the repair of choice on the cheek.
It must be kept in mind, however, that the cheek has both
concave and convex surfaces, so modifying the primary ­linear
closure to a crescentic closure or an S-shaped primary ­closure
often gives the best result. Few lines on the cheek are perfectly
straight. Be sure to mark the patient out while he or she is in an
upright position and prior to infiltration of local ­anesthesia.
• Maintain contour of the ear.
• Hyperevert wound edges to prevent notching.
• Remove Burrow’s triangles of cartilage when
performing wedge closures.
• Prophyl actic antibiotic coverage for
­pseudomonas is recommended.
• Consider the lobule for a reservoir of loose skin
when repairing the helix.
Pearls
A
B
C
D
Fig. 24-11  (A) Superficial defect on the sebaceous nasal tip foll owing Mohs’ surgery. (B) Side wall of defect and area around the defect
­foll owing erbium:YAG resurfacing. (C,D) Area 3 months later healed in with minimal scar formation.
• Helical notching
• Cartilage buckling
• Necrosis secondary to ischemia from
­inadequate blood supply
Pitfalls

433
Aesthetic surgical closures  •  Chapter 24
Defects of the cheek also lend themselves to flap recon­
struction, tapping into the laxity and tone and texture match
of adjacent skin. While the cheek may seem to be a vast
­expanse when compared to the lip or the nose, the dermato­
logic surgeon repairing defects on the cheek of a moderate
or large size must respect the multiple free margins and ad­
jacent structures that wound contracture on the cheek would
adversely affect. The eyelid margins, the lip margins, the
­inner canthus, and the oral commissure can all be distorted
by poorly planned or executed cheek reconstruction. Tack­
ing sutures into the periosteum along the malar eminence are
usually required with larger rotation flaps traversing under the
eye to prevent the weight of the flap from creating an ectro­
pion. These flaps should also be thinned as the thicker lateral
cheek skin is matched with the thinner skin of the eyelid.
Care needs to be taken in the mandibular cheek where
the contour becomes very convex. Closures over the convex
­surface should be avoided if possible since, as the scar con­
tracts along the long axis, it may create an unnatural dent over
the mandibular rim. Primary closures must be extended to at
least a 4:1 length to width ratio to prevent redundant cone
formation. Redundant cones of flap closures should also be
extended a bit in this area.
The chin is bound down by the labiomental crease that
extends under the jaw. The dense musculature, fibrosity, and
convex nature of the chin makes it a high-risk area for wound
contracture and depressed scars. Keeping closure lines along
the cosmetic unit junction lines, and especially in the men­
tal crease, will generally give the most aesthetic result. Like
other convex surfaces, closures should be lengthened over
the chin.
The use of skin grafts for repair and the allowance of heal­
ing by secondary intention should be avoided completely, if
possible.
A
B
C
D
Fig. 24-12  (A) Small defect in the alar crease foll owing Mohs’ surgery. (B) Alar rotation flap rotated and sutured into place. Tricone excised
along the crease into nares and tension adjusted so as not to distort the nasal ala. (C, D) Result 3 months postoperatively .

434
Chapter 24
Cosmetic surgery procedures and techniques
A
B
C
Fig. 24-13  (A) Small defect on the nasal tip foll owing Mohs’ surgery. (B) Conchal bowl full -thickness skin graft sutured into place. Graft
slightly undersized to minimize risk of pincushioning. (C) Result 3 months postoperatively .
• Close in cosmetic unit junctions when possible.
• Keep some curvature in closures on the cheek.
• Be sure there is no distortion of the eyelids, alae,
and corner of the mouth.
• Use tacking/suspension sutures when ­necessary.
• Avoid crossing the mandibular rim and the
­border of the chin and neck if possible.
Pearls
• Notching along mandibular rim/jawline
• Use of skin grafts and second intention healing
Pitfalls

435
Aesthetic surgical closures  •  Chapter 24
Forehead and temple
Reconstruction of forehead and temple defects is usually fairly
straightforward, with primary closure or advancement flaps
doing the job for the majority of cases.
Forehead defects located lateral to the medial aspect of the
eyebrow can frequently be closed in a horizontal side-
to-side fashion. This horizontal repair can close defects with
a ­superior–inferior dimension up to 1 cm, especially in older
patients with less skin elasticity and defects located on the su­
perior forehead where dermal thickness lessens. Temporary
brow elevation may occur in these patients, but this tends to
be short lived, correcting within a few weeks to months. Most
larger defects can be repaired with a type of advancement
flap. Forehead advancement flaps provide adequate lax tissue
for repair and permit placement of incisions within horizontal
forehead rhytides, helping to conceal resultant scars. Based
on the size and location of the ­defect and adjacent loose tis­
sue and the proximity of eyebrows and hairline, one might
consider a unilateral or bilateral advancement or island
­pedicle flap.
Centrally located defects superior to the glabella can be
aesthetically closed side-to-side in a vertical direction due
to the lack of frontalis muscle in the mid forehead. Larger
defects can be repaired using a local flap; however, the optimum
repair might be a rhombic transposition, rather than an ad­
vancement flap. Advancement flaps in this location risk long-
term distortion of the eyebrows medially or superiorly and
should be discouraged if any distortion is anticipated with the
B
A
C
Fig. 24-15  (A) Defect of the nasal dorsum foll owing Mohs’ surgery. (B) Hatchet-type rotation flap brought down from the glabell ar area and
sutured into place. (C,D) Result 3 months postoperatively .
A
B
C
Fig. 24-14  (A) Defect of the nasal sidewall foll owing Mohs’ surgery. (B) Superiorly based myocutaneous island pedicle flap sutured into place.
Tension diverted so as not to distort the nasal ala. (C) Result 3 months postoperatively .

436
Chapter 24
Cosmetic surgery procedures and techniques
A
B
C
D
E
F
Fig. 24-16  (A) Defect of the nasal supratip foll owing Mohs’ surgery. (B) Zitell i modification of the bilobed transposition flap sutured into place.
(C) Result 3 months postoperatively . (D) Defect of left ala with reverse modified bilobe flap design. (E) Reverse modified bilobe flap sutured in
place. (F) Result 3 months postoperatively .

437
Aesthetic surgical closures  •  Chapter 24
closure. Rhombic flaps can also be considered for repair of
lateral superior forehead defects, borrowing tissue from the
temple or temporal recession of a balding scalp.
Surgical defects of the temple may be aesthetically recon­
structed with a number of options. As a concave cosmetic
subunit, wounds heal well by secondary intention. This is
particularly true for defects distant to the eyebrow and lateral
canthus, two structures that act like free margins in this re­
gion. For small defects, side-to-side closure along relaxed skin
tension lines provides excellent results (Fig. 24-20). Larger de­
fects can be reconstructed with a transposition or other flap
(Fig. 24-21), but the surgeon should take care to avoid in­
jury to the temporal branch of the facial nerve in the tem­
ple and lateral forehead. This nerve branch runs superficial
in these areas and is most at risk over the zygomatic arch,
where a combination of thin skin and subcutaneous tissue,
especially in older patients, makes the nerve most susceptible
to injury.
A
B
C
D
Fig. 24-17  (A) Deep defect of the right ala
foll owing Mohs’ surgery. (B) Nasolabial trans­
position flap sutured into place. Special care
taken to tack down the flap at the alar crease
in attempt to recreate this crease. If this is not
done, the angle is blunted and the ala will
unnaturally blend into the cheek. (C,D) Result
3 months postoperatively .

438
Chapter 24
Cosmetic surgery procedures and techniques
Postoperative clinical ­considerations
Even when a closure has been planned considering all varia­
bles and executed with the most precise technique, sometimes
the final postsurgical scar does not meet the expectations of
the surgeon or the patient. Two time-honored postopera­
tive techniques for aesthetic improvement of scars are focal
dermabrasion and intralesional corticosteroid injections.
These techniques offer powerful tools to improve superficial
and deep textural imperfections of scars.
In addition to the time-tested techniques of dermabra­
sion and intralesional corticosteroid injections, there are a few
other techniques to optimize the aesthetics of a well-planned
and executed closure that did not heal in an ideal fashion.
The resurfacing (carbon dioxide and erbium:YAG) and frac­
tional resurfacing lasers can be used to improve textural flaws
of scars. Wet-dry sand paper has also been used successfully
to buff out scar edges.
• Think of the eyebrow as a free margin
(like eyelid or lip) and avoid repairs that will
significantly pull medially or distort shape.
• Be careful to avoid injury to the temporal branch
of the facial nerve in its superficial course
through the temple and lateral forehead.
Pitfalls
• Side-to-side repair for small forehead defects:
central is vertical; mid and lateral is horizontal.
• Side-to-side closure for forehead defects up to
1 cm in height, especially in older patients and
more superior location. The lifted brow will correct.
• Flaps: advancement for most forehead; transpo­
sition for glabell ar region, lateral forehead and
possibly , temple.
• Temple defects may heal well by secondary
intention.
Pearls
A
B
C
Fig. 24-19  (A) Full -thickness defect of the helix including cartilage foll owing Mohs’ surgery. (B) Ear wedge advancement flap sutured into
place. In addition to the wedge of cartilage taken out with the wedge closure, another small triangle of cartilage inferior to this was removed at
90 degrees to the main one in order to compensate for the difference in height of the two sides of cartilage. (C) Result 3 months postoperatively .
A
B
C
Fig. 24-18  (A) Superficial defect of the ear foll owing Mohs’ surgery. (B) Full -thickness skin graft harvested from the preauricular area and
sutured into place. Tissue chosen for match of color and texture. (C) Result 3 months postoperatively .

439
Aesthetic surgical closures  •  Chapter 24
Depressed, atrophic or contracted scars can be improved
with soft-tissue fillers. Although the majority of these filler
substances are temporary in nature, they create an inflam­
matory reaction that produces natural collagen and can
induce very long-standing if not permanent improvement
of depressed scars.
While the erythema along and around a scarline generally
improves with time, it can be quite marked and distressing to
the patient. It is important to ask your patients at postopera­
tive visits if the redness bothers them. This is especially true of
male patients who may not be as comfortable utilizing cosmet­
ics to conceal erythema and telangiectasia and who are less
likely to complain about this issue, even if it is of concern to
them. Postsurgical scars can be treated with the 585 or 595 nm
pulsed dye and 532 nm KTP lasers or intense pulsed light
sources to reduce erythema and improve texture. Although
some studies have used this type of treatment immediately
following suture removal, the vast majority of postsurgical pa­
tients will not require treatment, so the authors advise waiting
a month or two before making any assessment. The erythema
may be sufficiently improved with one laser treatment, but it
is not uncommon to need three to four treatments set at 4–6
weeks apart. Patients may anecdotally report improved tex­
ture of the scar, but this has not been studied in a controlled
manner and may be simply a result of normal wound healing
over time. Silicone-based sheeting or products may soften scar
firmness and improve final result, but this is frequently not
necessary.
A
B
C
Fig. 24-20  (A) Defect in the temple foll owing Mohs’ surgery. (B) Complex linear closure along relaxed skin tension lines. (C) Result 3 months
postoperatively .

440
Chapter 24
Cosmetic surgery procedures and techniques
In review, aesthetic reconstruction is dependent upon a
number of well-described principles based upon the defect
itself, the surrounding tissue, and the patient’s health and
expectations. Through training and experience, the derma­
tologic surgeon is well suited to produce excellent functional
and cosmetic repairs.
REFERENCES
  1. Stark RB. The history of plastic surgery in wartime. Clin Plast Surg
1975; 2(4):509–516.
  2. Dolsky RL. Cosmetic surgery in the United States: its past and present.
Dermatol Surg 1999; 25(11):886–892.
  3. Mahon-Deri B, O’Leary JP. The birth of modern ‘plastik’ plastic
surgery. Am Surg 1994; 60(9):719–720.
  4. Rohrer TE. Planning the closure. Semin Cutan Med Surg 2003;
22(4):244–254.
  5. Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps.
J Dermatol Surg Oncol 1991; 17(2):184–189.
  6. Bernstein G. Lines of elective incision on the skin. In: Lask G, Moy R,
eds. Cutaneous surgery. New York: McGraw Hill; 1996.
  7. Ridenour BD, Larrabee WF. Biomechanics of skin flaps. In: Baker SR,
Swanson NA, eds. Local flaps in facial reconstruction. St. Louis: Mosby;
1995:31–38.
  8. Milton SH. Pedicled skin flaps: the fallacy of the legnth:width ratio. Brit
J Surg 1970; 57:502–508.
  9. Daniel RK, Williams HB. The free transfer of skin flaps by
microvascular anastomoses. An experimental study and a reappraisal.
Plast Reconstr Surg 1973; 52:16–31.
10. Stell PM. The pig as an experimental model for skin flap behaviour: a
reappraisal of previous studies. Brit J Plast Surg 1977; 30:1–8.
11. Chilukuri S, Leffell D. Basic principles in flap reconstruction. In: Rohrer
TE, Cook JL, Nguyen TH, et al., eds. Flaps and grafts in dermatologic
surgery. London; Elsevier: 2007.
12. Mathes SJ, Naha F. The reconstructive triangle: a paradigm for surgical
decision making. In: Reconstructive surgery: principles, anatomy, and
technique. New York: Churchill Livingston; 1997:9–36, 153–160.
13. Fazio MJ, Zitelli JA. Flaps. In: Ratz JL, Geronemus RC, Goldman MP,
et al., eds. Textbook of dermatologic surgery, Philadelphia; Lippincott-
Raven; 1998:225–227.
14. Heniford BW, Bailin PL, Marisco RE. Field guide to local flaps.
Dermatol Clin 1998; 16(1):65–74.
15. Boyer JD, Zitelli JA, Brodland DG. Undermining in Cutaneous Surgery.
Dermatol Surg 2001; 27(1):75–78.
16. Guyton AC. Textbook of medical physiology. 6th edn. Philadelphia; WB
Saunders; 1981:344–356.
17. Pearl RM, Johnson D. The vascular supply to the skin: an anatomical
and physiological reappraisal. Part I. Ann Plast Surg 1983; 11:99–105.
18. Pearl RM, Johnson D. The vascular supply to the skin: an anatomical
and physiological reappraisal, Part II. Ann Plast Surg 1983; 11:196–205.
19. Johnson TM, Swanson N, Baker SR. Concepts of sliding and lifting
tissue movement in flap reconstruction. Dermatol Surg 2000; 26:
274–278.
20. Ratner D. Grafts. In: Bolognia J, Jorizzo J, Rapini R, eds. Dermatology,
New York: Mosby; 2003:2305–2320.
21. Waner M, Adams C, Ratner D. Skin grafts. In: Rohrer TE, Cook
JL, Nguyen TH, et al., eds. Flaps and grafts in dermatologic surgery.
London: Elsevier; 2007.
22. Hill TG. Contouring of donor skin in full-thickness skin grafting.
J Dermatol Surg Oncol 1987; 13(8):883–888.
23. Kaufman AJ. Adjacent-tissue skin grafts for reconstruction. Derm Surg
2004; 30:1349–1353.
24. Aköz T, Akan M, Yildirim S. If you continue to smoke, we may have a
problem: smoking’s effects on plastic surgery. Aesthetic Plast Surg 2002;
26(6):477–482.
25. Goldminz D, Bennett RG. Cigarette smoking and flap and full-thickness
graft necrosis. Arch Dermatol 1991; 127(7):1012–1015.
26. Dzubow LM, Zack L. The principle of cosmetic junctions as applied
to reconstruction of defects following Mohs’ surgery. J Dermatol Surg
Oncol 1990; 16(4):353–355.
27. Bennett RG. Fundamentals of cutaneous surgery. St. Louis; CV Mosby;
1988:361–364.
28. Bello YM, Phillips TJ. Recent advances in wound healing. JAMA 2000;
283(6):716–718.
29. Pollack SV. Wound healing: a review. IV. Systemic medications affecting
wound healing. J Dermatol Surg Oncol 1982; 8(8):667–672.
C
A
B
Fig. 24-21  (A) Large defect of the lateral forehead. (B) Advancement flap sutured into place. (C) Result 3 months postoperatively .

441
Aesthetic surgical closures  •  Chapter 24
30. Gette MT, Marks JG Jr, Maloney ME. Frequency of postoperative.
Allergic contact dermatitis to topical antibiotics. Arch Dermatol 1992;
128:365–367.
31. Futoryan T, Grande D. Postoperative wound infection rates in
dermatologic surgery. Dermatol Surg 1995; 21(6):509–514.
32. Kaufman AJ. Periorbital reconstruction with adjacent-tissue skin grafts.
Dermatol Surg 2005; 31:1.
33. Jelks GW, Jelks EB. Prevention of ectropion in reconstruction of facial
defects. Clin Plast Surg 2001; 28:297–302.
34. Zitelli JA, Brodland DG. A regional approach to reconstruction of the
lip. J Dermatol Surg Oncol 1991; 17:143.
35. Rohrer TE, Ugent SJ. Evaluating the efficacy of using a short-pulsed
erbium:YAG laser for intraoperative resurfacing of surgical wounds.
Lasers Surg Med 2002; 30(2):101–105.
36. Rohrer T. The use of conchal bowl skin grafting in nasal tip repairs.
American Society For Dermmatological Surgery, annual meeting, May
1995.
37. Mellette JR. Reconstruction of the ear. Principles and techniques of
cutaneous surgery, New York: McGraw-Hill; 1996:363–380.

History and Science
History
Dermabrasion is a skin resurfacing technique that surgically
abrades or planes the epidermis through the use of a rapidly
rotating wire brush or diamond fraise.1 In its simplest form,
dermabrasion was used by ancient Egyptians, in circa 1500
BC, who employed the abrasive characteristics of pumice
and alabaster to treat skin blemishes.2,3 Since the mid-1950s,
growing interest in the technique has culminated in its appli­
cation to a variety of lesions and has more recently expanded
to include facial scars secondary to acne, trauma, surgery,
and varicella-zoster virus. The growing number of applica­
tions of dermabrasion has been accompanied by evolution
of the technique from the use of common sandpaper in the
mid-twentieth century to electrically powered devices with
wire brush tips or diamond fraises of varying sizes, shapes,
and textures that can achieve speeds of over 33 000 revolu­
tions per minute.3 The most aggressive abrading end piece
is the wire brush, a 3.0×17.0 mm wheel with bristles radiat­
ing from the center. While the wire brush can be technically
difficult to master, its microlacerations are one of the most
efficient means of removing the nodules of rhinophyma, the
thick plaques of hypertrophic scars, or deep acne scars. As a
technique, dermabrasion has become the gold standard for
resurfacing and is, at present, the technique against which all
other means of resurfacing are evaluated.
Science
Dermabrasion following surgical or traumatic injury inter­
rupts the remodeling phase of wound healing. Before the
first-intention wound healing process is complete, the ablative
injury to the papillary and midreticular dermis superimposes
second-intention wound healing mechanisms on the primary
scar. As healing progresses, the epidermal component of the
scar is replaced by new epithelial cells migrating from viable
adnexal appendages. Defined ultrastructural and molecular
alterations accompany the clinically visible changes apparent
in the dermabraded area. These include increased collagen
bundle density and size with a tendency toward unidirectional
orientation of collagen fibers parallel to the epidermal surface,
as well as altered levels of α6- and β4-integrin expression in the
stratum spinosum and changes in the distribution of tenascin
expression.4 Dermabrasive modification of the extracellular
ligand expression of the primary cicatrix influences epithelial
cell-to-cell interactions and reorganization of the underlying
connective tissue, thereby producing a less perceptible scar.1
Studies
The literature supports a wealth of applications for derma­
brasion.2 Dermabrasion has been shown to produce signifi­
cant improvement in elevated full-thickness skin grafts on the
Dermabrasion
Christopher B. Harmon and
K. Wade Foster
C h a p t e r
25
P a r t 2
Key Points
n Dermabrasion following surgical or traumatic injury
interrupts the remodeling phase of wound healing
and superimposes second intention wound healing
mechanisms on the primary scar.
n Patient selection is key to obtaining excellent
results.
n A familiarity with perioperative care and proper
operative technique is instrumental to optimal
cosmetic outcomes.
n Dermabrasion is particularly useful in the treatment
of acne scars, post-Mohs’ partial-thickness defects,
and can significantly improve the appearance of
traumatic and surgical scars, and tattoos.

444
Chapter 25
Cosmetic surgery procedures and techniques
nose, periorbital area, and ears and has subsequently been
shown to be beneficial in the treatment of graft elevation in
all locations.5 Dermabrasion has also been used to successfully
treat milia en plaque and resulted in complete regression of
the lesion at a follow-up of 6 months.6 Similarly, dermabra­
sion produced excellent results in patients with Hailey-Hailey
disease that is unresponsive to conservative therapy.7
In addition to these uses, the utility of dermabrasion in
the treatment of actinic keratoses is well substantiated. Cole­
man et al.8 reviewed the clinical course of 23 patients with at
least 2 years of good clinical follow-up who were treated with
dermabrasion for actinic keratoses. Over a 5-year period of
follow-up, they found that 96% of patients remained free of
new actinic lesions for 1 year, 83% remained free for 2 years,
70% remained free for 3 years, and 64% and 54% remained
free of new actinic keratoses at 4 and 5 years, respectively.
The average time after dermabrasion before the appearance
of one actinic keratosis was 4 years. Similarly, Nelson et al.9
compared wire brush dermabrasion to diamond fraise der­
mabrasion in the treatment of photoaged skin. Both methods
of dermabrasion resulted in significant resolution of actinic
keratoses, lentigines, and wrinkling, but no significant differ­
ences were identified between the two treatment modalities.
Dermabrasion has also proven quite useful in the treatment
of surgical and traumatic scars and studies have demonstrated
that optimal results are obtained when the scar is still ‘young.’
In 1988, Yarborough10 showed that early dermabrasion
within 4–8 weeks after primary wounding results in superior
outcomes when compared to dermabrasion of mature scars.
Similarly, Katz and Oca11 used a split scar model to compare
the scar revision accomplished with diamond fraise dermabra­
sion at 4, 6, and 8 weeks after initial wounding. Although scars
were improved at 4 and 6 weeks after injury, a significantly
greater number responded to abrasion at 8 weeks, and trunk,
face, and extremities showed comparable improvement.
Discussion
In general, the indications for dermabrasion include those
lesions or skin defects of the epidermis, papillary dermis, and
upper reticular dermis that can be partially or completely
removed by surgical planing to the level of the reticular der­
mis.1 While dermabrasion can be used in the treatment of wide
variety of lesions including actinic and seborrheic keratoses,
angiofibromas, solar elastosis, and rhytides, it is particularly
useful in the treatment of acne scars and post-Mohs’ partial-
thickness defects, and can significantly improve the appear­
ance of traumatic and surgical scars, and tattoos.12 Although
the advent of ablative and nonablative lasers has broadened
the therapeutic armamentarium for skin resurfacing, the role
of wire brush surgery in the treatment of deep defects of
the skin continues to be an important one. An understand­
ing of the common clinical applications of dermabrasion, the
advantages of the technique, and its limitations can improve
outcomes and maximize patient satisfaction.
Procedures and Techniques
Preoperative clinical ­considerations
Patient selection is key to obtaining excellent results, and the
risk/benefit ratio of dermabrasion in patients who are immu­
nosuppressed or have a history of koebnerizing conditions such
as lichen planus or psoriasis, a propensity towards hyper- or
hypopigmentation, or hypertrophic scar formation may not
be favorable. Similarly, in patients who have undergone a prior
procedure involving the area to be dermabraded, e.g. surgi­
cal excision, grafting, or other procedures requiring extensive
undermining, at least 6–8 weeks should elapse before der­
mabrasion is considered, and many surgeons prefer to wait 6
months or more after a face-lift before dermabrading.
Because dermabrasion produces aerosolized particles, pre­
operative planning should begin with HIV testing and a hepa­
titis panel. A thorough past medical history including prior and
present acne regimens is also a necessary part of the preoperative
work-up for dermabrasion, and a recent history of isotretinoin
use is a contraindication to dermabrasion since this combina­
tion has been linked to the development of hypertrophic scars.13
As a general rule, 6 months is considered an adequate interval
between isotretinoin use and dermabrasion. A short (2–3 week)
preoperative course of tretinoin cream may have the benefit of
reducing the time required for re-epithelialization after derma­
brasion, and patients with Fitzpatrick type III or IV skin should
be treated with a 2–4 week preoperative course of hydroqui­
none cream 4% to minimize the risk of postoperative hyperpig­
mentation. Prophylactic antibiotics (cephalexin, 1–2 g daily for
10–14 days) should be given only to patients with a history of
impetigo but are otherwise not required. In contrast, the poten­
tial risk of herpes virus reactivation necessitates that all patients
be treated with prophylactic antiviral medications (valacyclovir
1 g daily or famciclovir 500 mg daily), and prophylaxis should
continue until full re-epithelialization has occurred, or for
14 days after the procedure.
Full-face dermabrasion requires oral or intramuscular seda­
tion in conjunction with the use of cryoanesthesia, local or
tumescent anesthesia, and nerve blocks. Meperidine hydro­
chloride 75 mg i.m. can be given with 25 mg of i.m. hydroxy­
zine 30–60 minutes prior to placement of central nerve blocks
and tumescent anesthesia, and 5–10 mg of diazepam can be
given sublingually to reduce intraoperative anxiety. Prior to
anesthetization, the operative area should be cleansed with
chlorhexidine 4% solution or similar product. Central nerve
blocks of the supratrochlear, supraorbital, infraorbital, and
mental nerves provide adequate anesthesia of the central face.
The perinasal ring block anesthetizes the nose, and the infiltra­
tion of the lateral cheeks with 150–250 cc of 0.25% tumescent
lidocaine solution delivered through a 25-gauge spinal needle
advanced medially from a preauricular insertion point provides
sufficient anesthesia for both superficial and deep abrasions in

445
Dermabrasion  •  Chapter 25
an office-based setting.14 Preoperative application of petroleum
jelly, aquaphor, or K-Y jelly along the hair line minimizes entan­
glement of the hair with the spinning tip of the hand engine.
Procedural techniques
Whether abrading acne scars or surgical scars, the technique
is similar. The hand engine (Bell, Osada, Permark) is held with
the four fingers of the hand, and the neck of the engine is stabi­
lized with the thumb (Fig. 25-1A). Refrigerant spray (Frigiderm,
containing Freon 114) is not required in every case but can be
a useful adjunct when treating large, thick scars. It should be
applied to the treatment area followed by a 5–10 second thaw
time, which provides some anesthesia, and most importantly
freezes the deeper and thicker scars so that they become a solid
substrate upon which the shoulders of the scar can be recon­
toured. Scars should be frozen without stretching, since this pre­
serves the relaxed natural state of the scar and allows for better
visualization of the fine textural detail. Once the scar is frozen,
three-point retraction is accomplished by the two hands of the
surgical assistant and the nondominant hand of the surgeon.
Passes over the treatment area are generally made with unidi­
rectional strokes perpendicular to the direction of the rotat­
ing wire brush (Fig. 25-1B). When dermabrading with the wire
brush, the direction of end piece rotation (with or against the
angle of the radiating bristles), controls the thickness of the tis­
sue plane removed with each pass. Consequently, thicker scars
are more efficiently treated with the wire brush rotating in a
clockwise direction (against the angle of the radiating bristles),
and counter-clockwise rotation (with the angle of the radiating
bristles) offers a less aggressive approach (Fig. 25-1C). With the
wire brush and the coarse diamond fraise, red papillary dots of
bleeding herald entry into the papillary dermis. The bleeding
foci become larger and admixed with frayed collagen debris
upon entry into the reticular dermis. Scars frequently crumble
or disintegrate upon abrasion, which provides another visual
end point for performing this resurfacing surgery. The bounda­
ries of the abraded area should be feathered in order to avoid
‘step-off ’ lesions or drastic pigment changes. Typically, treat­
ment zones are designed along the borders of cosmetic sub­
units for spot dermabrasion or 1–2 cm below the mandible for
full-face dermabrasion. For full-face dermabrasion, dependent
regions of the face, e.g. the mandible and lateral cheeks, should
be treated first, since visualization of these areas is the first to
become obfuscated by blood and debris. The nose and central
face are generally treated last. Cotton towels rather than gauze
pads should be used for blotting and retracting, since the latter
can become easily entangled in the rapidly rotating tip.
Dermabrasion of acne scars
Uncontrolled inflammatory acne can result in three main
types of scars.15 ‘Boxcar scars’ are small-diameter, shallow
lesions that often have an excellent response to dermabrasion
alone (Fig. 25-2). ‘Icepick’ scars are also small-diameter, but
A
B
C
Fig. 25-1  Technical considerations. (A) Proper grasp of the hand
engine. (B) The treatment stroke. After the wire brush comes in
contact with the skin surface (1), it is pulled across the treatment
area in a unidirectional fashion perpendicular to the direction of the
rotating wire brush (2). Following completion of the treatment stroke,
the wire brush is lifted from the surface of the skin (3), and in an
arciform fashion (4–5) is moved to a new area. (C) Clockwise
rotation (against the angle of the radiating bristles) of the wire brush
results in removal of a thicker plane of tissue with each pass than
counter-clockwise rotation (with the angle of the radiating bristles).

446
Chapter 25
Cosmetic surgery procedures and techniques
B
D
E
C
A
D
E
B
C
Fig. 25-2  Dermabrasion of acne scars. (A) Severe acne scarring present in an African-American male prior to dermabrasion. (B) Postoperative
appearance of the treated area. (C) Appearance of the treated area 4 weeks after dermabrasion. (D) Moderately severe acne scarring present in
a Caucasian female. (E) Appearance of the treated area 12 weeks after dermabrasion.

447
Dermabrasion  •  Chapter 25
are significantly deeper than the boxcar type and generally
require punch excision or punch grafting prior to dermabra­
sion to obtain the best results. ‘Rolling’ scars are large-diameter
atrophic, distensible, or bound-down scars that may require
subcision16 to release tethering scar tissue and thicken the der­
mis through fibroplasia, or laser resurfacing to tighten the skin.
As a complement to the use of injectable fillers, dermabrasion
can produce significant improvement in rolling acne scars as
well. Figure 25-3 demonstrates our approach to dermabrasion
of acne scars on the cheeks and glabella.
Spot dermabrasion of post-Mohs’
partial-thickness defects
Centrofacial skin is a common area for development of basal
and squamous cell carcinoma, and a subset of these lesions
are completely cleared leaving a relatively small post-Mohs’
partial-thickness defect on the nose tip, nasal ala, or free
edge of the lip. Subsequent dermabrasion of these defects
does not require application of refrigerant to the skin sur­
face and can produce results equal to or better than would
be observed with conversion of the defect to a full-thickness
wound followed by linear closure or coverage with a flap or
graft (Fig. 25-4). Pear-shaped fraises and cones are practical
when abrading around the nose and oral commissure where
angulated terrain predominates, and wheels can be used
over broader, flatter surfaces. In the case of small isolated
defects, manual dermabrasion with sandpaper (3M wet/dry
sandpaper 150–250 grit) may be convenient. Typically, the
sandpaper is secured around a rolled gauze or the barrel
of a syringe.17 Larger or deeper defects are more efficiently
treated with wire brush dermabrasion with counter-clockwise
rotation of the wire brush (with the angle of the radiating
bristles). Brush rotation in this direction offers a less aggres­
sive approach than with the firm substrate produced by
locally infiltrated anesthetic (1% lidocaine with epinephrine
1:100 000), decreases the risk of gouging the unfrozen skin of
the free edge of the lip or nose.
Revision of surgical or traumatic scars
using dermabrasion
Effective treatment of surgical or traumatic scars is of para­
mount importance since many of these, particularly facial scars,
can be physically disfiguring and have significant emotional
impact on patients.18 Programmed dermabrasion of surgical
and traumatic scars, also termed ‘scarabrasion,’ yields optimal
results when performed 6–8 weeks following the surgery or
traumatic injury and can significantly improve the thickness,
texture, and overall appearance of the scar (Fig. 25-5).
Dermabrasion of tattoos
Decorative and traumatic tattoos represent foreign-body
implantation into various depths of the dermis, and pig­
ment depth is the determining factor for tattoo removal.
Tattoos with superficial pigment that extends no deeper
than the papillary dermis can be predicted to have an excel­
lent response to dermabrasion, whereas those with pigment
deposition that extends completely throughout all layers of
skin and subcutaneous tissue can be successfully treated only
by lasers or surgical removal. Most tattoos fall somewhere
between these extremes and challenge the surgeon in choos­
ing the correct treatment modality for any given situation.
The first line of treatment for professional and amateur tat­
toos is generally the alexandrite (755 nm), ruby (694 nm), or
Nd:YAG (532 nm and 1064 nm) Q-switched lasers. However,
many tattoos have pigment that is deeper in the reticular
dermis than can be reached by the photons of the laser, and
some of the newer fluorescent tattoo pigments do not absorb
these wavelengths of laser energy. In tattoos such as these,
it is advisable to perform a test spot or punch biopsy of the
darkest area of the tattoo to determine pigment depth.19
Dermabrasion can be used to remove residual pigment that
persists after several laser treatments. And for tattoos with
pigment in the deep reticular dermis, dermabrasion may
produce some degree of scarring which is frequently pre­
ferred by patients over spotty, uneven, residual tattoo rem­
nants (Fig. 25-6).
Postoperative clinical considerations
After completion of a full-face dermabrasion, the application
of gauze soaked in 1% lidocaine with epinephrine (1:100 000)
under prechilled ice packs helps to achieve hemostasis and
soothes postoperative stinging. Triamcinolone acetonide
40 mg i.m. given immediately postoperatively and/or ice packs
reduces edema in the treated area, and 1–2 tablets of propox­
yphene N-100 every 4–6 hours helps to control postoperative
pain. The abraded area is then covered with a semipermeable
dressing (Vigilon, C.R. Bard, Inc., Covington, GA; 2nd Skin,
Spenco Medical Corp., Waco, TX), nonadherent pads (Fig.
25-7), paper tape, gauze, and Surgilast netting (Western
Medical Ltd., Tenafly, NJ). The use of semipermeable dress­
ings reduces the time for re-epithelialization by up to 40%
compared to open techniques of wound care, and this effect
is attributed to the ability of these dressings to maintain a
critical plane of humidity for epithelial cell migration.20 Post­
operative infections caused by bacteria and fungi present as
painful nonhealing erosions and, while relatively uncommon,
they can be further minimized by daily dressing changes with
careful debridement. If infection is suspected, therapy should
be initiated with empiric antibiotics and subsequent culture
and sensitivity should be used to guide therapy. The presence
of bright erythema after the first 2–3 postoperative weeks is
the first sign of early scar formation and, in addition to anti­
biotics and antifungal medications, should treated with topi­
cal high-potency steroid ointment or Cordran tape (Oclassen
Dermatologics, Corona, CA) and followed every 1–2 weeks.
Intralesional triamcinolone acetonide (5–40 mg/cc) should
be considered with any sign of ­hypertrophy, induration, or

448
Chapter 25
Cosmetic surgery procedures and techniques
A
C
E
D
B
F
Fig. 25-3  Dermabrasion of acne scars on the cheeks and glabella. Right cheek (A-H), left cheek and glabella (I-P). (A) The treatment area
has been marked with gentian violet (arrows). Dermabrasion begins with dependent areas of the lateral right cheek. Retraction provides a firm
surface upon which to dermabrade. (B, C) The skin of the medial cheeks is treated next. The wire brush is pulled over the surface of the skin
in a direction that is perpendicular (arrow) to the axis of wheel rotation (spiral). (D) Pinpoint foci of bleeding (arrows) herald penetration into the
papillary dermis. (E, F) Treatment of the right cheek is 90% complete.
(continued)

449
Dermabrasion  •  Chapter 25
G
H
I
J
K
L
Fig. 25-3–cont’d  (G) After the entire right cheek has been dermabraded, the treatment area is then ‘cross-hatched.’ This involves delicate
passes (black arrows) with the wire brush that are perpendicular to the original treatment stroke (white arrows). (H) Cross-hatching maximizes
surface uniformity. (I) Attention is turned to the left cheek. Retraction is provided by both hands of the assistant and the nondominant hand of the
surgeon. (J) As treatment of the dependent areas of the left cheek begins, different depths of penetration are apparent. The two central red areas
(within the dotted line) have been dermabraded to the level of the papillary dermis. Surrounding areas with a whiter appearance than adjacent
untreated skin (arrows) have been treated more superficially to the lower levels of the epidermis. (K) After the first pass, the area is cross-
hatched. (L) Treatment of the right cheek is complete, and after wiping away residual blood and debris, a uniform surface texture is present.
(continued)

450
Chapter 25
Cosmetic surgery procedures and techniques
elevation of the treated area. Insufficient response to topi­
cal or intralesional corticosteroids may indicate the need for
intervention with the pulsed dye laser, which can decrease
scar induration and erythema.21 Postoperative erythema
that ensues after complete re-epithelialization normally fades
completely within 2–3 months and green- and yellow-based
foundations are well suited for camouflaging this transient
condition. Patients are counseled to strictly avoid sun until
the postoperative erythema has resolved. In spite of complete
postoperative sun avoidance, however, some individuals may
show signs of hyperpigmentation over the malar prominences
and jawline. In this case, therapeutic bleaching regimens con­
sisting of topical hydroquinone and tretinoin creams applied
once to twice daily to affected areas are well tolerated and
may be started 3–4 weeks after dermabrasion. The bleach­
ing regimen should be continued for 4 –8 weeks after the
­hyperpigmentation resolves. Permanent hypopigmentation is
seen in 20–30% of patients and is more common in individu­
als with Fitzpatrick types III and IV skin. While the mecha­
nism of this condition is incompletely understood, a subset of
patients have been shown to respond to treatment with the
308 nm excimer laser.22 A similar condition called pseudohy­
popigmentation is seen when normally repigmented abraded
skin has a slightly lighter tone and appearance than that of
adjacent sun-damaged nonabraded skin. The disparity in
skin tones can be reduced with superficial- or medium-depth
chemical peels, nonablative lasers, and intense pulsed light to
blend the treated and untreated areas. Patients should also
be counseled to avoid strenuous exercise for at least 6 weeks,
since this helps to minimize petechiae in the treated area.
Acne flares from the occlusive nature of postoperative dress­
ings can be managed with oral antibiotics, and routine topical
M
N
P
O
Fig. 25-3–cont’d  (M) A small focus of acne scarring on the glabella is treated with spot dermabrasion. (N) The scars have been completely
obliterated with the wire brush and a uniform surface texture is present. (O) Arrows demonstrate the aerosolized blood and tissue that accumu­
late on the assistant’s gloved fingers from this procedure. Because this particulate matter could contain blood-borne pathogens, preoperative
patient evaluations should always include HIV and hepatitis serologies. (P) Feathering the border of the dermabraded area (arrows) helps to
minimize color differences between the treated and untreated areas.

451
Dermabrasion  •  Chapter 25
acne medications are well tolerated 2 weeks after dermabra­
sion. Milia formation is a common postoperative sequela fol­
lowing dermabrasion and is treated with gentle extraction
after a sturdy epithelium has formed.23 The appearance of
herpetic lesions should prompt a dose increase of valacyclovir
or famciclovir from the prophylactic dose of 1 g and 500 mg
daily to 1 g and 500 mg three times daily, respectively.
Summary
In the hands of the skilled practitioner, dermabrasion of acne
scars, surgical and traumatic scars, post-Mohs’ partial-thickness
defects, and tattoos can produce excellent results. Dermabra­
sion continues to be the technique best supported by the litera­
ture and surgical experience for scar revision2 and remains the
gold standard to which other resurfacing modalities are com­
pared. As such, future research efforts will continue to refine
this technique, and it will undoubtedly remain an extremely
valuable tool in the resurfacing armamentarium.
A
B
C
Fig. 25-4  Dermabrasion of a post-Mohs’ partial-thickness defect
of the nasal tip. (A) Primary basal cell carcinoma of the nose tip.
(B) Postoperative appearance of the treatment area. (C) Appearance
of the treated area 15 days after dermabrasion.
• In patients who have undergone a prior proce­
dure involving the area to be dermabraded, e.g.
surgical excision, grafting, or other procedures
requiring extensive undermining, at least 6–8
weeks should elapse before dermabrasion is
considered, and many surgeons prefer to wait
6 months or more after a face-lift.
• A short preoperative course of tretinoin cream
has the benefit of reducing the time required for
re-epithelialization after dermabrasion.
• Meperidine hydrochloride 75 mg i.m. can be
given with 25 mg of i.m. hydroxyzine 30–60
minutes prior to placement of central nerve
blocks and tumescent anesthesia, and 5–10 mg
of diazepam can be given sublingually to reduce
intraoperative anxiety.
• Preoperative application of petroleum jelly,
aquaphor, or K-Y jelly along the hair line mini­
mizes entanglement of the hair with the spinning
tip of the hand engine.
• When dermabrading a scar, it is important that it
be frozen without stretching, since this preserves
the relaxed natural state of the scar and allows
for better visualization of the fine textural detail.
• Thicker scars are more efficiently treated with
the wire brush rotating in a clockwise direction
(against the angle of the radiating bristles), and
counter-clockwise rotation (with the angle of the
radiating bristles) offers a less aggressive
approach.
• For full-face dermabrasion, dependent regions
of the face, e.g. the mandible and lateral cheeks,
should be treated first, since visualization of
these areas is the first to become obfuscated by
blood and debris. The nose and central face are
generally treated last.
• Triamcinolone acetonide 40 mg i.m. given
immediately postoperatively reduces edema in
the treated area, and 1–2 tablets of propoxy­
phene N-100 every 4–6 hours helps to control
postoperative pain.
Pearls

452
Chapter 25
Cosmetic surgery procedures and techniques
A
C
B
D
Fig. 25-5  Dermabrasion of postsurgical (A-B) and traumatic (C-D) facial scars. (A) Appearance of the surgical scar prior to dermabrasion.
(B) Appearance of the treated area 4 weeks after dermabrasion. (C) Appearance of the traumatic scar prior to dermabrasion. (D) Appearance
of the treated area 4 weeks after dermabrasion.

453
Dermabrasion  •  Chapter 25
A
B
C
Fig. 25-6  Dermabrasion of a professional tattoo. (A) Appearance
of the tattoo prior to dermabrasion. Appearance of the treated area 3
weeks (B) and 6 weeks (C) after dermabrasion.
Fig. 25-7  Postoperative coverage of the dermabraded area with
Vigilon semipermeable membranes and nonadherent pads.
• Avoid using gauze pads for blotting and
retracting during the procedure since these can
become easily entangled in the rapidly rotating
end piece. Cotton towels are preferable.
• Patients who are immunosuppressed or have
a history of koebnerizing conditions such as
lichen planus or psoriasis, a propensity towards
hyper- or hypopigmentation, or keloid or
hypertrophic scar formation may be at higher
risk for postoperative complications.
• Dermabrasion produces aerosolized particles
and could potentially result in exposure of
surgeon and staff to pathogens. Therefore,
preoperative planning should begin with HIV
testing and a hepatitis panel.
• Patients with unrealistic expectations will be
disappointed with any outcome, regardless of
the degree of improvement. The authors’ preop­
erative discussion with patients emphasizes that
dermabrasion generally results in at least 50%
improvement or more in the overall appearance
of the treated areas. The authors also stress
that a subset of individuals may get significantly
more or less improvement from the same proce­
dure, and this depends on the type of lesion that
is to be treated as well as their genetic makeup.
• The potential for scarring with herpes virus reac­
tivation during the re-epithelialization phase after
dermabrasion necessitates that all patients be
treated with prophylactic antiviral medications.
• Hypertrophic scars can result from dermabra­
sion performed on a patient with ongoing or
recent use of isotretinoin.
• There is increased risk of postoperative
hyperpigmentation in patients with Fitzpatrick
type III or IV skin, and patients should be aware
of this risk prior to the procedure and treated
with a 2–4 week preoperative course of 4%
hydroquinone cream.
Pitfalls

454
Chapter 25
Cosmetic surgery procedures and techniques
REFERENCES
  1. Harmon CB. Dermabrasion. In: Fitzpatrick’s dermatology in general
medicine, 6th edn, vol. 2. Freedberg IM, Eisen AZ, Wolff K, et al., eds.
New York: McGraw-Hill Professional; 2003:2536–2537.
  2. Lawrence N, Mandy S, Yarborough J. et al. History of dermabrasion.
Dermatol Surg 2000; 26:95–101.
  3. Padilla RS, Yarborough JM. Dermabrasion. In: Dermatologic surgery.
Ratz JL, ed. Philadelphia: Lippincott-Raven; 1998:473–484.
  4. Harmon CB, et al. Dermabrasive scar revision. Immunohistochemical
and ultrastructural evaluation. Dermatol Surg 1995; 21:503–508.
  5. Robinson JK. Improvement of the appearance of full-thickness skin
grafts with dermabrasion. Arch Dermatol 1987; 123:1340–1345.
  6. van Lynden-van Nes AM, der Kinderen DJ. Milia en plaque successfully
treated by dermabrasion. Dermatol Surg 2005; 31:1359–1362,
discussion 1362.
  7. Hamm H, Metze D, Brocker EB. Hailey-Hailey disease. Eradication by
dermabrasion. Arch Dermatol 1994; 130:1143–1149.
  8. Coleman WP 3rd, Yarborough JM, Mandy SH. Dermabrasion for
prophylaxis and treatment of actinic keratoses. Dermatol Surg 1996;
22:17–21.
  9. Nelson BR, et al. A comparison of wire brush and diamond
fraise superficial dermabrasion for photoaged skin. A clinical,
immunohistologic, and biochemical study. J Am Acad Dermatol 1996;
34:235–243.
10. Yarborough JM Jr. Ablation of facial scars by programmed
dermabrasion. J Dermatol Surg Oncol 1988; 14:292–294.
11. Katz BE, Oca, AG. A controlled study of the effectiveness of spot
dermabrasion (‘scarabrasion’) on the appearance of surgical scars. J Am
Acad Dermatol 1991; 24:462–466.
12. Roenigk HH Jr. Dermabrasion for miscellaneous cutaneous lesions
(exclusive of scarring from acne). J Dermatol Surg Oncol 1977; 3:
322–328.
13. Rubenstein R, Roenigk HH Jr, Stegman SJ, et al. Atypical keloids after
dermabrasion of patients taking isotretinoin. J Am Acad Dermatol
1986; 15:280–285.
14. Goodman G. Dermabrasion using tumescent anesthesia. J Dermatol
Surg Oncol 1994; 20:802–807.
15. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system
and review of treatment options. J Am Acad Dermatol 2001; 45:
109–117.
16. Alam M, Omura N, Kaminer MS. Subcision for acne scarring:
technique and outcomes in 40 patients. Dermatol Surg 2005; 31:
310–317.
17. Zisser M, Kaplan B, Moy RL. Surgical pearl: manual dermabrasion.
J Am Acad Dermatol 1995; 33:105–106.
18. Poulos E, Taylor C, Solish N. Effectiveness of dermasanding (manual
dermabrasion) on the appearance of surgical scars: a prospective,
randomized, blinded study. J Am Acad Dermatol 2003; 48:897–900.
19. Apfelberg DB, Manchester GH. Decorative and traumatic tattoo
biophysics and removal. Clin Plast Surg 1987; 14:243–251.
20. Pinski JB. Dressings for dermabrasion: occlusive dressings and wound
healing. Cutis 1986; 37:471–476.
21. Alster T. Laser scar revision: comparison study of 585-nm pulsed dye
laser with and without intralesional corticosteroids. Dermatol Surg
2003; 29:25–29.
22. Grime PE, Bhawan J, Kim J, et al. Laser resurfacing-induced
hypopigmentation: histologic alterations and repigmentation with
topical photochemotherapy. Dermatol Surg 2001; 27:515–520.
23. Spencer JM, Harmon CB. Microdermabrasion and dermabrasion. In:
Surgery of the skin, procedural dermatology. Robinson J, Hanke CW,
Sengelmann R, et al., eds. Philadelphia: Mosby; 2005.
• Noticeable pigmentary differences between
treated and untreated skin can be minimized by
feathering the borders of the treatment area.
• Postoperative infections caused by bacteria and
fungi often manifest as painful nonhealing
erosions.
• The presence of bright erythema after the first
2–3 postoperative weeks is the first sign of early
scar formation and should be treated with
topical high-potency steroid ointment or Cordran
tape and followed every 1–2 weeks.
• Intralesional triamcinolone acetonide
(5–40 mg/cc) should be considered with any
sign of hypertrophy, induration, or elevation of
the treated area. Insufficient response to topical
or intralesional corticosteroids may indicate
the need for intervention with the pulsed dye
laser, which can decrease scar induration and
erythema.
• Postoperative hyperpigmentation should be
treated with therapeutic bleaching regimens
consisting of topical hydroquinone and tretinoin
creams applied once to twice daily to affected
areas. Bleaching regimens may be started
3–4 weeks after dermabrasion and should be
continued for 4–8 weeks after the hyperpigmen­
tation resolves.
• Permanent hypopigmentation is seen in 20–30%
of patients and is more common in individuals
with Fitzpatrick types III and IV skin. This
condition responds to treatment with the 308 nm
excimer laser.
• Pseudohypopigmentation is seen when normally
repigmented abraded skin has a slightly lighter
tone and appearance than that of adjacent
sun-damaged nonabraded skin. This condition
responds to superficial- or medium-depth chemi­
cal peels, nonablative lasers, and intense pulsed
light to blend the treated and untreated areas.
• Acne flares from the occlusive nature of
postoperative dressings can be managed with
oral antibiotics, and routine topical acne
medications are well tolerated 2 weeks after
dermabrasion.
• Postoperative milia formation is a common
sequela that is treated with gentle extraction
after a sturdy epithelium has formed.
Pitfalls

HISTORY AND SCIENCE
Unsightly or symptomatic venulectasia or telangiectasia on
the legs occurs in 29–41% of women and 6–15% of men
in the United States.1 These smaller vessels are most often
directly or indirectly connected to larger reticular or varicose
‘feeding’ veins. Even though up to 53% of patients with leg
telangiectases have associated symptoms, the most common
reason patients seek consultation is cosmetic.2 The variation
in vessel size, flow, depth, and type preclude the possibility of
a single effective treatment modality. Vessel types include vari­
cosities, reticular or feeder veins, and superficial spider veins.
Telangiectases, although readily visible on the skin surface
of the leg, are often manifestations of abnormal physiology
of its venous system. When accompanied by larger varicose
veins, associated telangiectases cannot be successfully treated
without addressing the problems induced by hydrostatic pres­
sure. Hydrostatic pressure leads to sequestration and stagna­
tion in the venous system as blood backs up into veins with
malfunctioning valves. This process may cause even smaller
surface veins such as reticular veins and associated telangiec­
tatic webs to expand with pressure, producing symptoms.
Ambulatory phlebectomy allows treatment of virtually all
large truncal varicose veins; compression sclerotherapy can be
used to treat large varicose veins and reticular varicose veins.
Once venous pressure is addressed, telangiectases may be
treated either with sclerotherapy or with laser/light devices.
In patients with isolated telangiectases without pressure prob­
lems, sclerotherapy or laser/light therapy may be instituted
primarily. In cases where an incompetent valve occurs at the
main valve of the greater saphenous vein (GSV) at the junc­
tion of the femoral vein, other surgical techniques or the new
radiofrequency occlusion techniques may be required. All
these approaches may be performed in the office setting. Each
of these approaches and the role of lasers and light sources in
the treatment of leg veins will be addressed in this chapter.
Diagnosis
Physicians must acquire the knowledge to diagnose origins
of reverse flow, which causes varicose or reticular veins and
ultimately associated telangiectases. Reverse flow through
incompetent valves frequently leads to abnormal veins on the
leg. Diagnostic instruments include Doppler ultrasound and
duplex ultrasound.
Knowledge of basic superficial venous anatomy is essential.
Three important superficial venous systems include the greater
saphenous vein (GSV), the lesser saphenous vein (LSV), and
the lateral subdermic venous system (LSVS) (Figs 26-1, 26-2).
Physical examination is performed to determine ­whether
telangiectatic webs or varicose veins seen on the surface
Leg Vein Management
Jeffrey T.S. Hsu
C H A P T E R
26
P a r t 2
Key Points
n Treatment of leg veins requires thorough under­
standing of venous anatomy and diagnosis of the
origin of reflux.
n Compression remains a fundamental strategy in the
treatment of leg veins.
n While they may be effective in treating small
­telangiectasia, cutaneous lasers cannot adequately
treat large reticular veins and varicous veins.
n Patients must understand that perfect legs are not
possible.
n Foam sclerotherapy is a simple, effective
­modification on traditional sclerotherapy.

456
Chapter 26 
Cosmetic surgery procedures and techniques
­originate from venous pressure in one or more of these three
segments of venous anatomy. Younger patients (20s and 30s)
usually present with telangiectatic webs originating from
­reverse flow or reflux in the lateral venous system unless there
is a strong family history of larger varicose veins. When there
is a positive family history of large varicose veins, reflux origi­
nating from the GSV or LSV must be suspected. A duplex
ultrasound study on patients presenting for treatment of
‘cosmetic’ leg veins demonstrated a relatively high incidence
of early associated axial or truncal reflux in the GSV.3
The microanatomy responsible for the transmission of ve­
nous hypertension into telangiectases via reticular varicosities
has been documented by high-resolution duplex ultrasound.4
A reticular vein is a thin-walled blue superficial venulectasis
thought to be part of a network of subcuticular veins commu­
nicating with the venous system via direct connections to the
saphenous system or by small perforating veins that can course
through superficial and deep fascia. These reticular veins are
commonly called ‘feeder’ veins, since the assumption is that
reflux through them causes the groups of telangiectases, al­
though physiologically these reticular veins drain blood from,
not to, the telangiectases.
Doppler ultrasound findings on thousands of patients con­
firm that reflux through the lateral subdermal venous system
is very frequently associated with large areas of painful tel­
angiectatic webs on the lateral and posterior thighs.4,5 This
lateral venous system may receive reflux from knee perforating
veins, lateral thigh perforating veins, or posterior thigh perfo­
rating veins. Perforating veins connect the deep and superfi­
cial venous systems of the leg. Figure 26-2 shows a schematic
of the lateral subdermal venous system anatomy.
Algorithmic approach to the treatment
of leg veins
Treating varicosities successfully requires rational selection of
interventions (Fig. 26-3). To choose the optimal therapeutic
technique, physicians must first diagnose the origin of the
Common femoral
vein
Superficial circumflex
Anterolateral thigh
tributary
Anterior thigh
vein
Anterior branch
Dorsal arch
Greater saphenous vein
(superficial) joining common
femoral vein (deep) at the
saphenofemoral junction
Epigastric vein
Pudendal vein
Posteromedial thigh
tributary
Greater saphenous
vein
Posterior branch
Greater saphenous vein
The vein of Giacomini
connects the short
saphenous to the greater
saphenous vein in a
majority of cases
Popliteal vein
Short saphenous
vein
Femoral vein (deep)
The short saphenous vein
(superficial) joins the femoral
or popliteal deep vein at or
near the popliteal crease in
nearly 2/3 of cases. Many
other drainage patterns
may be seen
Posterolateral branch vein
Fig. 26-1  Superficial anatomy of the venous system. (A) Greater saphenous vein. (B) Short saphenous vein. (From Weiss RA, Feied CR,
Weiss MA. Vein diagnosis and treatment: a comprehensive approach. New York: McGraw-Hill; 2001.)

457
Leg vein management  •  Chapter 26
reflux. Physical examination is necessary to determine ­whether
the surface telangiectases originate from a deeper source of
incompetence. To make this determination, it is necessary to
have adequate knowledge of the superficial venous ­anatomy
and possess the proper diagnostic tools and equipment,
including ultrasound devices. If present, reticular or larger
varicose veins should be eliminated first either surgically or
through endovenous ablation. This should be followed by scle­
rotherapy of the remaining vessels, from largest to smallest.
Vessels that do not respond to sclerotherapy, that are too small
to be injected, or that remain after sclerotherapy, should be
considered for laser and light treatment. A primary indication
for laser and light sources is telangiectatic matting. By adher­
ing to these principles, patients will receive cost-effective, effi­
cient, and logical care.
Doppler ultrasound
The handheld Doppler ultrasound is the main tool used to
detect reverse flow or reflux in the superficial venous system.
Optimal frequencies for examining superficial vessels (1–2 cm
below the skin) are 8–10 MHz, while deeper vessels require a
lower frequency of 4–5 MHz.6,7 Blood flow is slow and inter­
mittent; it is mainly pulsed by calf muscle contraction. To
generate an audible signal of flow, a maneuver such as manual
compression of the calf (simulating a muscle contraction) must
be performed by the examiner. When compression is released,
gravitational hydrostatic pressure causes reverse flow to cease
within 0.5–1.0 second when valves are competent, but a long
flow sound is audible when valves are incompetent.
The Doppler examination is usually performed with the
patient standing or sitting, because gravitational hydrostatic
pressure enhances the volume and velocity of retrograde flow
and makes it easier to detect. To perform this test, the nondom­
inant hand gently squeezes the leg well below (distal compres­
sion) or above (proximal compression) the point of ­auscultation,
while the dominant hand holds the Doppler transducer lightly
against the skin. Under normal circumstances, flow should
be heard only during active distal compression. Flow that is
heard during proximal compression or immediately after the
release of distal compression is retrograde flow – a clear sign
of incompetent valves (Fig. 26-4).
Duplex ultrasound
Until recently, photoplethysmography (PPG) was used as an
adjunctive investigational tool to the handheld Doppler for
more accurate diagnosis of reflux. However, with the advent
of high-quality, affordable, and compact duplex ultrasound
machines, PPG has been replaced in most phlebologists’
offices. Duplex ultrasound is a dual-mode diagnostic tool that
allows a timed pulse echo to be superimposed with the con­
tinuous-wave Doppler. This allows one to ‘see’ the anatomy in
two dimensions while superimposing the Doppler flow signal
as a color marker. Reflux can then be demonstrated visually
rather than purely audibly as with the handheld device. The
site of origin of reflux can be pinpointed. Duplex may also be
used to guide treatment by direct visualization of the needle.
Structures that absorb, transmit, or scatter ultrasonic waves
appear as dark areas, while structures that reflect the waves
back to the transducer appear as white areas in the image.
Vessel walls reflect ultrasound, while blood flowing in a ves­
sel absorbs and scatters ultrasound in all directions; thus, the
normal vessel appears as a dark-filled, white-walled structure.
Nonflowing blood and thrombus are somewhat ultrasonical­
ly reflective, although less so than the vessel wall; thus, they
­appear as heterogeneous areas of gray echogenicity within
the vessel.
Reflux is diagnosed by placing the transducer over the
­vessel in a longitudinal plane and observing the Doppler signal
in the vessels while (with the free hand) the distal leg is mo­
mentarily compressed and released to increase the cephalad
movement of blood. Functional valves permit flow only in
Femoral vein
Knee perforating
veins
Lateral subdermic
venous system
(LSVS)
Lateral thigh
perforating vein
PTPV
Fig. 26-2  Lateral subdermic venous system. (From Weiss RA,
Feied CR, Weiss MA. Vein diagnosis and treatment: a
comprehensive approach. New York: McGraw-Hill; 2001.)

458
Chapter 26 
Cosmetic surgery procedures and techniques
the antegrade direction, but normal vessels can demonstrate
brief retrograde flow due to slow closing of valves (Fig. 26-5).
Retrograde flow of duration greater than 0.5 s is considered
pathologic reflux, and reflux that lasts more than 2 s is hemo­
dynamically significant.
In the longitudinal view, the origin of the greater saphen­
ous vein is identified as it courses off the common femoral
vein (Fig. 26-6). Two valves can be visualized in the greater
­saphenous vein. The first is the terminal valve, which lies at the
vein origin. Distal augmentation for Doppler flow reveals com­
petence or incompetence of this valve. The second valve, the
subterminal valve, is examined in the same fashion. Valsalva
maneuver may also show incompetence of these valves. Major
tributaries that empty into the region of the saphenofemoral
junction can be identified here. These include the circumflex,
pudendal, epigastric, and others. Most commonly seen is the
epigastric because of its size and position in the same plane as
the termination of the greater saphenous vein.
A
 
B
 
C
Fig. 26-4  Gravitational flow along with external muscle compression is required to hear flow sounds. (A) Compression and release with
normal valves. (B) Compression and release with refluxing valves. (C) Principle of Doppler transducer: audible signal is given to the examiner
when flow is detected in the vessel.
Physical exam
Varicose vein
Reticular vein
Reflux
No reflux
Spider telang
Matting
Saphenofemoral reflux
Branch varicosity
Ambulatory phlebectomy
Sclerotherapy
Sclerotherapy
Laser/light
Laser/light
Stripping/ligation
Endovenous occlusion
Ambulatory phlebectomy
Sclerotherapy
Fig. 26-3  Algorithm to diagnosis and treatment of leg veins.

459
Leg vein management  •  Chapter 26
Compression
Use of external compression therapy (CT) is a fundamental
strategy in the treatment of lower extremity venous disease.
Despite recent therapeutic advancements in leg vein treat­
ment, compression remains a simple, effective, and inexpen­
sive modality. It should be considered as the primary treatment
in many conditions, and as an adjunct when other treatments
are employed (Box 26-1).
Active and passive compression
Compression can be either passive or active. Passive compres­
sion is applied using inelastic bandages. As muscles contract,
the bandages resist the volume increase and thereby increased
pressure is delivered. As the muscles relax, the volume decreases
so that minimal pressure is applied by the bandages. On the
other hand, active compression using elastic bandages permits
application of pressure both during muscular exercise and at
rest. This constant pressure may not be tolerated by bed­
ridden or inactive patients, and may be contraindicated in
arterial insufficiency (Fig. 26-7).
Whether passive or active, compression improves venous
disease through several mechanisms. Compression narrows
the lumens of the veins in the superficial system, which accel­
erates venous flow, decreases venous pooling, and helps to shift
venous flow from the superficial into the deep venous system.
Compression also may partially restore valvular function, and
gradually reverse degenerative changes in the veins, thus also
reducing venous reflux.
Compression bandages
Short-stretch bandages  Various modalities are available
for compression. Completely rigid inelastic bandages, such as
the zinc gel Unna boot (Unna-Flex, Convatec, Princeton, NJ),
and the Gelocast (Beiersdorf Inc., Norwalk, CT), both dry
to form a cast around the leg. Short-stretch bandages such
as Comprilan (Beiersdorf, Norwalk, CT) are made of fabric
that stretches 30–50%. Inelastic bandages and short-stretch
bandages exert passive compression to treat edema, deep vein
thrombosis (DVT), or ulcerations due to chronic venous insuf­
ficiency (CVI). They must be applied by trained staff to ensure
proper fit, and remain in place for several days continuously.
However, as edema remits and leg circumference decreases,
the inelastic nature of the bandages fails to accommodate for
this change and corresponding pressure loss can occur as early
as within the first few hours of application.
Long-stretch bandages  Long-stretch bandages, made of
fabric that can stretch 100–200%, provide active compres­
sion, indicated after surgery, sclerotherapy, or thrombophlebi­
tis. Their main disadvantage is the potential hazard to patients
Normal competent
valve
Expanded and leaking
valve
Fig. 26-5  Valve leaflets that fail to meet allow reflux.
Fig. 26-6  Duplex view of the greater saphenous vein entering the
femoral junction, known as the saphenofemoral junction (SFJ).
Box 26-1  Indications for compression
Deep vein thrombosis (DVT) prophylaxis
Symptomatic varicose veins
Chronic venous insufficiency
Venous ulcers
Post-sclerotherapy
Post-phlebectomy
Pregnancy
Thrombophlebitis
Active DVT treatment