Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

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Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.9  Blepharoplasty questionnaire. (With permission from Weber PJ, Oleson GB, Moody BR. Evaluation documentation in
cosmetic oculoplastic surgery. Int J Cosmetic Surg 2000;2:41.)
Blepharoplasty questionnaire
1
CIRCLE THE ANSWERS; USE OTHER SIDE OF PAGE FOR LONGER ANSWERS PLEASE
No Yes 1. Do you wear glasses or contact lenses? (circle which)
No Yes 2. Do you have any history of glaucoma or other eye disease?
No Yes 3. Have you had any injuries or surgery to the eyes or lids? Explain:
No Yes 4. Do you have frequent irritations to the eyes themselves or the skin of the lids?
No Yes 5. Do you now take or have you taken medications or drops for the eyes? Explain:

No Yes 6. Are you bothered by dry eyes?
No Yes 7. Do your eyes tear excessively?
No Yes 8. Do you now have or have you ever had visual problems with one or both eyes? Explain:

No Yes 9. Are there any other problems we have not asked about that you feel we should know?
No Yes
10. On looking in a mirror, do you notice any differences between the right and left eyes?
No Yes
11. Do you notice any intermittent or cyclical swelling of the eyes? How often are the cycles?
Date of your last eye exam:
Name and address of the physician who performed the examination:
Continued

634
Part 3  Aesthetic Surgical Procedures
Blepharoplasty questionnaire (continued)
2
No Yes 12. Are you pleased with the appearance of your eyebrows? If not, why?
(Please refer to the diagram below) What do you believe are the problem areas of your eyes (as far as
appearance is concerned)? Indicate by circling.
Which of the following seven items regarding your eyes would you like to be changed? (circle which)
color texture fine wrinkles "bagginess" coarse wrinkles thin skin crow's feet
How many years younger do you wish your eyes to look? (circle) 20 10 5 or (appropriate for my age)
Please read the following and carry out the instructions:
Cover your RIGHT eye and read THIS sentence with your LEFT eye only.
Are you able to read it comfortably? with glasses (Y or N) without glasses (Y or N)
Cover your LEFT eye and read THIS sentence with your RIGHT eye only. with glasses without glasses.
If there is any difference in your vision please indicate:
Both eyes same (approximately) Right eye stronger Left eye stronger
I signify that the information provided above is correct to the best of my knowledge:

(signature)
(date)
Patient Name:
Date:
X
Figure 39.9, cont’d

635
Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.10  Blepharoplasty examination. (Modified with permission from Weber PJ, Oleson GB, Moody BR. Evaluation
documentation in cosmetic oculoplastic surgery. Int J Cosmetic Surg 2000;2:41.)
Blepharoplasty examination
Patient Name: Date:
LACRIMAL
GLAND:
+ or –, or
( ) Visible temporal fullness; ( ) lid double eversion;
( ) Visible on digital globe pressure; Schirmer test in mm ( ) vs. ( ) (+/–) anesthetized
PTOSIS LIDS:
(Lid margin coverage of limbus)
MRD upper lid:
MRD lower lid:
PTOSIS grade: ( ) middle middle( )
LEVATOR function: ( ) middle middle( )mm excursion
Upper lid from far upgaze to downgaze with the eyebrow fixed over three trials (normal = 12–16mm;
good = 8–12; fair = 5–7; poor ? 4mm)
Vertical palpebral fissure (N = 8–10mm) ( ) middle middle( )
Horizontal fissure (mm) ( ) ( )
UPPER LIDS: Skin thickness of upper lid (circle): very thin, thin, normal, thick
1
MRD Upper
Normal 4mm
Mild ptosis 1.5–2mm
Moderate ptosis 0.5mm
Severe ptosis -0.5mm
VISUAL FIELDS:
(2–3" from examiner, opposite eye occluded)
(lids and brows elevated)
I
I
I
I
(brows only elevated)
I
I
I
I
(untouched)
I
I
– nasal
I
I
nasal –
EYEBROW:
Hair density: 0 + ++ +++ Symmetry: vs.
Brow insertion (at or above) orbital rim (circle):
Segmental brow ptosis? If yes, what is the lift necessary (mm)?
lat( ) mid( ) nasal( ) nasal( ) mid( ) lat( )
(+/– ) High forehead; (+/– ) receding hairline; (+/– ) sparse scalp hair
VISUAL
ACUITY:
With contacts or glasses in: ( ) 20/20 , ( ) 20/20
Ophthalmologist or optometrist (circle):
Refraction: : / : / Exam date:
OTHER:
( ) ( ) Bell’s phenomenon
PERRLA: + or – (circle)
Pigment or tattoo at lid margins: upper Iower lids
( ) Round facies; ( ) hypertrichosis; ( ) thinned eyebrows;
( ) protuberant globes; ( ) sweating
R
R
R
R
L
R
R
R
L
R
L
R
L
R
L
– nasal
nasal –
R
L
– nasal
nasal –
R
L
R
L
R
L
L
L
R
L
L
L
L
R
L
R
L
A
Continued

636
Part 3  Aesthetic Surgical Procedures
Blepharoplasty examination (continued)
Patient Name: Date:
XS-skin (mm):
XS-skin (mm): lateral( ) middle( ) nasal( ) nasal( ) middle( ) lat( )
UPPER LIDS (cont'd):
Natural crease height (by pulling up on lower eyebrow) in mm:
lat( ) mid( ) nasal( ) nasal( ) mid( ) lat( )
Estimated excision (mm necessary) upper lid SKIN:
Muller's muscle/epi. Test: neosynephrine response ( ) middle middle( )
FATTY pockets
(eyes closed tightly, gentle pressure on globes, 0, +, or ++):
uppers:
lowers:

lat( ) mid( ) nasal( ) nasal( ) mid( ) lat( )
TENZEL
‘Snap-back’ (laxity gradation: ‘mild’ = no ‘show’, slowly back; ‘mod’ = >1 mm ‘show’,
2–3 blinks for return; ‘marked’ ≥ 1mm of ‘show’ and/or ectropion)
LATERAL CANTHAL
TENDON:
Lateral canthal ‘web’: 0 , + , ++ ( ) middle middle( )
Distance between lateral orbital rim and canthus in mm (N << 1 fingerbreadth)
MARGIN DISTRACTION
(‘Pull test’ 6–8 mm = lax) ( ) middle middle( )
MEDIAL CANTHAL
TENDON:
Abn., if able to be pulled to medial limbus: ( ) ( )
(Tenzel: abn., if pulled ≥ 3mm from med canthus): ( ) ( )
2
OTHER:
Pt. Anxiety level (0 (lowest) – 5 (high)): ; Unreasonable expectations or ‘perfectionist’:
Appears: ( ) unkempt ( ) hygiene; ‘dry eyes’ ; ‘scars’
Thyroid symptoms: ; Who desires blepharoplasty?
Underlying concerns: ( ) social; ( ) business; ( ) other
Brow aches ; eye ‘fatigue’ ; visual field loss
bleeding history ; ASA products ; arthritis ; hypertension
FH ptosis: ; child pictures if ptotic?
Daily history of varying ptosis (myasthenia gravis):
Previous eye surgery (cataract, retina, trauma, neovascularizing diseases, etc.)
Blepharochalasis (at puberty, bouts of allergic edema, +FH)
HORIZONTAL TONE /
LAXITY:
‘Snap-back test’ (w/o blinking) 0/ +/ ++ seconds : ( ) middle middle( )
(Orbicularis ‘cheating’ = with # of blinks) #: ( ) middle middle( )
LOWER lids:
‘Bags on bags’ (orbicularis festooning), 0 / + / ++ ( ) middle middle( )
If + and not longstanding: Allergy:
Renal: Thyroid:
Scleral ‘show’ (mm):
uppers ( ) middle middle( ); lowers ( ) mid mid( )
Eyelid edema/erythema: ( ) middle middle( )
Tattoo or pigment?
Hypertrophic orbicularis muscle: ( ) middle middle( )
Hypoplasia of maxilla, malar eminences? Y / N, if ‘yes’ discuss:
R
R
R
L
L
L
R
R
R
L
L
L

lat( ) mid( ) nasal( ) nasal( ) mid( ) lat( )
R
R
R
L
L
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
R
R
L
L
L
Figure 39.10, cont’d

637
Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.11  Traditional surgical approaches to brow lifting.
Modified anterior hairline incision
Coronal lift
Endoscopic forehead incisions
Direct brow lifting
Mid-forehead lift
Transpalpebral browpexy
Mid-forehead
brow lifting
Temporal brow lifting
Traditional approaches to brow lifting
Figure 39.12  (A) Preoperative view and (B) 3 weeks after laser-assisted upper eyelid blepharoplasty and browpexy.
A
B
for more effective eyebrow lifting, because the postero-
cephalic advancement of the skin–muscle flap of the forehead
will also eliminate the risk of forehead wrinkle formation
above the eyebrow. For under-brow fixation, we recommend
absorbable suture material. If asymmetry of the eyebrow
position becomes a concern after surgery, massaging the more
highly located eyebrow downwards along with using absorb-
able sutures will help restore brow symmetry.
Direct brow lifting is the simplest and most direct approach
performed only with local anesthesia and can be considered
if asymmetries in brow position exist. Due to visible scars,
the authors recommend using this procedure only in older
patients (Fig. 39.13).
Mid-forehead brow lifting may also be considered when
brow asymmetries are present. Ideal candidates for this pro-
cedure are male or female patients with deep forehead lines
and high foreheads. Perfectly placed incisions in forehead
creases and accurate suture techniques are mandatory to
avoid visible scars (Fig. 39.14). First, the excess skin is
removed using a plane of dissection in the subcutaneous
tissue. The first author (AF) recommends splitting the fron-
talis muscle and moving the skin–muscle flap upwards using
a dissection plane under the deep galea for a longer-lasting
effect. Using the Ramirez #4 and #7 dissectors, a release of
the deep galea at the supraorbital rim will help move the flap
upwards. The wound closure will not be under any tension,

638
Part 3  Aesthetic Surgical Procedures
Figure 39.13  (A,B) A 72-year-old man with asymmetric brow ptosis, marked upper and lower eyelid dermatochalasis, pseudoptosis of
the right eye, prolapse of the medial and central fad pads, and of the lacrimal gland (upper eyelid), scleral show, and lower lid laxity.
(C) Intraoperative view, immediately after direct brow lifting, laser-assisted upper eyelid blepharoplasty, repositioning of the lacrimal
gland within the lacrimal fossa, and canthopexy (right eye). (D) Postoperative result 2 years later. Note: despite maximum lifting effect
immediately postoperatively, there is a tendency for recidivism of the dermatochalasis in older patients. From Fratila AM. Laser-
Assisted Blepharoplasty In: Goldman MP, Weiss R, eds. Advanced Techniques in Dermatologic Surgery. Informa Healthcare; 2006.
A
B
C
D
and the risk of dehiscent scars is minimized. As with any
surgical dissection, the surgeon should bear in mind the loca-
tion of important nerves, for example the supraorbital and
supratrochlear.
Temporal brow lifting can be employed if there is more
lateral brow ptosis with accentuated crow’s feet in patients
with relatively narrow temples. Tyers & Collin prefer to
remove an ellipse of skin and muscle based on a lateral fore-
head skin crease.14 We consider temporal brow lifting to be
the method of choice for patients with pseudodermatochala-
sis who are returning for a second blepharoplasty (Fig. 39.15)
and perform this method with the help of the lighted retrac-
tor or the endoscope (Fig. 39.16). It can be done in combina-
tion with upper eyelid blepharoplasty if this is also necessary.
The incision may be curved, beginning and ending the incision
away from the hairline or as an irregular incision.22 In both
cases, incisions are marked approximately 2–3 cm inside the
temporal hairline. With a blunt dissection, the temporal flap
is undermined just superficial to the deep temporal fascia
(DTF) and is carried inferomedially down to the supraorbital
rim. The orbital retaining ligament bridges the zygomatico­
frontal suture and inserts into the overlying orbicularis muscle
and skin close to the tail of the eyebrow. For a more effective
posterocephalic advancement of the temporal flap, this liga-
ment should be divided (see Fig. 39.16A). Wound closure is
accomplished with buried subdermal suture 3-0 polyglactin
(Vicryl) to suspend the temporal flap to the DTF and relieve
all tension from the wound’s edges. If the desired lifting
effect is not accomplished, an additional lifting of the eyebrow
is accomplished using a thread running through a buttonhole
incision at the apex of the eyebrow then coming back and
sutured to the DTF (see Fig. 39.16B). The wound closure is
completed with stainless steel skin clips and a pressure dress-
ing is applied (see Fig. 39.16C).
The concept of using suture material to suspend the brow
has considerable appeal. The basic concept is to place percu-
taneously a suspending suture from the brow to a fixation
point superior to the brow. A number of different materials
and techniques have been proposed, but all essentially achieve
the same result.23–25 Unfortunately, the results are neither
impressive nor long lasting.
Mid-forehead lifting is very similar to mid-forehead brow
lifting. The difference is that the incision runs continuously
within a prominent horizontal forehead crease.
Pretrichal forehead lifting is suitable for very high fore-
heads, because it avoids postoperative elevation of the frontal
hairline (a side effect of the endoscopic forehead and coronal
lifts). The incision is made following the frontal hairline and
slightly oblique to the hairline. During the healing phase, the
hairs will grow through the incision, making the scar almost

639
Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.14  (A) A 56-year-old woman with brow ptosis, pseudoptosis, marked upper eyelid dermatochalasis, and prolapse of the
medial and central fat pads. (B) Twenty-seven months after mid-forehead brow lifting and laser-assisted upper eyelid blepharoplasty.
(C) Six days after surgery, lateral view. (D) Twenty-seven months after surgery, lateral view. From Fratila AM. Laser-Assisted
Blepharoplasty In: Goldman MP, Weiss R, eds. Advanced Techniques in Dermatologic Surgery. Informa Healthcare; 2006.
A
B
C
D
Figure 39.15  (A) A 47-year-old woman after upper eyelid blapharoplasty complaining of lateral brow ptosis. (B) Thirteen days after
temporal brow lifting. (Courtesy of Dr A Fratila.)
A
B
invisible. Tardy et  al.22 prefer to dissect downwards in the
subgalea plane; other surgeons prefer the subcutaneous plane.
Again, the forehead nerves should not be damaged. For
perfect scar healing, a meticulous closure with buried vertical
mattress sutures 4-0 polydioxanone (PDS) followed by an
intradermal continuous suture is necessary.
Forehead lifting, whether open or endoscopic, typically
requires some form of heavy sedation or general anesthesia.
Coronal forehead lifting has been the gold standard against
which other approaches have been compared. This lifting is
intended to improve brow ptosis as well as diminish rhtyides
in the forehead and glabella.26 The overall surgical plan

640
Part 3  Aesthetic Surgical Procedures
involves a long coronal or modifed anterior hairline incision
as demonstrated in Figure 39.11.
Endoscopic forehead lifting, introduced in the early 1990s,
gained wide acceptance as an alternative to coronal forehead
lifting. The endoscopic approach seeks to minimize many of
the unfavorable sequelae of the open approach, most notably
scalp hypoesthesia, alopecia, scarring, and alteration of the
hairline.27,28
A detailed description of forehead lifting procedures is
beyond the scope of this chapter and can be read in the cited
sources.29,30
Upper eyelid blepharoplasty
The fundamental purpose of upper eyelid blepharoplasty is
to remove redundant skin and muscle from the upper eyelid
along with or without variable amounts of fat.
Skin marking
The upper eyelid crease is marked, preferably by a series of
dots: in women approximately 8–10 mm above the lash line
and 10–15 mm below the eyebrow; in men 6–8 mm above
the lash line and 10  mm below the eyebrow (Fig. 39.17)
After marking, the patient should assume an upright position
to recheck the surgical markings. Pinch testing the planned
resection with non-toothed forceps helps ensure an appropri-
ate surgical plan, leaving enough skin to allow complete eyelid
closure. The amount of skin removed must be customized for
each patient and should be conservatively done.19 The goal of
surgery is to create a symmetric result, even if an asymmetric
removal of skin, muscle, and/or fat is needed. Concomitant
brow lifting will require a more conservative skin excision.
Anesthesia, skin preparation, and draping
Depending upon the patient and the complexity of the
required surgery, upper eyelid blepharoplasty may be per-
formed as an office-based procedure entirely under local
anesthetic. Commercially available lidocaine 2% with epine-
Figure 39.16  (A) Intraoperative view: temporal brow lifting
using a lighted retractor and a #7 Ramirez dissector to divide
the orbital retaining ligament. (B) Using a thread fixation of the
lateral brow to the deep temporal fascia will increase the lifting
effect during the healing period immediately postoperatively.
(C) Procedure completed: see the lifting effect of the lateral
eyebrow, the pressure dressing applied, and the author’s (AF)
self-made instrument to facilitate the guided thread fixation
through a buttonhole incision in the eyebrow. (Courtesy of Dr A
Fratila.)
A
B
C
Figure 39.17  Skin markings for upper blepharoplasty. In
women the upper eyelid arease is placed 8–10 mm above the
lash line and 10–15 mm below the lower edge of the brow. The
excision is planned to achieve placement of the incision into the
upper eyelid.
Women: 10–15mm
Men: 10mm
Women: 8–10mm
Men: 6–8mm
Skin markings for upper blepharoplasty

641
Chapter 39  Blepharoplasty and Brow Lifting
phrine 1 : 100 000 is the preferred initial anesthetic injection
and is buffered to decrease patient discomfort. The initial
anesthetic may be followed with a 50/50 mixture of lidocaine
2% and bupivacaine 0.5% with epinephrine. Some surgeons
use hyaluronidase mixed with the local anesthetic as well.
The second author (BM) does not routinely use hyaluronidase
as there is a small risk of allergic reaction, and the lack of
hyaluronidase does not hamper the efficacy of the surgery.
For laser-assisted blepharoplasty with or without brow lifting,
intravenous sedation or general anesthesia performed by an
anesthesiologist and augmented by a local and nerve block
injection is preferable. Approximately 1–1.5 mL of anesthetic
is injected subcutaneously into each eyelid by creating a
lateral depot, which is gently massaged through the entire
eyelid, thus minimizing the risk of hematoma formation.13,19
We use a 3-mL syringe and a 30-gauge needle. Ten minutes
are allowed to lapse to achieve maximum vasoconstriction
from the epinephrine. A sterile surgeon’s bonnet cap covers
and controls the patient’s hair. The entire surgical field,
including the exposed face, is then prepped. Sterile drapes
are then placed around the patient’s face and head.
Skin and muscle excision
Using a surgical blade or an electrosurgical needle, the skin
and underlying orbicularis oculi are incised. Once the initial
incisions have been made, the skin–muscle flap can be excised
with scissors, a #15 scalpel blade, or an electrosurgical needle.
The choice of instrumentation is based upon surgeon prefer-
ence and practice. If no fat pad extraction is planned, the
orbital septum is left intact and skin closure is performed.
When fat pad extraction is planned, the orbital septum is
opened. Some surgeons advocate that septal incision occurs
with the skin–muscle flap while others feel that this should
be a separate step in the procedure.19,31 Remaining standing
cutaneous cones at the lateral aspect of the excision can be
removed by extending the excision into a crow’s feet line. In
patients with marked tissue redundancy at the medial aspect
of the excision, a Burow’s triangle of skin can be removed, or
W-plasty performed. Care must be taken to avoid extending
the excision much beyond the medial punctum as a medial
canthal web can result.32 If it is necessary to extend the
medial excision beyond the punctum, a slight upturning of
the excision will help prevent webbing. Sutures can be placed
to affix the eyelid crease prior to skin closure.
Fat pad extraction
Fat removal is determined by: how much fat should be
removed to achieve the desired aesthetic result and how
much fat can be removed based upon the patient’s fat pad
anatomy. The correct amount of fat extraction is the lesser
of these two amounts. Overly aggressive fat removal can
result in a hollowed appearance to the upper eyelid. Fat
removal is determined by the amount of fat that prolapses
after opening the septum and teasing the fat out. Fat should
never be placed under significant traction as there is a risk of
vascular injury with retrobulbar hematoma.31,32
If the septum has not been opened as part of the skin–
muscle flap, it may now be incised. Identification of the
orbital septum is based upon the visible fibrous strands within
the septum.19 Additionally, gentle traction with forceps will
confirm the septum’s attachment to the orbital rim. The
septum can be opened in two ways. The entire septum can
be opened as a single incision over both nasal and central fat
pads, a simpler technique advocated by most surgeons.19,31,32
Alternatively, other surgeons prefer separate incisions over
the medial and central fad pads.15 To avoid injuring the
levator aponeurosis, the septum may be opened midway
between the upper tarsus and orbital rim.33
Once the septum has been opened, fat pad dissection can
begin. The yellowish preaponeurotic fat will usually be
evident. Additional local anesthetic should now be injected
into the fat pads. Monopolar electrosurgical needle usage in
the retroseptal planes can be painful in the awake patient.
If the patient does not tolerate the use of the monopolar elec-
trosurgery, bipolar or disposable hand-held cautery may be
employed. The preaponeurotic fat is excised first, then atten-
tion is paid to the nasal fat pad. The capsule of the whiter nasal
fat is opened and the fat is teased out. The fat pads, with or
without cross-clamping, can be removed with scissors or elec-
trosurgically cut. Care must be taken to avoid injury to the
trochlea and superior oblique muscle tendon.15 In the upper
eyelid, there is no temporal fat. A protrusion in this area may
be caused by a prolapsed lacrimal gland (Fig. 39.18).3 Meticu-
lous hemostasis aids in reducing hemorrhagic complications.
Figure 39.18  (A) Prolapsed lacrimal gland: intraoperative view. (B) Intraoperative view after repositioning of the lacrimal gland within
the lacrimal fossa. (Courtesy of Dr A Fratila.)
A
B

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Part 3  Aesthetic Surgical Procedures
UPCO2 laser-assisted surgical procedure
of the skin–muscle–fat excision
Protect the eye undergoing surgery with the David-Baker
Retractor12,34 and perform the skin incision with the UPCO2
laser using the 0.2-mm hand piece in ultrapulse mode at
15 mJ and 4 watts (W). Some surgeons prefer 25 mJ/pulse
at a power of 5 W35 or even a continuous wave (CW) CO2
laser at 6 W. Incise the skin flap at a constant speed (usually
about 1 cm per second). If you slow down, the incision will
be deeper. Stay in focus and do not use multiple passes. If
the sutures have to be removed after 5–7 days, you may
consider performing the skin incision with a scalpel, but the
risk of bleeding is higher. The temporal portion of the incision
should extend only through skin so as to avoid cutting termi-
nal branches of the lacrimal artery, which pass between skin
and orbicularis muscle at the level of the lateral orbital rim.35
A skin–muscle flap is raised centrally and nasally. Grasp the
skin flap with a forceps at the temporal end of the marked
ellipse and perform the excision of the skin flap with the
UPCO2 laser using the 0.2-mm hand piece defocused at 6 W
in CW mode. With gentle traction on the flap once the orbital
rim has been crossed, the plane of dissection is deepend to
excise a skin–muscle flap (Fig. 39.19A). Protection of the
nose with the Jaeger stainless steel plate is mandatory. Stay
anterior to the orbital septum at all times. Defocus the beam
and vaporize any bleeding vessels. Always have a bipolar
cautery available in case a vessel bleeds. At this surgical step,
the first author replaces the David-Baker retractor with stain-
less steel shields to avoid pressure trauma and prolonged
edema of the pretarsal skin. This permits better ballottement
of the globe and exposure of the preaponeurotic fat pads as
well. Open the septum superiorly over each fat pad to avoid
injury to the levator aponeurosis using the Rabkin spatula as
a back-stop (Fig. 39.19B). This seems to avoid the so-called
‘A-shape’ of the upper eyelid creases. Pass the spatula beneath
the septum and incise it across its temporal extent. First the
middle, then medial fat pads (Fig. 39.19C) are resected using
a Jaeger spatula as a back-stop. Do not remove excessive fat,
only the fat herniating anterior to the orbital rim, to avoid
skeletonization or an A-shape deformity of the eyelid, as well
as retrobulbar hematoma.
Figure 39.19  Laser-assisted upper eyelid blepharoplasty – intraoperative views. (A) Using a David-Baker lid retractor to protect the
globe and stretch the upper eyelid, a skin–muscle flap is raised centrally and nasally. (B) Using a Rabkin spatula as a back-stop the
septum is opened. (C) The medial fat pad is resected using a Jaeger plate as a back-stop. (D) Supratarsal fixation for a better
definition of the upper eyelid crease with suture completed. Note: maximal lifting effect but no lagophthalmos at the end of the
surgery. (Courtesy of Dr A Fratila.)
A
B
C
D

643
Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.20  Transconjunctival lower eyelid laser-assisted blepharoplasty: intraoperative views. (A) Jaeger plate swept back from
the orbital rim produces bulging of fornix of conjunctival recess. (B) Fat pads are transected using DesMarres retractor as a
back-stop. (Courtesy of Dr A Fratila.)
A
B
If fullness of the lateral brow is due to descent or hyper-
trophy of the ROOF, sculpt this region with the CO2 laser
defocused beam. Be conservative in the amount of ROOF
vaporized. According to the modern concept of eyelid reju-
venation, the first author performs and recommends lipofill-
ing to restore the convexity of the lid–brow junction and thus
the youthful appearance of the eyelid. If upper eyelid lateral
fullness is present, one should consider a prolapsed lacrimal
gland (see Fig. 39.18A). In this case, a horizontal mattress
suture is placed through the periosteum of the inner aspect
of the superior orbital rim – the lacrimal fossa – and the
capsule of the lacrimal gland (see Fig. 39.18B). The orbital
septum does not require closure.19
Skin closure
To create a symmetric and well-defined lid crease, now
remove the metal eyeshield. This facilitates visualization of
the iris and the symmetric placement of crease-defining
sutures (supratarsal fixation). Place three interrupted 7-0
Prolene sutures through the skin, the levator aponeurosis at
the superior tarsal border, and skin again on the superior
border of the wound (Fig. 39.19D). These sutures can be
removed after 3 days. The most frequent error is an asym-
metric placement of the sutures medially, which can create
a very apparent difference in lid crease position and depth of
the superior palpebral sulcus in the upper eyelids. The goal
of aponeurosis fixation sutures is to stretch the pretarsal skin
vertically and create a defined superior lid crease.
A running subcuticular suture using 7-0 Prolene is recom-
mended and removed after 10 days when using the CO2 laser
beam to cut the skin, or after 5 days if the skin incision was
performed with the scalpel.
Lower eyelid blepharoplasty
Lower eyelid blepharoplasty may be performed alone or in
combination with upper eyelid blepharoplasty. Traditionally,
it was performed transcutaneously with a subciliary incision.
In the last decade, a renaissance of the transconjunctival
approach to remove the herniated fat pad occurred. Rizk &
Matarasso found that they performed transconjunctival
blepharoplasty slightly more frequently than the transcutane-
ous approach.36 The transconjunctival approach essentially
addresses fat pad herniation. Many experienced surgeons
have abandoned the transcutaneous lower blepharoplasty. If
there is lower lid laxity and periorbital wrinkles, a simultane-
ous fractional resurfacing or a CO2 laser skin resurfacing
procedure can be performed. The presence of pronounced
excess skin and muscle usually requires the use of the trans-
cutaneous approach alone, or a skin excision (pinch excision)
in combination with the transconjunctival approach.
Transconjunctival lower eyelid blepharoplasty
Skin marking
Mark the prolapsed fat pads with the patient sitting up and
looking in upward gaze.
Anesthesia, skin preparation, and draping
The procedure may be performed with local anesthesia alone.
However, patient comfort may be increased with the use of
oral or intravenous sedation. The conjunctiva is anesthetized
with topical anesthetic drops. Injection of local anesthetic
may take place from both a transconjunctival or transcutane-
ous approach. Skin preparation and drapes are the same as
with upper blepharoplasty.
Transconjunctival incision
Use a Jaeger plate or stainless steel corneal shields with a gel
as a lubricant to protect the globe. An assistant’s fingertips at
the lid margin are gently pulling downwards on the lower
eyelid and the surgeon is holding the Jaeger plate and the
0.2-mm CO2 laser hand piece. When the Jaeger plate is swept
back from the orbital rim, it produces bulging of the inferior
fornix of conjunctiva and the prolapsed fat pads are exposed
(Fig. 39.20). Make the transconjunctival incision 5–7  mm
below the eyelid margin, from the medial caruncle to the
lateral canthus. Use the 0.2-mm focused hand piece of the
UPCO2 laser in CW mode with a power of 6 W and perform
two to three passes. You may also use the Colorado needle
or the Micro Stan RF Forceps of the Ellman Surgitron (Ellman

644
Part 3  Aesthetic Surgical Procedures
International, Inc, Oceanside, NY) to perform the incision.
The first pass transects the conjunctiva and the second one
the lower eyelid retractors. The retroseptal approach is more
popular.14,37 Stay anterior to the orbital rim and avoid the
inferior oblique muscle found between the nasal and middle
fat pads.38 The assistant pulls the lower eyelid away with the
left hand, placing a 9-mm DesMarres lid retractor into the
incision. With the Jaeger plate in the right hand, the assistant
protects and gently pulls down the globe, to help the pro-
lapsed orbital fat to bulge. Open each fat pocket and transect
first the lateral fat pad, than the middle and medial one using
the CO2 laser slightly defocused. Use the DesMarres retrac-
tor as a back-stop and excise only the fat that prolapses
anteriorly to the orbital rim. Do not cut larger blood vessels.
Remember what Baker likes to say: ‘The vessel not cut is the
one that will not bleed.’11
Suturing of the transconjunctival incision is not neces-
sary,13,37 although Tyers & Collin14 and Spinelli39 prefer to use
an absorbable suture. As recommended by Baker, the first
author (AF) has never sutured a transconjunctival incision
since this may increase the risk of developing pyogenic gran-
uloma. Judge the amount of fat to be resected by visual
quantification of fat pads on ballottement of the globe. At
the end of the operation, gently pull the lower eyelid upwards
to prevent adhesion of the incision to the orbital rim. At this
moment, the UPCO2 laser skin resurfacing (Fig. 39.21) or
the fractional resurfacing may be performed if required. If
not, compress the infraorbital area with Suture Strip Plus
(Derma Sciences, Toronto, Canada) to prevent swelling and
hematoma in this area (Fig. 39.22). Apply cold packs in the
postsurgical care unit and instruct the patient to keep the
head elevated for at least 1 week postoperatively. Topical
steroid-containing eyedrops can be prescribed prophylacti-
cally for a week to lessen chemosis. Contact lenses should
not be worn for about 2 weeks.
Figure 39.21  (A) A 68-year-old woman with deep nasojugal
sulcus (the so-called ‘tear trough deformity’), deep malar
sulcus, and herniated lower eyelid fat. (B) Ten days after
transconjunctival lower eyelid blepharoplasty, lipofilling to the
nasojugal and malar sulci, and UPCO2 laser skin resurfacing
periorbitally. (C) Postoperative result 11 months later. (Courtesy
of Dr A Fratila.)
A
B
C
Figure 39.22  Immediate postoperative view after laser-assisted
upper eyelid blepharoplasty, transconjunctival lower eyelid
blepharoplasty, and fractional CO2 laser resurfacing ActiveFX
with the UPCO2 Encore (Lumenis, Inc, Santa Clara, CA) laser
to the entire face. To prevent hematoma, a pressure dressing is
applied to the infraorbital area. After 3 days, the pressure
dressing is removed and the skin under the dressing is treated
with fractional resurfacing ActiveFX for a nice uniform result of
the entire facial skin. (Courtesy of Dr A Fratila.)

645
Chapter 39  Blepharoplasty and Brow Lifting
UltraPulse CO2 laser skin resurfacing or fractional
resurfacing to the periorbital area
This is first author’s (AF) method of choice when moderate
dermatochalasis or wrinkling of the periorbital skin is treated.
The postoperative erythema which may persist from 3 weeks
to 2 months is the only concern after UPCO2 laser skin
resurfacing. To avoid long-lasting erythema, intense pulsed
light treatment after approximately 3 weeks is recommended.
We prefer to combine UPCO2 laser skin resurfacing of the
periorbital area with fractional resurfacing of the rest of
the face to avoid notable differences between resurfaced
areas and non-resurfaced facial skin. In the first author’s (AF)
experience, when using the UPCO2 EncoreTM (Lumenis, Inc,
Santa Clara, CA) laser with the computer pattern generator
(CPG) UltraScan® EncoreTM (Lumenis, Inc) for periorbital
skin resurfacing, the parameters given in Table 39.1 have
proved to be safe. For the crow’s feet area, the same param-
eters as for resurfacing of the facial skin can be used. Usually,
the pretarsal skin is not treated because this might increase
postoperative edema (Fig. 39.23). Perforated Silon-TSR
(BMS, Allentown, PA) is used for about 1 week postopera-
tively to protect the wound after skin resurfacing, and changed
every second day. This dressing makes the wound less sus-
ceptible to infections, guarantees a moist environment of the
wound and no crust formation, and reduces discomfort and
pain.40 Silon-TSR is transparent and thus the wound can be
easily examined, microperforations allow the exudate to run
off, and it is not adhesive to the wound. The most important
benefit of using the Silon-TSR dressing is shortening the
postoperative erythema and reducing the burning sensation.
After 10 days, the skin is completely healed and light make-up
can be used to cover the erythema. If fractional resurfacing,
such as DeepFXTM using UPCO2 EncoreTM (Lumenis, Inc)
laser is performed instead of skin resurfacing, we use only an
ophthalmic ointment or Cold-Cream (La Roche-Posay,
France) postoperatively. Sun exposure should be avoided for
at least 3 months. Strenuous activities, vomiting, constipa-
tion, and extreme heat or cold temperatures are also avoided
in the postoperative period.
Transcutaneous lower eyelid blepharoplasty
Consider the transcutaneous approach to lower blepharo-
plasty in patients with excess dermatochalasis and festoons,
prolapsed fat pads, and orbicularis oculi hypertrophy.
Skin marking
Mark the incision 2 mm below the lashes from the medial
punctum to the lateral canthus. If an upper blepharoplasty
is also performed, the planned lower lid incision should be
8–10 mm below the incision from the upper blepharoplasty.3
Anesthesia, skin preparation, and drape
Use 2–3  mL of 2% lidocaine with 1 : 100 000 epinephrine
transcutaneously in a subdermal plane and a little amount
transconjunctivally as well.
Table 39.1  Suggested parameters using the UltraScan Encore (Lumenis, Inc)
REGION
PASSES
ENERGY
FLUENCE
REPETITIONS/RATE
PATTERN
SIZE
DENSITY
Eyelid
1st pass
80 mJ
6.0 J/cm2
200 Hz
3
5
5
2nd pass
70 mJ
5.2 J/cm2
200 Hz
3
5
4
Crow’s feet
1st pass
100 mJ
7.5 J/cm2
200 Hz
3
5
6
2nd pass
80 mJ
6.0 J/cm2
200 Hz
3
5
5
Figure 39.23  Periorbital area: intraoperative view. (A) Cutis laxa with periorbital wrinkles after UPCO2 laser skin resurfacing of the
face was performed. (B) Immediately after UPCO2 laser skin resurfacing of the lower and upper eyelid skin (left eye). The main
advantage using a collimated scanner in a non-touch manner like the UltraScanTM EncoreTM (Lumenis, Inc) is that the periorbital skin
may be resurfaced up to 2 mm from the eyelashes. The pretarsal skin on the upper eyelid is usually not treated (right eye, same
patient). (Courtesy of Dr A Fratila.)
A
B

646
Part 3  Aesthetic Surgical Procedures
generally lead to ectropion. The lower lid is also subject to
retraction if the structures in the middle lamella (orbital
septum, orbital fat) or the capsulopalpebral fascia in the
posterior lamella are injured. Other techniques to tighten the
lower eyelid include the lateral tarsal strip, lateral canthal
tendon plication, or resection techniques.42 These techniques
seek to tighten and anchor the posterior lamella.
Care should be taken not to excise, excessively cauterize,
or overly traumatize the conjunctiva. Scarring may lead to
symblepharon or shortening of the inferior fornix.43
To prevent lid malposition, take special note of patients
who have hypoplastic malar eminences (negative lateral
vector), or those who have had prior surgery or exhibit lid
laxity.
Fat removal in blepharoplasty has become very conservative
in recent years since aging is not only a problem of tissue
descent but also one of involutional changes. Some have
advocated that fat pad removal has a negative aesthetic effect
by causing a concavity below the tarsal plate. The contour
of a child’s face with a full lower eyelid–cheek continuum is
the rational for the aesthetic concerns of fat removal. Some
surgeons are now stressing fat conserving and redistributing
approaches to blepharoplasty.44 Fat transplantation to the
lower eyelids has been reported in select patients to achieve
a youthful appearance of the lower eyelid (see Fig. 39.21).
Techniques that plicate the orbital septa45,46 or resuspend
the capsulopalpebral fascia have been proposed as alterna-
tives to fat pad extraction.47 Electrocautery or CO2 laser
beam defocused to tighten lax septa has been reported to
be effective in both upper and lower blepharoplasty.48 In
patients with tear trough deformity, repositioning of the
orbital fat to blunt the concave appearance of the tear trough
may be a successful technique.49 While there is intuitive
appeal to fat-sparing techniques, the abandonment of fat
extraction in lower lid blepharoplasty is far from being
universally accepted.
The surgeon should be aware of the concept of lower
eyelid orbicularis oculi hypertrophy. Orbicularis oculi hyper-
trophy describes the appearance of a thickened pretarsal
lower eyelid muscle and overlying skin redundancy. Failure
to address this anatomic feature in lower blepharoplasty may
result in a hollow lower sulcus and an aesthetically unappeal-
ing convexity–concavity deformity. Numerous techniques to
Skin incision
Dissect the skin and orbicularis oculi just inferior to the
tarsal plate and extend the skin–muscle flap down to the
orbital rim.3,19
Fat pad extraction
Open the orbital septum and the fibrous capsule by spreading
scissors over each fat pad herniation.3 Excise the fat without
pulling, to avoid retrobulbar hemorrhage. Gentle pressure on
the globe will help prolapse the fat. Add some local anesthetic
into the fat pads prior to removal.
Excise skin and muscle
Correct the horizontal lid laxity, if necessary, by creating a
small orbicularis muscle flap out of the inferolateral portion
of the skin–muscle flap (Fig. 39.24). Anchor the muscle flap
to the superolateral orbital rim using 5-0 Vicryl sutures.19,41,42
You may also perform a canthopexy or a canthoplasty to
stabilize the lower eyelid. If no lid-tightening procedure is
planned, resect only the excess skin both infraciliary and at
the lateral canthus. The skin–muscle flap should be draped
across the lid margin in such a manner as to avoid tension.31
In general, skin–muscle excision should be conservative to
avoid lower eyelid retraction (Fig. 39.25).
Skin closure
Skin closure is performed along the subciliary incision with
running suture 7-0 Prolene.
Advanced considerations of lower
blepharoplasty
For many surgeons, achieving a superior aesthetic and func-
tional outcome is more difficult with lower than upper
blepharoplasty.41
Lid retraction, ectropion, and scleral show are postopera-
tive complications that have both aesthetic and functional
consequences. The cause of lower eyelid malposition after
surgery may result from a combination of factors. A useful
rubric to approach malposition is from an anatomic stand-
point. Defects in the anterior lamella (skin and orbicularis)
Figure 39.24  Transcutaneous lower eyelid blepharoplasty in a patient with lower lid laxity, intraoperatively. (A) A small orbicularis
muscle flap is passed through a tunnel deep on the periosteum and anchored to the orbital rim. (B) After fixation of the lower eyelid
orbicularis muscle flap to the orbital rim and skin closure of the upper eyelid, the excess skin is resected. From Fratila AM. Laser-
Assisted Blepharoplasty In: Goldman MP, Weiss R, eds. Advanced Techniques in Dermatologic Surgery. Informa Healthcare; 2006.
A
B

647
Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.25  (A) 60-year-old woman with marked
dermatochalasis of the upper and lower eyelid, prolapse of the
preaponeurotic fat pads on the upper eyelid, lymphedema,
festoons, and lower lid laxity. (B) Seventeen days after laser-
assisted upper eyelid blepharoplasty and transcutaneous lower
eyelid blepharoplasty with muscle–flap fixation to the
supraorbital rim. (C) Postoperative result 3.5 months later.
(Courtesy of Dr A Fratila.)
A
B
C
manage orbicularis oculi hypertrophy center upon reduction
of orbicularis function. Described methods include surgical
thinning of the muscle,50 electrosurgical reductions in
muscle function,51 and chemodenervation with botulinum
toxin A.
Laser resurfacing, as discussed elsewhere in this text, is a
useful adjuvant procedure to improve skin tone and pigmen-
tary irregularities.
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 Blindness can result from hemorrhage: reduce the risk of
perioperative and postoperative bleeding by preoperative
evaluation and adjustment of risk factors, and by advising the
patient about postoperative activity and warning signs.
 Monitor patients throughout surgery for signs of bradycardia
or dysrhythmia, which can be triggered by the oculocardiac
reflex, and have a crash cart available.
 Treatment with lubricants and the taping of lids may help
prevent keratoconjunctivitis.
 Conservative skin excision is the best way to avoid
lagophthalmos.
Complications from blepharoplasty range from aesthetic to
functional to catastrophic. As previously discussed, the lower
eyelid is more at risk for a poor outcome including retraction
and scleral show than the upper lid.
Appropriate outlining and removal of upper eyelid skin can
only be achieved when the eyebrows and the forehead have
been stabilized in an appropriate position. To avoid lagoph-
thalmos, first perform eyebrow lifting, then re-evaluate the
amount of skin to be excised on the upper eyelid, and be
conservative with skin excision.
If ptosis affects only the lateral end of the eyebrow, correct
this by removing an ellipse of skin hidden in a lateral forehead
crease (mid-forehead brow lifting) or by performing a tem-
poral brow lift. The first author prefers a horizontally ori-
ented ellipse excision since this better corrects the lateral
brow ptosis.
Visible scars are the main concern in mid-forehead brow
lifting. Use precise suture technique to close the wound
without any tension and adequately mobilize the forehead
flap. Sensation above the incision is often compromised;
therefore, be gentle and avoid damaging the forehead nerves.
It is imperative that surgical incision lines are marked prior
to infiltration of the local anesthetic with a marking pen
resistant to surgical prep. Mark the preaponeurotic fat pads
and the incision lines on the upper eyelid preoperatively with
the patient in an upright, sitting position.
The fat pads on the lower eyelid are accentuated in upgaze.
Be conservative with fat excision, both on the upper and
lower eyelids, especially in younger patients to avoid hollow-
ing of the eyelids. The fat removed may be used to correct
the deep nasojugal fold or the malar sulcus to create a
smoother infraorbital area. Consider CO2 laser skin resurfac-
ing or CO2 fractional resurfacing periorbitally to treat lines
and wrinkles and tighten the skin. Exclude lymphedema over
the malar eminence if pseudoherniation of the orbital fat pad
does not worsen in upward gaze. Lymphedema is not perma-
nent but usually more noticeable in the morning. Skin reduc-

648
Part 3  Aesthetic Surgical Procedures
tion is often unnecessary in the lower eyelid, especially in
younger patients. Consider reducing the fat pads transcon-
junctivally as a method of choice and combine it whenever
necessary with CO2 fractional resurfacing.
Correct lower eyelid laxity either separately or at the
time of blepharoplasty if scleral show or ectropion are
expected.
Perform a skin–muscle flap blepharoplasty if excessive
lower eyelid skin has to be removed (festoons) and stabilize
the lower eyelid, suturing a thin muscle flap on the upper
orbital rim. The main complications following skin–muscle
flap lower eyelid blepharoplasty are lid retraction with scleral
show and ectropion. Avoid excessive skin and fat removal and
correct lid laxity using canthoplasty or canthopexy at the time
of the blepharoplasty.
Moisturize the globe with lubricants to prevent keratocon-
junctivitis.
Blindness is a serious complication usually resulting from
retrobulbar hematoma, leading to a compartment syndrome,
increased orbital pressure, and optic nerve ischemia. There-
fore, reduce the risk of pre- and postoperative bleeding by a
thorough preoperative check of coagulopathy, control hyper-
tension, stop the intake of anticoagulative medications or
supplements perioperatively, avoid excessive pulling on the
fat pads during surgery, perform meticulous hemostasis, and
educate the patient about postoperative activities and warning
signs for retrobulbar hematoma. Blindness due to retrobulbar
hematoma usually occurs within the first 24 hours postop-
eratively.31,52,53 However, there exist reports of delayed
hematoma occurring 7 days postoperatively.54 Estimates of
this complication are in the range of 1 in 40 000. Small ret-
robulbar hemorrhages occur in around 1 in 2500 cases and
usually spontaneously resolve. Limiting postoperative activity
and avoiding increases in blood pressure or Valsalva maneu-
vers (cough, vomit, straining at stooling) are advised. Early
recognition and treatment of retrobulbar hematoma may
spare one’s vision. Generally, blepharoplasty elicits little
pain. Therefore significant pain or visual changes should be
urgently evaluated. To resolve retrobulbar hematoma, consult
an ophthalmic surgeon. In severe cases, lateral canthotomy
and cantholysis should be considered. Other treatments
include osmotic agents, topical β-blocker drops, and surgical
exploration.52
Extraocular muscle injury resulting in diplopia is another
rare complication of blepharoplasty. If severe, the inferior
rectus and inferior oblique muscles may have been injured
during surgery. However, permanent injury can occur and
strabismus surgery may be required in rare cases.55–57 Minor
diplopia or other ocular motility disturbances resulting from
local anesthesia, edema, hemorrhage, or minor muscle injury
are usually transient and observation is all that is required.
Cautious upper lid dissection, piecemeal fat removal, and
judicious use of electrocautery may help minimize superior
oblique tendon injury.58
Dry eyes, including frank exposure keratitis, can result
from blepharoplasty. Temporary lagophthalmos is common
in the immediate postoperative period. Treatment with lubri-
cants and lid taping may help prevent keratoconjunctivitis. If
lagophthalmos persists, additional downward massage of the
upper eyelid after healing of the wound may help. In extreme
cases, a full-thickness skin graft to the upper eyelid may be
necessary.59 Lower-lid retraction can also cause exposure
keratopathy. Initial remedies include upward massage of the
lower eyelid and aggressive topical lubricants at bedtime. If
persistent, surgical intervention may be required.32 Dry eyes
diagnosed preoperatively require hyaluronic eye drops to be
used continuously postoperatively.
The oculocardiac reflex is a trigeminal–vagal arc that can
lead to bradycardia or arrhythmia when excessive ocular
manipulation takes place during blepharoplasty. Precipitating
events include pressure applied to the globe, and traction on
extraocular muscles and fat pads. Patients should be continu-
ously monitored and, if bradycardia is noted, the manipula-
tion should be stopped. Atropine is the treatment for the
oculocardiac-induced bradycardia and should be adminis-
tered if the heart rate does not spontaneously normalize. A
crash cart should be available.60
 SUMMARY
Examination of the upper face involves careful consideration
of factors relating to dermatochalasis of the eyelids and brow
ptosis. Blepharoplasty and brow lifting are traditional and
successful treatments to rejuvenate the upper face. Blepha-
roplasty may be performed either as an inpatient or outpa-
tient procedure under local anesthesia with or without oral
or intravenous sedation. If intravenous sedation is utilized,
the presence of an anesthesiologist is mandatory. Laser-
assisted blepharoplasty has many advantages such as shorter
operating time, reduced hematoma and swelling postopera-
tively, but the intraoperative pain due to the heat generated
by the laser requires, at least, intravenous sedation, if not
general anesthesia. Since CO2 skin resurfacing and fractional
resurfacing have become popular methods for skin rejuvena-
tion and tightening, simultaneous transconjunctival blepharo-
plasty has become the method of choice for aesthetic lower
eyelid surgery. Aesthetic surgery of the eyelids is neither
simple nor ought to be undertaken as only skin surgery.
However, excessive removal of orbital fat pads should be
avoided to prevent skeletonization of the eye complex. The
surgeon has to tailor the procedure to satisfy the patient’s
needs and achieve a maximum aesthetic improvement with
long-term results. The goals are to restore the volume of
youth, especially the convexity of the lid–brow junction and
refill the concavity of the tear trough deformity as well as the
malar sulcus (lipofilling). Modern eyelid surgery means rede-
fining the upper eyelid crease at a lower level and, generally,
restoring rather than distorting.
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45. Huang T. Reduction of lower palpebral bulge by plicating attenuated
orbital septa: a technical modification in cosmetic blepharoplasty. Plast
Reconstr Surg 2000;105:2552–2558.
46. De la Plaza R, Arroyo JM. A new technique for the treatment of palpe-
bral bags. Plast Reconstr Surg 1988;81:677–685.
47. Parsa FD, Miyashiro MJ, Elahi E, et al. Lower eyelid hernia repair for
palpebral bags: a comparative study. Plast Reconstr Surg 1998;102:2459–
2465.
48. Choo PH, Rathbun JE. Cautery of the orbital septum during blepharo-
plasty. Ophthal Plast Reconstr Surg 2003;19:1–4.
49. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of
orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg
2000;105:743–748.
50. Bernardi C, Dura S, Amata PL. Treatment of orbicularis oculi hypertro-
phy in lower lid blepharoplasty. Aesthetic Plast Surg 1998;22:349–351.
51. Weber PJ, Wulc AE, Moody BR, et al. Electrosurgical modification of
orbicularis oculi hypertrophy. Ophthal Plast Reconstr Surg 2000;16:407–
416.
52. Wolfort FG, Vaughn TE, Wolfort SF, et al. Retrobulbar hematoma and
blepharoplasty. Plast Reconstr Surg 1999;104:2154–2162.
53. Sutcliffe T, Baylis HI, Fett D. Bleeding in cosmetic blepharoplasty: an
anatomical approach. Ophthal Plast Reconstr Surg 1985;1:107–113.
54. Cruz AAV, Ando A, Monteiro CAC, et al. Delayed retrobulbar hematoma
after blepharoplasty. Ophthal Plast Reconstr Surg 2000;17:126–130.
55. Ghabrial R, Lisman RD, Kane MA, et al. Diplopia following transcon-
junctival blepharoplasty. Plast Reconstr Surg 1998;102:1219–1225.
56. Syniuta LA, Goldberg RA, Thacker NM, et al. Acquired strabismus fol-
lowing cosmetic blepharoplasty. Plast Reconstr Surg 2003;111:2053–
2059.
57. Harley RD, Nelson LB, Flanagan JC, et al. Ocular motility disturbances
following cosmetic blepharoplasty. Arch Ophthal 1986;104:542–544.
58. Wesley RE, Pollard ZF, McCord CD Jr. Superior oblique paresis after
blepharoplasty. Plast Reconstr Surg 1980 Aug;66:283–286.
59. Lyon DB, Raphtis CS. Management of complications of blepharoplasty.
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651
40
Rejuvenation of the Neck Using
Liposuction and other Techniques
Carolyn I Jacob MD and Michael S Kaminer MD
Summary box
 Evaluate submental adipose tissue, skin elasticity, and
platysma laxity/integrity.
 Neck liposuction is appropriate for those with pre-platysmal
fat, good skin quality, and absence of platysma bands.
 Laser-assisted liposuction can be beneficial in patients with
submental fat and lax skin.
 Add platysmaplasty for patients with good skin quality but
with a non-decussated, lax platysma.
 Patients with poor skin quality may require superficial
musculoaponeurotic system plication, platysmaplasty, as well
as skin excision.
 Botulinum toxin treatment is an option for patients with good
skin tone and platysma bands visible during teeth clenching.
 Radiofrequency for tissue tightening of the submentum is
beneficial for patients with mild submental and jowl laxity.
 INTRODUCTION
The effects of age, sun, and adipose redistribution take their
toll on the neck as well as the face. It is important to keep
this in mind when evaluating a patient with photoaging. The
appearance of an aged neck in contrast to a newly resurfaced
or lifted face is undesirable and a ‘white flag’ that one has had
surgery. In order to balance the face and neck, there are a
variety of procedures available. Non-surgical or surgical reju-
venation of the neck can be performed using botulinum toxin,
fractional laser resurfacing, standard ablative laser resurfac-
ing, radiofrequency tissue tightening, laser-assisted liposuc-
tion, and liposuction with or without platysma repair or
superficial muscular aponeurotic system (SMAS) plication.
These therapies can be used alone or in combination depend-
ing on the condition of the neck tissues. This chapter will
focus on surgical recontouring of the neck using fractional
CO2 laser resurfacing, liposuction, laser-assisted liposuction,
platysma repair, SMAS plication, and tissue tightening using
radiofrequency energy.
With the advent of tumescent liposuction in 1987, liposuc-
tion of excess adipose tissue from the submental area, jowls,
and neck has become an attractive alternative to the face lift
for cervicomental aesthetic surgery. With time, sun damage,
and gravity, increased deposition of fatty tissue in the sub-
mental area, descent of the malar pads and sagging jowls, and
neck skin redundancy with or without banding of the platysma
muscle occur. This may give the appearance of excessive
weight gain or aging to an otherwise healthy person. The
traditional approach to these patients has been face-lift
surgery, but with tumescent anesthesia, neck liposuction has
evolved as a safe procedure to enhance the appearance of the
neck and jawline in such individuals. Many variations and
additions to neck liposuction have been employed. These
include concomitant simple platysma plication, the corset
platysma repair, laser-assisted liposuction, and a combination
of neck liposuction, platysma plication, and SMAS plication.1
Platysma repair can improve refinement of the cervicomen-
tal angle in addition to eliminating visible bands. The etiology
of platysma bands is speculated to be due to stretching and
loss of contractility of skin and fat overlying the anterior
platysma, plus stretching of the overlying SMAS which nor-
mally retracts the muscle.2 Both of these contractility failures
are exacerbated with overuse of the muscles and advancing
age. An alternative treatment for early and mild platysma
muscle banding is botulinum toxin A (BTX-A) (Allergan, Inc,
Irvine, CA) injections into the vertical platysma bands.
Although quite useful for patients with platysmal show during
muscle contraction, BTX-A injections provide temporary
(3–6 months) improvement and do not help patients with
persistent sagging bands.3
Those patients with excessive jowling or poor skin elasticity
can benefit from concomitant SMAS plication and skin exci-
sion with repositioning. For patients with severe elastosis of
the face with sagging skin at the temporal and malar areas, a
full face lift may be appropriate. However, many patients
have aging changes limited to the lower cheek and jowl, which
can be greatly improved via SMAS plication and skin excision
alone. The advantage of this safe, less invasive, and less time-
consuming procedure, performed under local anesthesia, is
that it eliminates the risks of intravenous or general anesthe-
sia and gives excellent results with reduced morbidity. Some
surgeons noted a disadadvantage of limited SMAS placation
is a potential reduction in the durability and longevity of the
correction.
In addition, newer filler substances, such as hyaluronic acid,
can be used to volumize the face, allowing for central lifting
and decreased sagging. For patients with poor skin elasticity,
fractionated laser resurfacing has been shown to improve the
texture and tautness of the skin, and can be used on the neck
and chest area as well.

652
Part 3  Aesthetic Surgical Procedures
excised directly. Asking the patient to place their tongue up
against the hard palate will also help the surgeon to identify
fat location as more retroplatysmal fat will protrude. The
surgeon should also release the skin as part of a snap test to
determine skin elasticity. If the skin feels loose and does not
recoil quickly, or if the skin reveals vertical banding at rest,
then liposuction alone is unlikely to provide maximal benefit
(Fig. 40.2). This type of patient may be a good candidate for
a partial SMAS plication, platysma repair, radiofrequency
tissue tightening after liposuction, or laser-assisted liposuc-
tion. The clenched teeth test is also useful to evaluate the
platysma location and banding as non-decussating platysma
For those patients with mild jowling and submental neck
skin laxity who do not wish to undergo surgery, there is
radiofrequency tissue tightening. Radiofrequency as an energy
source has been used for years in electrosurgery, but a device
which uses capacitive coupling and an epidermal coolant has
been developed to tighten tissue and regenerate collagen. In
addition, this device, the Thermage NXT ThermaCool (Ther-
mage Corporation, Hayward, CA), can reduce unwanted
submental neck skin laxity.4 Studies have proven its ability to
tighten forehead skin and ‘lift’ the eyebrows and upper lids,5
and the device has been used to soften the nasolabial fold,
improve cheek contour, and tighten the mandibular line.6
Figure 40.1  Optimal liposuction candidate.
Figure 40.2  Aged neck displaying poor skin quality.
History of neck rejuvenation
 1968 Millard, Pigott, and Hedo describe the submandibular
lipectomy for neck enhancement.
 1971 Cronin and Biggs describe the T–Z plasty for the male
‘turkey-gobbler’ neck.
 1978 Illouiz develops liposuction.
 1987 Klein develops tumescent liposuction.
 1992 Feldman describes the corset platysmaplasty.
 2001 Carruthers and Carruthers describe the use of
botulinum in the mid and lower face and neck.
 2003 Radiofrequency tissue tightening is used to enhance
cervicomental angles.
 2005 Laser-assisted liposuction revisited.
 2007 Ablative fractionated lasers are developed for skin
rejuvenation.
Patient evaluation
Choosing appropriate candidates for neck rejuvenation is
essential and perhaps one of the most important determi-
nants of the postoperative result. Examination for submental
adipose, skin quality, and platysma laxity or prominence
during teeth clenching can guide the physician to the appro-
priate procedure or combination of procedures. In addition,
several analyses of cervicomental aesthetics have been per-
formed, and show that patients with ideal neck proportions
have cervicomental angles between 90 and 135°.7–11 The ideal
position of the hyoid bone was found to be at the C3–C4
level, and at a location equal to or higher than the menton
(the most inferior point on the mandibular symphysis in the
midsagittal plane)12 (see Fig. 1.14). These details should be
considered when selecting patients for neck liposuction, as
additional procedures may need to be employed for maximum
results. For example, those patients with relatively low-set
hyoid bones are less likely to achieve a sharp cervicomental
angle because their underlying anatomy will not support it.
Hyoid position is an important landmark for muscular attach-
ments and thus is an important determinant of neck angles
and contour. Optimal candidates for neck liposuction include
those patients with full jowls but otherwise good skin elastic-
ity, patients with high-set hyoid bones, and those with sub-
mental fat pads palpable by pinch techniques (Fig. 40.1).
Several maneuvers can be performed to assess submental
fat; the patient is asked to clench their teeth, which will
tighten the platysma muscle and define the fat as pre- or
retroplatysmal fat. Preplatysmal fat can be suctioned through
a small submental incision, but retroplatysmal fat must be

653
Chapter 40  Rejuvenation of the Neck Using Liposuction and other Techniques
of the sternocleidomastoid (SCM) muscle, left and right
platysma bands (if present), and the thyroid cartilage. This is
done with the patient in a seated position (Fig. 40.4). Care
must be taken to identify the jowl bilaterally as it will extend
slightly below the mandibular ramus. The superior extents of
the jowl should be marked as well. These guides help to
delineate the areas for liposuction, and the top of the ‘T’
placed at the level of the thyroid cartilage marks the distal
extent for plication of the platysma, if necessary. Preopera-
tive marking is essential to define landmarks that will be
otherwise distorted after tumescence.
The procedure is performed in a well-equipped ambulatory
surgery setting, with appropriate sterile technique and nursing
staff assistance. The patient’s face, neck, and upper shoulders
are cleansed thoroughly with povidone-iodine and sterile
towels are wrapped around the head. After the patient is
prepped and draped in sterile fashion, a small amount of local
full-strength (0.1% lidocaine) tumescent anesthesia is admin-
istered in the submental crease. With a #11 blade, a small
2–3-mm incision site is made in the anesthetized area. The
patient’s head is gently extended back with the chin raised.
A small-diameter, 6-inch, sprinkler-tipped infusion cannula is
used to carefully deliver full-strength (0.1% lidocaine) tumes-
cent solution through the submental incision into the imme-
diate subdermal adipose compartment. Before and after
tumescence, the patient is asked to purse the lips and clench
the lower teeth to check the functioning of the marginal
mandibular nerves. Occasionally the anesthesia will inhibit
functioning of the nerve, which is important to note before
proceeding with the liposuction. For the lateral cheeks, a
20-gauge, 3.5-inch spinal needle (Becton Dickinson and Co,
Franklin Lakes, NJ) is used to create infusion points 2 cm
below the tragus. Tumescent solution is infused into the
subcutaneous cheek and jowl areas bilaterally. Caution must
be exercised during this buccal infiltration as overzealous
filling can potentially lead to intraoral airway occlusion. A
muscle fibers become evident. Patients with prominent
platysmal banding should be given the option for platysma
repair at the time of liposuction as this will maximize final
results (Fig. 40.3).
The surgeon should also evaluate submandibular gland posi-
tion. Many patients have ptotic submandibular glands which
appear as a subcutaneous fullness bilaterally along the inferior
mid-portion of the mandibular ramus. This ptotic gland can
resemble jowls, and is important to identify preoperatively.
Platysma repair over these glands can improve this ptosis in
some patients.
Gender may play a role in patient selection as well. We
have found that male neck skin takes longer to retract and
redrape after neck liposuction as compared with female neck
skin. Whether this is due to differences in hormones, skin
thickness, or volume of fat removed remains unclear. As with
all patients, postoperative skin retraction with liposuction
alone may be suboptimal if preoperative skin elasticity is
poor. However, radiofrequency tissue tightening can be per-
formed to improve laxity either prior to, or after liposuction.
In addition, laser-assisted liposuction may heat and retract
the underside of the dermis, allowing for smoother redraping
and retraction of the skin.
Patients with mild jowling, good skin quality, submental
neck skin laxity, and minimal submental adipose tissue are
good candidates for the Thermage NXT ThermaCool (Ther-
mage Corporation) radiofrequency treatment. Optimal
patient selection parameters include patients aged 35–55, and
those with thinner faces and thin skin.13
 TECHNICAL ASPECTS
Liposuction of the neck
The process of neck liposuction involves first marking the
mandibular border, jowls, submental fat pad, anterior borders
Figure 40.3  Prominent platysmal banding.
Figure 40.4  Preoperative patient markings.

654
Part 3  Aesthetic Surgical Procedures
cheeks as this can result in unwanted dimpling or hollowing.
This is most likely to occur at the junction of the buccinator
and masseter muscles where the parotid duct travels through
the buccinator to the oral mucosa. Labiomandibular tethering
near the depressor anguli oris may require gentle blunt dis-
section with the cannula to allow adequate adipose removal
and contouring of the jowls. Removal of neck adipose tissue
extending to the medial border of the SCM muscles bilater-
ally and to the thyroid cartilage inferiorly is necessary if the
surgeon will be performing platysma repair. After contouring
is achieved, a 4-mm closed-neck dissector (Byron Medical,
Tuscon, AZ) may be used to release the superficial submen-
tal and anterior neck septae via the submental incision (Fig.
40.7). In some patients, it can be of value to release these
tethering fibrous bands to allow smooth redraping of the neck
skin. The sharp ‘V’-shaped notch of the dissector allows a
more thorough and gentle approach than aggressively swiping
the area with a blunt cannula. Gentle rasping of the underside
of the dermis may also facilitate tightening and adherence of
the skin to the underlying muscle, but this concept is anec-
dotal and unproven. A cannula may then be used in a side-
to-side motion to check for full release of the fibrous bands.
Figure 40.8 shows the results of a neck liposuction-only
procedure.
total of 300–500 mL of tumescent anesthesia is required to
anesthetize the average patient’s neck, cheeks, and jowls.
After tumescent anesthesia is complete and allowed to take
effect over a 45-minute time period, a 3-mm spatula-tipped
liposuction cannula is used to gently debulk the submental,
anterior, and lateral neck adipose tissue via machine suction-
ing through the submental incision (Aspirator III, Wells
Johnson, Tuscon, AZ) (Table 40.1). This is fine tuned by
aspiration using a 2-mm, 3–4-inch spatula-tipped cannula
attached to either machine suction or a 5-mL syringe (Fig.
40.5). The syringe method of suction has been evaluated by
several surgeons and found to be a precise and controlled
method for adipose removal.14,15 Caution must be used to
keep the cannula in the mid to superficial fat and to stay
medial to the anterior border of the SCM muscle. This
helps to avoid injury to large veins in the area (Fig. 40.6).
Suctioning is then continued with the 2-mm spatula-tipped
cannula through #11 blade stab incision sites placed along
the lateral portion of the jawline. Head extension and lateral
rotation provides appropriate positioning for suctioning the
cheek, jowl, lateral neck, and jawline. The mid-plane of jowl
suctioning is first identified with syringe-assisted hand suc-
tioning, followed by gentle contouring of the jowl and jawline
via machine-assisted liposuction. During suctioning, the oper-
ator’s free hand is used to identify the mandibular rim and
the skin is lifted upwards by the cannula motion to prevent
injury to the marginal mandibular nerve. It is important to
note that while the patient’s head is extended and laterally
rotated, the marginal mandibular nerve (see Figs 1.16 and
37.2) may drop as much as two fingerbreadths below the
mandible, become more superficial, and pose a greater risk
for nerve injury. Care is taken to stay in a mid to superficial
adipose plane.
At times it can be helpful to briefly turn the cannula
opening upwards towards the dermis, particularly in the sub-
mental region. While contouring the cheeks and jowls, one
must avoid aggressive suctioning of the medial and superior
Table 40.1  Neck liposuction instruments
INSTRUMENT
MANUFACTURER
3-mm, 6-inch spatula-tipped
cannula
Bernsco Surgical Supply, Inc,
Seattle, WA
2-mm, 3-inch spatula-tipped
cannula
Wells Johnson, Tuscon, AZ
4-mm closed-neck dissector
Byron Medical, Tuscon, AZ
Figure 40.5  Three-inch, 2-mm spatula cannula.
Anterior border of the
sternocleidomastoid muscle
The path of neck liposuctioning
Figure 40.6  The path of neck liposuctioning. The lateral
borders of the sternocleidomastoid muscles of the neck define
the area of neck suctioning.

655
Chapter 40  Rejuvenation of the Neck Using Liposuction and other Techniques
improved results. The 1064-nm wavelength produces more
broad-based, low-intensity heating that may be more effec-
tive for skin tightening than fat removal. Both 1320 nm and
1319  nm are highly efficient wavelengths for intense heat
production in a small volume of tissue, perhaps indicating
improved efficacy for fat heating and destruction.
Early results are promising with both devices. It appears
that the combination of wavelengths provides significant
advantages over the previous generation single-wavelength
systems. Fat destruction and skin tightening are achieved
simultaneously when the two wavelengths are used together.
In unpublished studies, the magnitude of both tightening and
fat removal appears to be greater than that seen with the early
generation single-wavelength devices (Fig. 40.10).
When treating the neck, it is critical to use low power, in
particular when using 1319 or 1320 nm. These wavelengths
produce intense heat at the laser fiber tip, and can cause
significant damage to underlying anatomic structures. In par-
ticular, the marginal mandibular nerve is likely at increased
risk when laser-assisted liposuction is used. Whereas in tra-
ditional liposuction safety is enhanced through the use of
blunt-tipped instruments, the laser has the ability to pene-
trate the platysma muscle and directly injure the nerve (as
well as vascular and other structures). For these reasons,
addition of laser-assisted liposuction should be approached
conservatively, and only by those practitioners with extensive
experience in treating the neck. For example, Katz & McBean
reported local complications such as skin burns in 0.93% of
patients in a retrospective study of 537 cases treated with
the original 1064-nm laser.17 Albeit a low statistic, it is clear
that the surgeon had performed more than 500 procedures,
and was therefore experienced in the technique. Further
prospective safety studies need to be performed from several
investigative sites to determine the true rate of complications
with these devices.
Details of the clinical protocol for laser-assisted liposuction
are evolving. The most favorable ratio of 1064  nm to
1319/1320 nm has yet to be determined, and may be differ-
ent for skin tightening and fat removal. In addition, physicians
are investigating whether it is preferable to use the laser
before or after cannula-assisted fat removal. As these varia-
Laser-assisted neck liposuction
First studied in 1994, recently laser technology has been
revisited for use as an adjunct to traditional neck and jowl
liposuction. To date, these lasers have not been replacements
for liposuction, but rather potentially useful complements to
the liposuction procedure. Several companies have developed
laser-assisted liposuction technology. The two most widely
studied systems are SmartLipo (Cynosure, Inc, Bedford, MA)
and ProLipo (Sciton, Inc, Palo Alto, CA). The original device
from both companies was centered on a 1064-nm platform,
and provided moderate skin tightening in some patients. Fat
removal with the 1064-nm wavelength, when used alone in
the absence of cannula-assisted fat removal, was less than
optimal. Higher-powered 1064-nm devices (greater than 10
watts) seemed to slightly improve efficacy for fat removal.
More recently, other wavelengths for laser lipolysis have
been studied, including 1320 nm and 2100 nm. Researchers
found in ex-vivo studies that all wavelengths caused thermal
damage of fibrous septae, with the greatest amount of damage
seen in the specimens with the highest energy per pulse.16
Both Cynosure and Sciton have released dual-platform laser
technologies. The systems from both companies retain their
roots in the 1064-nm wavelength, but Cynosure has added
1320 nm, while Sciton has added 1319 nm (Fig. 40.9). With
both systems, individual wavelengths can be used alone, or
they can be used in combination to theoretically provide
Figure 40.7  Byron closed-neck dissector.
A
B
Figure 40.8  (A) Patient preoperatively,
side view. (B) Patient postoperatively,
side view, 3 weeks after neck liposuction
alone.

656
Part 3  Aesthetic Surgical Procedures
rior approach to platysma tightening and correction of sub-
mandibular ptosis.18,21
Simple midline platysma repair with transection
Following liposuction, a 3-cm ellipse is removed encompass-
ing the submental incision site. Gentle lifting of the submen-
tal skin for platysmal visualization is performed with a Deaver
retractor (Sklar Instruments, Westchester, PA) (Fig. 40.11)
(Table 40.2). After diligent hemostasis using an electrocau-
tery pen equipped with a 13-cm straight electrode extension
adapter (Surgistat, Valley Labs, Boulder, CO), the platysma
bands are identified using long Metzenbaum scissors (Sklar
Instruments) and forceps. Platysma repair is performed by
approximating the medial portions of the left and right
platysma bands with CV-4 Goretex (WL Gore & Co, St
Louis, MO) or similar buried sutures. Other authors have
used 4-0 polyglactin 910 (Vicryl, Ethicon, Inc, Somerville,
NJ) or polyglycolic acid (Dexon, Davis & Geck, Wayne, NJ)
sutures with similar results.21,22 The platysma repair is con-
tinued inferiorly to just above the level of the thyroid carti-
lage. Electrosection is then used to transect the distal portion
bles are studied and resolved, it is likely that laser-assisted
liposuction results will continue to improve.
Platysma repair and SMAS plication
In patients who lack decussation of the platysma (crossing of
the medial fibers of the platysma), or who have visible
platysma bands or laxity of the muscle fibers, plication can
be performed. Current methods of platysma repair include
bilateral platysma plication, midline platysma plication with
transection of distal fibers, and neck lift with skin exci-
sion.18–20 The corset platysmaplasty, originally described by
Feldman, is an extremely effective and comprehensive ante-
Figure 40.9  SmartLipo device (Cynosure, Inc).
A
B
Figure 40.10  (A) Patient before and
(B) after SmartLipo (Cynosure, Inc)
treatment.
Table 40.2  Corset platysma repair instruments
INSTRUMENT
MANUFACTURER
Neck liposuction
instruments*
Surgical loupes and fiber-
optic headlight
SurgiTel Systems, Ann Arbor, MI
Electrocautery pencil with
13-cm straight electrode
extension adapter
Surgistat, Valley Labs, Boulder, CO
Deaver retractor
Sklar Instruments, Westchester, PA
Long Metzenbaum scissors
Sklar Instruments, Westchester, PA
7-inch DeBakey atraumatic
tissue forceps
Sklar Instruments, Westchester, PA
7-inch Webster smooth
needle holder
Sklar Instruments, Westchester, PA
*See Table 40.1.

657
Chapter 40  Rejuvenation of the Neck Using Liposuction and other Techniques
bone, a small amount (approximately 3 mL) is excised after
careful dissection of the superficial fascia (Fig. 40.12). Care
is taken to identify, divide, and coagulate any prominent veins
when necessary as they may lie in the fat deep to the fascia
and the medial platysma edges. The medial borders of the
split platysma bands are then identified with blunt and sharp
dissection to produce clearly defined borders for suturing the
muscle together. Hemostasis is then confirmed. A running
4-0 mersilene (Ethicon, Inc) or 3-0 polydioxanone (PDS;
Ethicon, Inc) suture is used, and with a 7-inch needle holder,
a running suture is started at the superior portion of the split
platysma bands. Seven-inch DeBakey atraumatic tissue
forceps (Sklar Instruments) are used to gently grasp the
medial edges of the platysma bands, and suturing is continued
inferiorly in a running locked fashion as the edges of the right
and left platysma muscle are approximated. The running
suture proceeds inferiorly towards the thyroid cartilage,
making sure that adequate sections (approximately 1 cm) of
platysma and overlying fascia are incorporated into each bite.
Upon reaching the level of the thyroid cartilage, the running
suture is continued in a running reverse direction proximally
while plicating the more lateral borders of the platysma
muscle over the now sutured medial fibers (Fig. 40.13). This
is the corset portion of the repair, and the double-layer plica-
tion creates a smooth surface to the midline plication as well
as superb muscular apposition and tightening. This ‘overplica-
tion’ produces firm tightening of the anterior platysma and
sharpening of the cervicomental angle as well as the jawline.
Figure 40.11  Visualization of the platysma using a Deaver
retractor. View is from the top of the patient looking down to the
chin and submental incision. Black ink markings are noted on
the neck.
Figure 40.12  Retroplatysmal fat.
Reverse running suture of the
corset platysmaplasty
Figure 40.13  The reverse running suture of the corset
platysmaplasty.
of the platysma bilaterally from the proximal midline bundle.
The skin incision is closed with 5-0 polyglactin 910 and 6-0
polypropylene sutures. The small incision sites on the cheeks
and jawline are left for drainage purposes and heal by second
intention.
The corset platysma repair
The corset platysma repair is performed following liposuction
of the neck, and is begun by creating a 3-cm elliptical incision
enveloping the submental crease incision. Surgical loupes
(SurgiTel Systems, Ann Arbor, MI) and a fiber-optic head-
light are essential to obtain an adequate visual field. A Deaver
retractor is used to retract the skin and the medial bands of
the platysma are identified and isolated via blunt dissection
using long Metzenbaum scissors. Hemostasis is achieved and
any further platysma–dermal tethers are removed via elec-
trocautery. The retroplatysmal space is then accessed through
a small incision in the fascia overlying the midline platysma.
If excess retroplatysmal fat is present superior to the hyoid

658
Part 3  Aesthetic Surgical Procedures
can be performed in the preauricular zone. Following liposuc-
tion and repair of the platysma muscle, lidocaine (1% with
1 : 100 000 epinephrine) is locally injected along the planned
periauricular incision line to an area 5 cm anterior to the ear
(in the lateral cheek area in the region to be undermined), as
well as in the postauricular sulcus. An incision is made along
Upon reaching the submental incision site, the suture is tied
upon itself in buried knot fashion. During the overplication
corset phase of the repair, there is a gratifying part of the
procedure where the platysma literally falls onto the underly-
ing hyoid bone as the muscular tightening causes the muscle
to assume its natural shape on the neck.
Some patients have prominent submandibular glands due
to ptosis of the glands inferior to the jawline. These patients
benefit from an oblique plication performed on the left and
right submandibular area to further tighten the platysma
muscle and elevate the ptotic submandibular gland. These
lateral platysma bands and associated muscle laxity are less
clearly identified, and the lateral positioning makes the
approach to their repair challenging through the small sub-
mental incision. On each side, small oblique running sutures
are placed to a length of 5–8 cm with 4-0 mersilene or 3-0
PDS suture. A locked running suture is first placed from
proximal to distal, and then a running ‘baseball-type’ stitch
is performed as the suture is continued from distal to proxi-
mal (Fig. 40.14). The suture is then tied upon itself. Finally,
in the original description by Feldman, two interlocking sling
sutures are performed, one from the right submental platysma
fibers to the left mastoid process, and one through the left
submental platysma fibers to the right mastoid process.21 The
sutures are interlocked in the submental position. We have
not found this portion of the procedure to be necessary in
the majority of patients, but it may benefit those patients
with extreme platysma laxity or ptotic submandibular glands.
Redraping of the neck and jawline skin occasionally requires
further release of the lateral platysma–dermal bands to avoid
puckering of the skin at the lateral neck line. Occasionally,
redundant skin occurs submentally after the plication. Exci-
sion of this skin at the level of the submental incision can be
performed if the superfluous skin is substantial. Closure of
the submental incision is accomplished with 5-0 polyglactin
910 and 6-0 polypropylene sutures (Fig. 40.15).
SMAS plication
In patients with excessive sagging of the jowl and jawline skin,
or advanced age and poor skin elasticity, a SMAS plication
Plication over the lateral
submental platysma
Figure 40.14  Plication over the lateral submental platysma.
A
B
Figure 40.15  (A) Patient preoperatively,
side view. (B) Patient postoperatively,
side view, 2 months after liposuction and
platysmaplasty. Note softening of the
jowls as well as improved contours of the
cervicomental angle.

659
Chapter 40  Rejuvenation of the Neck Using Liposuction and other Techniques
ment of electrons creates heat relative to the amount of
current I (amps) and time t (seconds). The resulting energy
(joules; J) is equal to the current squared multiplied by
impedence and time (J = I2 × Z × t). The device used, known
as the Thermage NXT ThermaCool (Thermage Corporation),
is unique in its ability to provide capacitive coupling of radio­
frequency to the skin, creating a uniform electric field (zone
of heating) in tissue at controlled depths. The energy is dis-
persed across a specific treatment tip membrane to create
this effect (Fig. 40.17).
A study by Alster & Tanzi4 evaluated cheek laxity in 30
patients and neck laxity in 20 patients after one treatment
the inner rim of the tragus (similar to standard face-lift inci-
sion in this area),23 extended inferiorly anterior to and under
the ear lobe, and then superiorly along the posterior ear sulcus
to approximately one-third to one-half the length of the ear.
Undermining 3 cm anteriorly from the incision in the mid-
subcutaneous plane allows visualization of the SMAS. Suture
plication of the SMAS is performed in a superolateral direc-
tion and the skin is redraped. SMAS plication is intended to
tighten the musculature along the jawline and upper neck. A
total of 7–10 sutures are used, with plication extending down
from the pretragal region, anterior to the earlobe, and along
approximately 3–5  cm of the superior aspect of the SCM
muscle. It is essential to place buried knot plication sutures
along vectors that optimize jawline definition and enhance-
ment. Redundant pre- and postauricular skin is excised and
the edges are reapproximated with 5-0 polyglactin 910 and
6-0 polypropylene sutures.
Postoperatively, conventional bandages, a tape support (3M
Medical-Surgical Division, St Paul, MN), and a five-tabbed
compression neck liposuction garment (Flex support com-
pression garments, Universal facial garment, Wells Johnson,
Co, Tuscon, AZ) are applied and left in place for 24 hours.
The bandages are then removed, and the patient is instructed
to wear a two-tabbed garment (Facial, Chin, Neck Supporter,
Cosmetic Surgery Suppliers, Tucker, GA) layered with a
chin-strap support garment (The Wrap, Byron Medical,
Tuscon, AZ) 23–24 hours daily for 1 week, then at least 8
hours a day for the following 3–4 weeks. The use of double-
layered postoperative compression garments appears to
enhance skin redraping and jawline contouring. Final cos-
metic results occur several weeks to months postoperatively,
as mild edema requires time to resolve, and skin retraction
may be slower in the aging neck (Fig. 40.16).
Radiofrequency tissue tightening
Electrical energy, when selectively focussed in the dermis and
while simultaneously providing a coolant to protect the epi-
dermis, leads to tissue tightening. With radiofrequency, heat
is generated based on tissue’s resistance to the movement of
electrons within an electric field. This follows the principles
of Ohm’s law, where impedance in Z (ohms) to the move-
A
B
Figure 40.16  (A) Patient preoperatively,
side view. (B) Patient postoperatively,
side view, 3 weeks after liposuction with
platysmaplasty and SMAS plication.
Although this is a relatively short follow
up, this photo shows the immediate skin
tightening achieved with this technique.
Figure 40.17  The Thermage NXT ThermaCool (Thermage
Corporation) radiofrequency device.

660
Part 3  Aesthetic Surgical Procedures
area laterally, and the jawline and submentum inferiorly (Fig.
40.18). This treatment area extends approximately 3–4 cm
below the mandible. A coupling gel is spread on the treatment
area to allow complete contact of the treatment tip with the
skin. After the grid markings are placed, a 3-cm2 treatment
tip is attached. Tips with varying amounts of pulses are
available, and most medium-sized cheek and submental areas
can be treated with 600 or 900 pulse tips. Treatment settings
for the first pass are usually in the 362.0–365.0 range for the
entire lower face (Fig. 40.19A). One side of the face can be
performed at a time to compare treated versus untreated
sides. A second pass at 362.0–364.5 (depending on patient
with the original Thermage ThermaCool TC. Patients were
pretreated with 5–10 mg of oral diazepam as well as topical
anesthetic cream (LMX-5% cream, Ferndale Laboratories,
Inc, Fernadale, MI). The cheek treatment area extended
from the nasolabial folds to the preauricular margin and down
to the mandibular ridge. Treatment of the neck extended
from the mandibular ridge to the mid-neck. Fluences ranged
from 97 to 144 J/cm2 on the cheeks and from 74 to 134 J/
cm2 on the neck. Mild post-treatment erythema was seen in
all patients and persisted up to 12 hours after the procedure.
Fifty-six percent of subjects complained of soreness at the
treated sites; the soreness resolved with oral non-steroidal
anti-inflammatory drugs (NSAIDs). Erythematous papules
that resolved over 24 hours were observed in three patients.
One patient developed dysesthesia along the mandible that
resolved over 5 days. No blistering or scarring was observed.
A quartile grading system was used and independent assess-
ment noted improvement in 28 of 30 patients who were
treated on the cheeks and 17 of 20 patients who were treated
on the neck. The five subjects who demonstrated no clinical
improvement were all older than 62. At 6 months, the mean
clinical improvement score was 1.53 on the cheeks and 1.27
on the neck (scale of 1 = 25–50% improvement, 2 = 51–75%
improvement). On a scale of 1–10, the average patient satis-
faction score was 6.3 for cheek treatment and 5.4 for neck
treatment.
Weiss et al.24 analyzed the safety and efficacy in 600 patients
treated over a 4-year period. They found very few side effects
(2.7%), most of which were transient. Three patients noted
tenderness of the neck for 2–3 weeks after treatment.
Treatment method
The patient’s face is cleansed and a temporary ink treatment
grid is placed along the cheeks, extending from the malar
edge superiorly, the nasolabial fold medially, the preauricular
Figure 40.18  Placement of the treatment grid on the cheeks
and jawline.
A
Figure 40.19  (A) First, (B)
second, and (C) third pass
suggested treatment areas
for tissue tightening of the
cheeks, jawline, and neck.

661
Chapter 40  Rejuvenation of the Neck Using Liposuction and other Techniques
vectors towards the lateral malar area. Some physicians will
use an overlapping pattern by treating one square and then
an adjacent circle on the grid in a zig-zag fashion. This must
be done at low fluences to prevent excessive dermal heating
or ineffective epidermal cooling. After 5–7 passes, one can
often see a visible tightening of the skin.
There are differing theories as to the mechanism of action
of the third through sixth or seventh passes, and they include:
tolerance) is performed in the lateral cheek and preauricular
region, as well as the jawline, submental region, and upper
neck (avoiding the thyroid cartilage). The medial upper cheek
is avoided with this second pass (Fig. 40.19B). A third pass
can then be performed in an ‘L’-shaped pattern including the
malar area and nasolabial folds (Fig. 40.19C), and this can be
followed by subsequent passes in areas that require maximum
contraction, usually over the jawline in sweeping upward
B
C
Figure 40.19, cont’d

662
Part 3  Aesthetic Surgical Procedures
ard CO2 resurfacing was not recommended on the neck
because of risks of scarring and hypopigmentation. The frac-
tionated CO2 lasers allow for microthermal zones of energy
to be delivered to the deep dermis, while adjacent normal
skin provides for rapid healing. Because fractions of normal
skin containing sebaceous and eccrine glands remain, the risk
of scarring and hypopigmentation is lowered when proper
settings are used. There are a number of newly released,
effective fractionated CO2 laser devices on the market,
including those from Reliant (Fraxel Re:pair), Lumenis
(Active and DeepFX), and DEKA (SmartXide).
The SmartXide DOT (DEKA, Calenzano, Israel) allows
significant flexibility in treatment settings. DOT stands for
dermal optical thermolysis (Fig. 40.22). This device uses a
350-µm spot size which creates a ‘bowl-shaped’ thermal foot-
print. The spaces between the microthermal zones (‘dots’)
can be adjusted from 0.2 to 2.0 mm. The distance between
microthermal zones is termed ‘pitch.’ It is inversely related
to the density of the dots. The device also allows for adjust-
ment of the pulse duration (longer leads to greater thermal
damage) from 0.2 to 2 milliseconds, and power up to 30
watts. You can also use the device in standard ablative CO2
mode, but this is not recommended off the face due to the
lower amount of adnexal structures on the neck and higher
risk of scarring. The treatments are performed using topical
anesthesia alone (lidocaine, prilocaine, phenylephrine mixture,
Scripts Pharmacy, Florida).
After cleansing of the skin, the topical anesthetic is applied
for approximately 30 minutes. The face is then washed and
degreased with alcohol. Protective eye wear (metal goggles
or eye shields) is used by the patient. The SmartXide DOT
therapy has variable treatment patterns including rectangle,
triangle, parallelogram, hexagon, and line. These patterns also
come in four sizes. Treatment is typically performed starting
at the jawline, placing the large square pattern at the base of
the jaw and working upwards toward the cheek in a columnar
fashion. Typically the full face is treated to avoid leaving a
line of demarcation. Using the varying patterns and sizes, any
missed areas that do not conform directly to the square
pattern can be filled in. Attention is then turned to the neck
area. Columns of squares are treated from the jawline to the
• tissue tightening in the x (horizontal) and y (vertical)
plane along the cutaneous surface
• melting of fat and tissue tightening in the z-axis
perpendicular to the skin, which pulls tissue in toward
the bony underlying structures
• a combination of the two.
This z-axis effect appears to be an important element of the
improved results seen recently in treatment of the lower face
(Fig. 40.20). Whether this comes from additional tightening
in the x (horizontal) and y (vertical) plane or from a direct
third-dimension effect on subdermal fat and collagen of the
fibrous septae remains to be determined. However, treating
physicians can use these z-axis changes to their advantage.
The third pass can therefore be carefully placed in areas
where maximal z-axis improvement is needed. This would
include the jowl and submental regions. Additionally, further
x- and y-axis changes can be produced with this third pass,
and should include the preauricular region to create a ‘vector’
of pull laterally. The fourth and subsequent passes are used
to augment the results of the third pass, and in many cases
to achieve visible tissue tightening and contour changes at the
time of the procedure.
The patient is asked to rate the sensation of the electrical
energy at 0 (no sensation) to 4 (prominent discomfort).
Patients are treated at energy levels which correspond to a
personal rating of 3 (moderate sensation but tolerable). A
dynamic cooling spray delivers precooling, postcooling, and
simultaneous cooling during each cycle. Each cycle (firing of
the device) currently takes approximately 3 seconds, and
treatment of the cheeks and jawline with 6–7 passes takes
about 45 minutes in total. In a study by Iyer et  al.,25 70
patients were treated and 70% noted significant improvement
in skin laxity and texture 3 months post-treatment with the
original ThermaCool device. Patients may be treated more
than once at 8–12-week intervals and may notice further
improvement after successive treatments (Fig. 40.21).
Fractionated CO2 laser resurfacing
For patients with moderate skin laxity and little submental
adipose, newer resurfacing techniques have emerged. Stand-
A
B
Figure 40.20  (A) Patient before, and (B)
after treatment with Thermage NXT
ThermaCool (Thermage Corporation).

663
Chapter 40  Rejuvenation of the Neck Using Liposuction and other Techniques
produce skin that shows signs of ridging and puckering. If the
surgeon sees any signs of skin irregularity during the first
postoperative week, it is important to take the time to gently
release the skin from the underlying tissue and redrape it in
a more neutral position.
Compression garments are worn 23 hours a day for the first
postoperative week, then 8–10 hours a day for the next 3–4
weeks. For those patients who suffer from claustrophobia, it
may be beneficial to have them try on the garments several
weeks before the procedure to make sure they will be able
to comply with postoperative instructions.
For fractionated CO2 laser resurfacing procedures, a
number of wound care strategies have evolved, including both
open and closed techniques. One such strategy, with rapid
recovery and epithelialization, includeds soaks with Avene
(Pierre Fabre Corporation, France) thermal spring water, fol-
lowed by Cicalfate (Pierre Fabre Corporation), a healing oint-
ment with sunblock. Most patients are able to use make-up
again by day 5.
 OPTIMIZING OUTCOMES
The most important element of the neck rejuvenation pro­
cedure is preoperative patient assessment. The initial evalu-
ation of the patient in many ways determines the ultimate
result the patient will receive. If the initial exam is per-
formed thoroughly, then the surgeon is able to accurately
determine a treatment plan that is appropriate for the patient.
If, on the other hand, the initial evaluation fails to identify,
or take into account, certain elements of the patient’s
anatomy, then the ultimate result may be compromised. For
example, if the patient has platysma bands, mild jowl forma-
tion, and lax skin with submental ridging at the preopera-
tive exam, the surgeon must form a treatment plan that takes
into account all of these elements. Failure to adequately plan
for treatment of the submental ridging (via submental skin
excision and/or SMAS plication with periauricular skin exci-
distal neck. A line of demarcation has to be denoted at some
region of the neck, usually the collar line. Therefore this
treatment is not recommended for patients with severe pho-
tobronzing of the chest as there will be a color mismatch with
the newly treated skin. During treatment, visible tightening
is noted, especially when using higher energies. Standard set-
tings for mild to moderate rhytides include a pitch of 400
microns, pulse duration of 1000 microseconds, energy of
20 mJ, and power of 20 watts. Ice packs are recommended
for comfort for the first 48 hours, and patients use soaks and
healing ointments 4–5 times a day until the skin has finished
peeling. Single treatments are intended for improvement;
however, a series of treatments is safe to perform for
maximum benefit (Fig. 40.23).
 POSTOPERATIVE CARE
There are two important elements of postoperative care:
reduction of complications and enhancement of results. For
the surgical procedures, bleeding risks can be reduced through
meticulous surgical technique, avoidance of certain medica-
tions before and after surgery (NSAIDs, vitamin E), and the
use of adequate compression bandages postoperatively. Infec-
tion can be minimized with the use of sterile technique and
peri- and postoperative antibiotics. Oral cephalosporins are
usually sufficient for neck surgery in the non-penicillin-aller-
gic patient. Seroma formation can virtually be eliminated
through the use of compression bandages and garments for
23 hours a day for 7 days postoperatively.
Results can be enhanced by using carefully applied com-
pression bandages and garments. Skin redraping is an essential
component of the healing process, and skin can be guided
into place with externally applied bandages. These materials
are used to gently hold the skin in place during the healing
process, facilitating the skin’s attachment to the underlying
structures. Failure to adequately compress and support the
skin during the important first 7 postoperative days can
Figure 40.21  Patient before
(left), and after (right)
treatment with Thermage
NXT ThermaCool (Thermage
Corporation). Note the
improved cervicomental
angle. (Photograph Courtesy
of Ruth Hillelson, MD.)

664
Part 3  Aesthetic Surgical Procedures
skin surgery, infectious complications following surgery to the
tissues of the neck can be catastrophic.
Patients need to be informed that some of the procedures
may require maintenance, such as radiofrequency tissue tight-
ening, or fractionated CO2 resurfacing. There are currently
no standards for these time lines, but physicians must discuss
this probability with the patient prior to treatment.
 PITFALLS AND THEIR MANAGEMENT
Figure 40.22  SmartXide DOT (Dekka, Israel) fractionated CO2
laser.
Figure 40.23  Before (left)
and after (right) one light
treatment of the neck with
the SmartXide DOT (Dekka,
Israel) fractionated CO2 laser.
Pitfalls
 Overagressive suctioning of the cheeks leading to dimpling.
 Seroma formation if proper garments are not worn.
 Idiopathic submental nodule formation.
 Marginal mandibular nerve injury.
 Submental skin ridging and puckering.
sion) will likely lead to a paradoxical increase in ridging post-
operatively, which will yield both an unhappy patient and
surgeon.
An additional factor that at times is minimized during skin
surgery is sterile technique. Due to the invasive nature of the
platysma repair procedure, sterile technique is of paramount
importance. All surgeons who perform this procedure must
have thorough knowledge of the key elements of sterile tech-
nique. In addition, the operative suite and ancillary surgical
staff must be properly trained in sterile technique. Although
minor breaks in sterility can often be overcome during simple
The neck can be a challenging anatomic region to rejuvenate,
and complications are a legitimate concern. There are inher-
ent risks of tumescent neck liposuction which include bleed-
ing (intraoperative and postoperative), seroma formation,
injury to the marginal mandibular nerve, and vertical band
formation with poor skin retraction. But, with careful patient
selection, surgical neck recontouring can be performed in a
safe and efficient manner.
Injury to the marginal mandibular nerve is a known com-
plication of neck surgery. In particular, the nerve is vulnerable
to injury as it crosses the mandible in the vicinity of the facial
artery and vein, as well as at the posterior angle of the man-
dible. Injury to the nerve can be avoided by suctioning in the
mid-fat over the nerve, and avoiding suctioning that crosses
over the mandibular ramus. In instances where injury to the
marginal mandibular nerve is the result of liposuction, our
experience is that it resolves completely within 2–3 months.
The incidence of nerve injury is less than 1–2% of all cases.
However, injury to the marginal mandibular nerve can be
permanent if the nerve is transected during platysma repair
or SMAS plication. It is imperative that the surgeon be famil-
iar with the anatomy of the neck, and to be cautious to
operate in the mid-fat when in the danger areas for injury to
the marginal mandibular nerve.

665
Chapter 40  Rejuvenation of the Neck Using Liposuction and other Techniques
5. Fitzpatrick R, Geronemus R, Goldberg DJ, et al. First multicenter study
of a new non-ablative radiofrequency device to tighten facial tissue.
Radiofrequency controlled tissue rejuvenation. ASLMS, April 9–13,
2003.
6. Ruiz-Esparza J, Gomez JB. The medical face lift: a noninvasive, nonsurgi-
cal approach to tissue tightening in facial skin using nonablative radiofre-
quency. Dermatol Surg 2003;29:325–332.
7. Marino H, Galeano EJ, Gondolfo EA. Plastic correction of double chin:
importance of the position of the hyoid bone. Plast Reconstr Surg
1960;31:45.
8. Ellenbogen R, Karlin J. Visual criteria for success in restoring the youth-
ful neck. Plast Reconstr Surg 1980;66:826.
9. Worms F, Isaacson R, Speidel T. Surgical orthodontic treatment
planning – profile analysis and mandibular surgery. Angle Orthod
1976;46:1.
10. Legan H, Burstone C. Soft tissue cephalometric analysis for orthognathic
surgery. J Oral Surg 1980;38:744.
11. Sommerville JM, Sperry TP, BeGole EA. Morphology of the submental
and neck region. Int J Adult Orthod Orthognath Surg 1988;3:97.
12. Moreno A, Bell WH, Zhi-Hao Y. Esthetic contour analysis of the sub-
mental cervical region. J Oral Maxillofac Surg 1994;52:704–713.
13. Kaminer MS, Hsu J. The use of nonablative radiofrequency technology
to tighten the lower face and neck. Semin Cutan Med Surg 2003;22:115–
123.
14. Toledo LS. Syringe liposculpture. Clin Plast Surg 1996;23:683–693.
15. Hunstad JP. Tumescent and syringe liposculpture: a logical partnership.
Aesthetic Plast Surg 1995;19:321–337.
16. Khoury JG, Saluja R, Keel D, et al. Histologic evaluation of interstitial
lipolysis comparing a 1064, 1320, and 2100 nm laser in an ex vivo model.
Lasers Surg Med 2008;40:402–406.
17. Katz B, McBean J. Laser-assisted lipolysis: a report on complications.
J Cosmet Laser Ther 2008;10:231–233.
18. Jacob CI, Berkes BJ, Kaminer MS. Liposuction and surgical recontouring
of the neck: a retrospective analysis. Dermatol Surg 2000;26:625–
632.
19. Knize DM. Limited incision submental lipectomy and platysmaplasty.
Plast Reconstr Surg 1998;101:473–481.
20. Cardoso de Castro C. The changing role of platysma in face lifting. Plast
Reconstr Surg 2000;105:764–775.
21. Feldman JJ. Corset platysmaplasty. Clin Plast Surg 1992;19:369–382.
22. Kamer FM, Lefkoff LA. Submental surgery: a graduated approach to the
aging neck. Arch Otolaryngol Head Neck Surg 1991;117:40–46.
23. Alt TH. Facelift surgery. In: Elson ML, ed. Evaluation and treatment of
the aging face. New York: Springer-Verlag 1995; 110–168.
24. Weiss RA, Weiss MA, Munavalli G, et al. Monopolar radiofrequency
facial tightening: a retrospective analysis of efficacy and safety in over
600 treatments. J Drugs Dermatol 2006;5:707–712.
25. Iyer S, Suthamjariya K, Fitzpatrick RE. Using a radiofrequency energy
device to treat the lower face: a treatment paradigm for a nonsurgical
facelift. Cosmet Dermatol 2003;16:37–40.
Important measures for maximizing results in neck liposuc-
tion include using small (2–3-mm) cannulas, combining hand
and machine suctioning, creating sufficient numbers of entry
sites for thorough suctioning, releasing submental fibrous sub-
cutaneous bands, and having the patient wear appropriate
postoperative garments. Despite proper postoperative care,
some patients will develop soft vertical bands or small sub-
mental nodules which resolve with time (usually 6–12
months). Resolution of these may be hastened with the use
of ultrasound massage.
 SUMMARY
Neck liposuction, either alone or in combination with
platysma repair, and in some cases SMAS plication, can
produce excellent recontouring of the aging or obese neck
and jawline. Patients with mild submental laxity or adipose
may benefit from non-surgical radiofrequency tissue tighten-
ing alone or in combination with these procedures. Fraction-
ated CO2 laser resurfacing can improve textural irregularities
on the neck. The goal of these procedures is to define the
cervicomental angle and jawline and improve the overall
appearance of the neck. It is important to educate patients
regarding duration of healing, as results will continue to
improve over several months as the skin tightens and redrapes
over the neck. By carefully utilizing these complementary
procedures in one surgical session, the surgeon can safely and
effectively improve neck contours.
 REFERENCES
1. Cook WR Jr, Johnson DS. Advanced techniques in liposuction. Semin
Cutan Med Surg 1999;18:139–148.
2. Webster RC, Smith RC, Smith KF. Face lift, part 2: etiology of platysma
cording and its relationship to treatment. Head Neck Surg 1983;6:590–
595.
3. Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and
lower face and neck. Dermatol Surg 2003;29:468–476.
4. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a non-
ablative radiofrequency device: a lifting experience. Dermatol Surg
2004;30:503–507.

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PART 4
Special Procedures

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669
41
Keloid Management
Hilary Baldwin MD
Summary box
 Keloids are a hyperproliferative response of connective tissue
to trauma, appearing most commonly in areas of high skin
tension.
 Their etiology and pathogenesis are poorly understood,
though multiple endocrine factors may play a part, and there
is evidence of genetic predisposition.
 In the early stages, diagnosis may be difficult, but mature
keloids are easily distinguishable from hypertrophic scars.
 Keloids often itch, burn, and cause pain, and in certain
locations may cause dysfunction because of restriction of
movement.
 Treatment depends on the morphology and location of the
keloid, and techniques include corticosteroid therapy, surgical
excision, laser surgery, radiation therapy, compression
therapy, application of silicon products, interferon injection,
imiquimod application, cryotherapy, and 5-fluorouracil
therapy.
 Prevention is a major goal in patients with a history of keloids
and surgical procedures should be planned with prevention in
mind.
 INTRODUCTION
Unlike many skin anomalies described in textbooks, scarring
is not new. Descriptions of keloids can be found in the Smith
Papyrus dating back to 3000 BC.1 The Yoruba tribe of Western
Africa recorded their knowledge of keloids in paintings and
sculptures as far back as AD 1600.2 Despite this long duration,
we have made remarkably little progress since the Yorubas
towards understanding keloid prevention and purposeful pro-
duction. It is likely that our current lack of consistently reli-
able, safe treatment measures is grounded in our ignorance
of keloid pathogenesis. There are aspects of keloids that are
preventable; one can avoid trauma resulting from voluntary
and elective procedures to adorn, augment, or improve.
Aggressive prevention of keloids after accidental trauma and
necessary surgery is also within our abilities. However, some
putative causative factors of keloid formation are out of our
control: ethnicity, skin pigmentation, age, gender, and genetic
makeup.
This chapter will review briefly what is known about keloid
epidemiology and pathogenesis in an effort to gain insight into
the development of a rational treatment and prevention plan
for these unsightly lesions.
Epidemiology
The reported incidence of keloid formation is highly variable
depending on the population studied. It has been reported to
range from a low of 0.09% in England to a high of 16% in
Zaire.3 Such variation is explained by numerous variables
including race and degree of skin pigmentation. In predomi-
nately black and Hispanic populations, incidences between
4.5% and 16% have been reported.4 Darkly-pigmented indi-
viduals form keloids 2–19 times more frequently than Cau-
casians.5,6 Ethnicity, regardless of pigment intensity, is also a
factor. In Aruba, more children of the lighter-skinned Poly-
nesian population form keloids than those of African descent.7
In Malaysia, those of Chinese decent are more prone to keloid
formation than are the darker-skinned Indians and Malays.8
Although Caucasians form keloids less frequently, those who
do can be very lightly complected. These patients are often
among the most difficult to treat.
Keloids can occur at any age. New keloid formation is
relatively less common in the very young and the elderly. In
young children, the low incidence may be explained by the
rarity of significant skin trauma. Aging fibroblasts may be less
capable of collagen overproduction.9,10 Keloid regression after
menopause has been reported.11 In an unpublished study
of 212 Caribbean-American and African-American keloid
formers at King’s County Hospital, we found that age as an
isolated factor did not correlate with keloid frequency.
Rather, the timing of the pierce relative to puberty was pre-
dictive of keloid incidence.
Small gender differences that have been reported in the
literature are likely to have resulted from cultural trends and
reporting bias. Multiple ear pierces are far more common in
women than men as are the resulting keloids. Additionally,
women may more readily seek medical attention for cosmetic
improvement.
Etiology
The plethora of existing theories regarding the etiology of
keloids is indicative of our lack of understanding of the con-
dition. The factors that are most consistent are some form of
skin trauma occurring in individuals with a genetic predispo-
sition for keloids. Increased wound tension at closure and
situations such as infection and trauma that can result in
additional wound tension may also play a role (Box 41.1).

670
Part 4  Special Procedures
possible that the chronic edema caused by the pierce (and
subsequent reaction to the presence of a metal foreign body)
could result in increased incidence of keloid formation.
Infection
There is no evidence to support the supposition that infec-
tious agents themselves cause keloids. Reports of keloids
following infections with varicella, smallpox, syphilis, and
tuberculosis were probably related to the trauma, edema, and
increased tension that occur as a result of wound infection.16,17
This highlights the importance of assiduous avoidance and
aggressive treatment of wound infections, especially in the
keloid-prone individual.
Endocrine factors
Multiple and diverse endocrine factors have been associated
with keloid incidence although causality is unproven. Keloids
have been reported to grow more readily or to appear de novo
during pregnancy.11,14 Keloids have been shown to be more
common after puberty than before. This was well known by
the Yorubas in the 1600s who knew to pierce ears early in
life to prevent keloiding. They also used this knowledge to
perfect ritual keloiding in intricate designs after the age of
puberty (Fig. 41.1). In a study at King’s County Hospital, ear
pierces that resulted in keloids occurred at a median age of
6.4 years postmenarche whereas those that did not keloid
were pierced at a median age of 4.25 years premenarche.18
Lane et al.19 found that earlobe keloids were more far more
likely to form in patients who were pierced after the age of
11 (80%) than before (23.5%).
Melanocyte-stimulating hormone (MSH) has been postu-
lated to play a role in keloid formation. This hypothesis is
based on the observation that keloids are more common in
patients with hyperpigmentation associated with pregnancy,
puberty, and hyperthyroidism. Melanocytes in patients with
skin of color may be more reactive to MSH than Caucasians,
explaining the higher incidence of keloids in darker-skinned
Trauma
Although ‘spontaneous’ keloids arising in non-injured skin
have been suggested, trauma is probably a requisite for keloid
formation. The severity of the trauma may be sufficiently
insignificant as to go unnoticed by the patient. Minor abra-
sions and burns, insect bites, varicella and zoster, vaccina-
tions, and tattoos can result in significant keloiding. Acne
lesions of the anterior chest and deltoid areas often morph
imperceptibly into keloids. Isotretinoin treatment in these
patients can prevent additional keloids even when the acne
lesions are not readily identifiable. Deep and significant surgi-
cal wounds are often less likely to keloid than are the minor
wounds described above. We often see drain site keloids next
to the larger surgical wound that failed to keloid.
However, trauma only serves as a potential precipitating
etiologic factor. Intrapatient variation is marked; most
patients experiencing the same trauma do not keloid. One
could propose that a second, perhaps genetic, factor would
be a necessary second trigger for keloids to form following
trauma. However, there is marked variation even within a
given patient. Areas prone to trauma such as the hands and
feet rarely keloid. This could be explained by evidence of a
phenotypic difference between fibroblasts taken from earlobe
keloids and palmar skin.12 Less easy to explain are the common
observations that acne lesions immediately adjacent to each
other often heal differently and bilateral pierces or adjacent
pierces often have different scar outcomes.
Skin tension
Keloids appear most commonly on areas in which skin tension
is the highest, namely the jawline, anterior chest, upper back,
and deltoid areas. As they progress in these areas, they tend
to stretch along skin tension lines forming linear or bow-tie
shaped lesions.
Closing a wound against the relaxed skin tension lines
results in a wound with twice the tension of one closed along
Langer’s lines.13 Postsurgical wound tension has been impli-
cated in the literature as a contributing factor in keloid forma-
tion.14,15 Since the loss of tissue that results from surgical
excisions increases wound tension, skin grafts may be prefer-
able to primary closure of a tight wound. However, donor
site keloids may occur. The use of tissue expanders to stretch
the skin preoperatively offers an alternative that both reduces
wound closure tension and applies pressure preoperatively
that might help reduce postoperative fibroblast function.
Wound tension as a primary etiologic factor in keloid for-
mation loses credibility when one considers the high inci-
dence of earlobe keloids following piercing. The only tension
on this wound is that of the minor edema that results from
the trauma of the pierce. Chronic edema has been reported
to increase glycosaminoglycans (GAGs) in the dermis.16 It is
Figure 41.1  Intricate ritual keloiding of the Yoruba tribe.
Box 41.1  Etiologic factors in
keloid development
 Trauma.
 Skin tension.
 Infection – primary infection and wound infections.
 Endocrine – estrogens and melanocyte-stimulating hormone.
 Genetic.

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Chapter 41  Keloid Management
keloid that can be a difficult diagnosis. Hypertrophic scars
develop rapidly after surgery, whereas keloids may occur
months after the inciting trauma. Ultimately hypertrophic
scars may subside with time while keloids generally progress
until such time as they become stable. They rarely, if ever,
regress. Hypertrophic scars achieve a shape that is commen-
surate with the size and shape of the preceding trauma
whereas keloids exceed, sometimes greatly, the extent of the
initial trauma. Hypertrophic scars are more likely to occur in
areas prone to excessive motion such as those across joints.
Keloids are most often found in areas in which there is limited
or no motion such as the chest and back. Careful and thought-
ful excisional surgery often results in resolution of the hyper-
trophic scar. Keloids (except perhaps on the earlobe) nearly
always recur unless adjunctive therapy is implemented. The
postoperative keloid recurrence is frequently worse than the
initial lesion.
Keloids are often symptomatic, causing itching, burning,
and pain. The sensation of pain can be the result of a lesion
that is in itself tender, or because of rubbing of the keloid
against clothing or furniture. Although cosmetic improve-
ment is the most common reason for patients to seek derma-
tologic care for keloids, some patients who seek medical care
are concerned primarily or solely with symptoms of itch and
pain. Increased symptomatology is also a useful clinical sign
of lesion progression, as stable, mature keloids are generally
asymptomatic. Resolution of symptoms during treatment is
often rapid and can be used as a guide to treatment success.
Once the symptoms are alleviated, the patient may choose
to discontinue therapy.
Keloids of the jaw, neck, and anterior chest can also cause
dysfunction. Patients with large lesions of the jaw and neck
may be unable to fully turn the head from side to side or to
extend or flex the neck (Fig. 41.2). Keloids of the mid-chest
often pull breast or adipose tissue towards the center of the
chest, creating the sensation of tightness and/or the appear-
ance of cleavage. This is particularly troublesome to male
patients. These lesions need not be fully removed to alleviate
the dysfunction. Portions of the lesions tethering the skin can
be excised to improve mobility, or high-dose corticosteroid
injections can be used to intentionally cause atrophy with
resultant skin relaxation.
Large keloids of the anterior chest and posterior scalp will
often form draining sinus tracts with multiple large, terminal
hairs trapped within. Excision of, at minimum, the immediate
surrounding tissue is usually necessary, but these patients
may respond to a short course of oral antibiotics.
patients. Additionally, keloids are rare on the melanocyte-
poor regions of the palms and soles. However, the highly
pigmented area of the genitalia is also an infrequent site of
keloid formation. Finally, there has never been a reported
case of keloid development in an albino patient, even one of
African decent.
Genetic predisposition
Keloids are believed to have a familial predisposition although
the pattern of inheritance is unclear.3,20 In our study at King’s
County Hospital, we found a familial pattern in 32% of keloid
formers. However, it is not clear if the familial tendency to
keloid is genetically inherited or if it is merely related to the
similarity of skin coloration between family members.
Pathogenesis
Our understanding of keloid pathogenesis is composed of
numerous isolated facts that as yet fail to form a cohesive
picture. The simple answer to the pathogenesis puzzle is that
keloid formation is caused by an increase in anabolic activity
in the absence of increased catabolism. Why this happens is
not known.
After normal wounding takes place, various signals are sent
to the neighboring fibroblasts to increase collagen and GAG
production. Upon completion of the rebuilding task, signals
are again sent to the fibroblasts to return to their prewound
status. Abnormalities in these signals, particularly those that
indicate reduction in collagen production, are believed to be
responsible for keloid growth. Interferons may be one of
those ‘stop’ signals. In normal wounds, there is regression of
connective tissue elements after the third week. In keloid
tissue, however, fibroblasts proliferate around the plentiful
new and dilated capillaries. Collagen synthesis and GAG
synthesis are markedly increased; collagen synthesis is 20
times greater in keloids than in normal skin.21,22 The absolute
number of fibroblasts within the entire keloid is not increased,
and they appear histologically normal, but the activity of
proline hydroxylase is markedly elevated, suggesting that the
rate of collagen biosynthesis is increased in a normally-sized
fibroblast population.21,23 Keloidal fibroblasts also appear to
resist programed cell death.24,25 Defective apoptosis within
keloids may be due to a dysfunctional form of p53. Injectable
interferon may be effective in treating keloids by its enhance-
ment of native p53.
Although collagenase is also increased, collagen degradation
is not, possibly due to an increased deposition of α-globulins
within the keloid.26,27 Serum α-globulins are known inhibitors
of collagenase.26 Estrogens increase the level of serum
α-globulins, which may help to explain the increased inci-
dence of keloids in pregnant women.26 Corticosteroids, in
contrast, have been shown to reduce the alpha-globulin
deposits within keloids.26 They too may act by increasing
activation of collagenase with subsequent breakdown and
resorption of the excessive collagen and clinical flattening.27
Clinical manifestations
Keloids rarely represent a clinical dilemma except in distin-
guishing them from hypertrophic scars (Table 41.1). This is
not merely an academic issue as the lesions respond quite
differently to therapy. A mature, aged keloid presents little
clinical debate. It is the early, pruritic, relatively flat, red
Table 41.1  Clinical features differentiating keloids from
hypertrophic scars
KELOIDS
HYPERTROPHIC SCARS
Develop slowly over months
Develop rapidly after skin insult
Continue to grow for
extended period
Subside with time
Exceed size of initial trauma
Stay within initial wound footprint
Occur in areas with little
motion
Occur in areas of motion (i.e. joints)
Recur after therapy
Regress with therapy
Often dome-shaped or
pedunculated
Broad and flat-topped

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Part 4  Special Procedures
This is nowhere more evident than in the field of keloidal
scarring in which one must sift through large numbers of
anecdotal reports and pure conjecture. The problem begins
with the delineation of hypertrophic scars from keloids (Box
41.2). Many studies include both entities in the admittance
criteria yet fail to reveal which lesions ultimately responded
to therapy. Other patient and lesion characteristics routinely
omitted from these studies include such important factors as
patient race and age, lesion age and symptomatology, lesion
size and location, recurrence versus virgin lesion, and lesion
morphology (sessile versus pedunculated or dome-shaped).
Most reports also suffer from inadequate follow-up time
of less than 6 months. It is true that keloid removal is easy;
the trick is preventing recurrence or occurrence.
In a recent review article, Shaffer et al.28 concluded that
despite a plethora of papers on the topic of keloids, ‘there
are no definitive treatment protocols.’ This is a result of
poorly designed and uncontrolled studies in which the end
point of therapy (cosmesis, function, or symptoms) is rarely
identified. Only radiation therapy (RT) in combination with
surgery met their standards for proven therapy. Mustoe et
al.29 also lamented the absence of well-controlled studies and
concluded that corticosteroid injection and silicone gel sheet-
ing (SGS) are the ‘…only treatments for which sufficient
evidence exists to make evidence-based recommendations.’
Durani & Bayat found SGS and laser therapy to have the
highest level of support, albeit sub par.30 Leventhal et al.31
noted that ‘most treatments for keloidal and hypertrophic
scarring offer minimal likelihood of improvement.’ Other
treatments at this time are still lacking the proof of efficacy
that arises only from a well-designed, randomized, placebo-
Lastly, the morphology and location of the lesion will often
dictate the therapeutic plan. Pedunculated lesions, particu-
larly when they occur on soft, mobile skin such as the axilla
or earlobe, are amenable to simple excisional surgery (Fig.
41.3). Tight, flat, sessile keloids such as those on the anterior
chest are not amenable to surgery and will respond best to
injectibles (Fig. 41.4). Earlobe keloids come in five varieties:
anterior button, posterior button, dumbbell, wraparound, and
lobular. Button keloids can be shaved off in their entirety.
Dumbbell keloids have a core component within the lobe.
Wraparound keloids form a cuff around the lobe from one
side to the other. Lobular keloids entirely replace the fatty
lobe and are often recurrent lesions. Wraparound and lobular
keloids often require wedge excisions for complete removal
(see Earlobe keloids, under Surgery, below).
 TECHNICAL ASPECTS
In any medical inquiry, a literature review of available therapy
requires attention to study design and validity of conclusions.
Figure 41.2  Keloid limiting mobility of neck and head.
Figure 41.3  Pedunculated keloid of the earlobe.
Figure 41.4  Sessile keloids of the chest and arms.
Box 41.2  Keloid characteristics serving as
entry criteria for studies
 Adequate differentiation between keloids and hypertrophic
scars.
 Patient age and race.
 Lesion age and symptomatology.
 Lesion size and location.
 Lesion status – recurrent versus virgin.
 Morphology – pedunculated versus sessile.
 Follow-up time.

673
Chapter 41  Keloid Management
lesion will not be eradicated fully. It is important that the
patient realize that the appearance of the skin will improve
but will never normalize. The overall lateral dimensions or
‘footprint’ of the keloid will not improve; in fact, footprints
often enlarge with therapy. When explaining realities of treat-
ment to the patient, it is often helpful to use the modeling
clay analogy: as the keloid is flattened, it will become wider.
Although this does not always happen, it is a prudent concept
to bring into the informed consent process.
Corticosteroids are less helpful as solo therapy in pedun-
culated or particularly raised lesions. Although they may be
useful for palliation of symptoms, repeated injections into a
pedunculated or high, dome-shaped keloid will soften and
shrink the keloidal tissue, rendering it a saggy pouch that will
eventually need to be excised. An argument can be made,
however, that the saggy pouch is more amenable to surgical
excision with relaxed closure than was the parent lesion.
Corticosteroids often have an impressive initial effect on
existing keloids. Patients report improvement in symptoma-
tology within a week. Reduction in firmness occurs more
slowly, often appearing after the second or third injection.
This minor clinical improvement is almost never noticed by
the patient, and should be demonstrated to impress upon
him/her the need for subsequent injections. Ultimately, after
many injections the lesion will appear flatter or smaller.
Unfortunately, this response is often temporary and the
patient may need to return after several months for repeat
treatments. Kiil34 and Griffith et al.35 reported recurrences of
50% at 5 years and 11.2% at 4 years, respectively.
Depending on keloid size, shape, age, and location, dilu-
tions of triamcinolone acetonide (TAC) from 10 to 40 mg/
kg can be used. The most common cause of steroid failure is
the use of overly dilute concentrations. Concentrations less
than 10 mg/mL are rarely effective in a mature keloid; most
will require 40 mg/mL. A keloid occurring in thin skin is still
a keloid and should be treated as such. This means that the
total area treated in one session will be limited by total safe
dose constraints. The standard of care is not to inject more
than 40 mg per session. The source of this ‘rule’ is not iden-
tifiable, but it is clearly based on the desire not to suppress
the hypothalamic–pituitary axis. However, since 40  mg of
triamcinolone is the equivalent of 50  mg of prednisone, a
higher dose delivered monthly would still be within most
physicians’ comfort zone, particularly in a heavier individual.
This concept must be kept in mind when planning the surgi-
cal excision of an existing keloid. It is imprudent to remove
more keloid volume than can be subsequently injected for
recurrence prevention; staged excisions may therefore be
preferable.
When the keloid is particularly large, or when a patient
presents with numerous lesions, choices must be made.
Diluting the steroid to ‘get it all’ is destined to failure. Spread-
ing the injections too thin is similarly ineffective. Better to
query the patient as to which lesion or which area of a large
keloid is most symptomatic or bothersome. Utilize the entire
daily allotment in the area chosen and save other areas for
another day. With subsequent treatments, the strength of the
steroid can be reduced in order to fine-tune the ultimate
outcome. The remainder can be utilized in the next area of
patient preference.
Injections can be repeated every 2–4 weeks, depending on
the strength/total dose of steroid used and the size of the
keloid. Although additional areas may be injected on the fol-
controlled trial with adequate patient numbers. The nature
of keloid therapy is such that a comparison of various tech-
niques is often not amenable to double blinding. We look
forward to more studies in which single techniques are com-
pared to controls, vehicles, or dummy therapy.
At the present time, we must recognize that keloid treat-
ment and prevention techniques are not necessarily evidence
based. Presented below are the techniques that have become
the standard of care in the field despite the lack of conclusive
data (Box 41.3).
Corticosteroids
Because of their ease of administration, low cost, and low
risk, intralesional corticosteroids alone and in combination are
the work horses of keloid therapy. Corticosteroids are one of
the only agents that can be used to treat existing keloids as
solo therapy without prior surgical removal. One of the most
successful uses of corticosteroids, however, lies in its use
postoperatively to prevent keloid occurrence or recurrence.
Although no solid evidence-based literature supports their
use in these roles, they have become the first-line approach
of most physicians dealing with this condition worldwide.
The effect of corticosteroids on collagen synthesis and deg-
radation is not completely understood. In young keloids, they
have been shown to increase the production of collagenase
and reduce the collagenase-inhibiting α-globulins.26 Tumor
necrosis factor (TNF)-β may also play a role.32 Corticosteroid
injections postoperatively have been shown to downregulate
type I collagen gene expression.33
Solo therapy for existing keloids
When used as solo therapy, corticosteroids are most useful
in sessile, flat, and broad keloids. Corticosteroids will flatten
and soften lesions and symptoms will resolve. However, the
Box 41.3  Common therapies for keloids
Topical
Corticosteroids
Retinoids
Imiquimod
Mederma
Vitamin E
Injectable
Corticosteroids
Interferons
5-Fluorouracil
Verapamil
Bleomycin
Surgical
Surgical debulking or excision
Laser debulking or excision
Physical
Laser therapy
Radiation therapy
Compression therapy
Silicone sheeting
Cryotherapy

674
Part 4  Special Procedures
Side effects
Common side effects of steroid injections include hypopig-
mentation and skin atrophy (Fig. 41.5). Hypopigmentation is
often a marker of clinical success and skin atrophy is fre-
quently a necessary consequence of adequate therapy. It is
prudent to tell patients that both will happen. The hypopig-
mentation can be pronounced and may last 6–12 months
before resolving. In this author’s experience, patients are
uniformly less bothered by the dyspigmentation than the
keloid that preceded it. Both hypopigmentation and atrophy
can be reduced by avoiding accidental injections into the sur-
rounding normal tissue. This most often occurs when attempt-
ing to force steroids into a particularly firm keloid. A good
rule of thumb is to either push harder or to redirect the
needle, but not both simultaneously. This helps to avoid the
sudden dump of steroids into the softer subcutis or surround-
ing skin. Extensive misplacement of steroids can cause tem-
porary linear hypopigmentation or atrophy extending out
from the treatment site. After treatment, the atrophic foot-
print of the keloid may appear wrinkled or shiny, and tel-
angiectasias are common. This appearance improves with
time. Alternatively, vascular lasers can be utilized to lessen
the telangiectasias. Since pulsed-dye lasers have been dem-
onstrated to produce a small, but perceptible, improvement
in relatively flat and erythematous scars, they might have two
advantages in this regard (see Laser surgery, below).
Surgery
Surgical removal of keloids is often necessary. Large, bulky
keloids will respond poorly to solo treatment with injectables.
Surgical debridement also allows for the use of adjunctive
techniques that are ineffective in pre-existing keloids but
useful postoperatively. Surgical techniques vary according to
the size, location, and shape of the keloid. Pedunculated
keloids with narrow bases can be excised and closed primarily
with little wound tension. Sessile keloids with broad bases
are much more difficult to treat surgically. However, mono-
therapy results in a high incidence of recurrence, often 50–
100%.37,42 Surgical removal is easy; prevention of recurrence
is the art. Surgery must be combined with adjunctive tech-
niques such as RT, steroids, or interferon. Several general
rules of thumb are indicated:
lowing weeks, it is best not to inject the same area with high
concentrations at less than 2-week intervals. The depot effect
of the steroids are such that repeat injections done too close
together can result in too much thinning too fast, leaving an
atrophic area. Hypopigmentation is also more likely in this
setting.
Occasionally, mature keloids are so firm that injection is
impossible. In this case, the deposition of steroid into the
needle tract is the best option. In order to be effective, mul-
tiple parallel tracts must be made with a large-bore (23-gauge
or larger) needle. Luer-lock syringes are essential to avoid
splashes. Because of the high pressure within the firm keloid,
the steroids will start to leak out the moment the needle is
removed. This can be avoided by applying a small drop of
cyanoacrylate glue to the hole prior to injecting, and then
covering it rapidly with precut plastic tape immediately upon
withdrawal of the needle.
Patients with very firm keloids generally require some form
of anesthesia in order to make the requisite number of tracts.
For pain control, topical eutectic mixtures of local anesthet-
ics are unhelpful. The pain the patient experiences with these
injections is not that of the needle passing through the epi-
dermis. The pain is deeper, and appears to be related to the
displacement of the fibrotic tissue by the force of the liquid.
This pain is beyond the scope of the topical anesthetics, even
after hours of occlusion. They can be used, however, to numb
the skin surrounding the keloid so that painless injections of
lidocaine can be given as a ring block. Mixing lidocaine with
the steroids makes little difference as the pain of the injection
is over before the lidocaine takes effect. Lidocaine will,
however, help those uncommon patients who complain of
persistent postinjection pain.
Solo therapy for keloid prevention
Corticosteroids are an integral part of keloid prevention – for
both de novo occurrence in a new surgical wound in a known
keloid former and for recurrence following keloid excision.
This author carries out the following injection schedule:
• On the day of surgery, and then at 2, 4, and 6 weeks,
the wound margins are injected with TAC 40 mg/mL
regardless of the appearance of the wound.
• At 2 months, and every month thereafter, injections are
given as clinically necessary. At that point, dosage of the
corticosteroids given at each session is determined
clinically by the site, size, degree of firmness, and
symptoms the patient is experiencing.
• Preventive therapy is best carried out for 1 full year;
early discontinuation is associated with a higher
incidence of unnecessary recurrences.
Polytherapy for keloid prevention
Corticosteroids can be combined with any other treatment
modality to improve outcome. Following surgical excision,
many authors have shown a reduction in recurrence rates
with the addition of postoperative corticosteroids.36,37 Com-
binations with cryotherapy and silicone gel sheets have been
shown to be superior to either modality alone.38 Corticoster-
oids plus α-interferon have been shown to be more effective
than corticosteroids alone.39,40 Combinations with lasers and
α-interferon also have shown promise41 (see Combination
therapy below).
Figure 41.5  Hypopigmentation (central keloid) resulting from
corticosteroid injections.

675
Chapter 41  Keloid Management
bells, wraparounds, and lobular (Figs 41.6–41.10). Anterior
and posterior buttons (much more common) are most easily
removed by simple shave followed by secondary intention
healing.
So-called dumbbell keloids (anterior and posterior button
keloids connected by a smaller core of keloid tissue) are more
complicated. In 1983, Salasche & Grabski reported a novel
and elegant method for removing dumbbell keloids.53 In this
method, the anterior and posterior portions of the keloid
were first dissected away from the earlobe. Then the core
within the lobe was dissected from the normal lobular skin,
and the entire keloid removed en bloc through the posterior
opening. A simpler method that this author prefers is a shave
of the anterior and posterior buttons, allowing visualization
and palpation of the firm tissue remaining within the adipose
tissue of the earlobe. The diameter of the core is measured
and punched out with a disposable punch at least 1 mm larger
than the core itself. The defect is closed horizontally on the
Use the smallest incision possible  The smallest incision
possible is made, extending less than the entire length of the
keloid. Dissect off any usable epidermis from the keloid for
ease of closure.
Remove all keloidal tissue  Unless it would result in gross
deformity or loss of function, all of the keloid material should
be removed. Dogma has it that remaining keloid serves as a
nidus for keloid reformation. Although data are scarce, it does
appear to be a truism. Care should be taken to remove any
trapped hairs. If left behind, they will in-grow, ultimately
causing an inflammatory response that has no outlet. Patients
will report repeated episodes of the sudden onset of tender-
ness and swelling followed by drainage.
Minimize wound tension  Closure should be done with the
least amount of tension. In a large wound with significant
tension, surgery followed by grafting alone may result in a
superior non-recurrence rate over primary closure.20 However,
donor-site keloids are possible. Tissue expanders may be pref-
erable in this situation.
Suture considerations  Whenever possible, monofilament
suture should be used to reduce the incidence of wound infec-
tion, abscess formation, and inflammation along the suture
line. Buried sutures may serve as a nidus for keloid reforma-
tion. Sutures often need to be left in longer than usual to
prevent dehiscence. This is especially true when steroids are
injected postoperatively. If the resulting wound is fairly
superficial or very broad, and the patient is amenable, allowing
the wound to heal by second intention often results in better
cosmetic outcome and a lower incidence of recurrence. Some
surgeons have recommended that if the lesion is too large to
be closed primarily, a rim of keloid tissue should be left
behind to act as a splint to prevent excessive central tensile
contraction.43 A full-thickness skin graft is placed on top.
Earlobe keloids
Earlobe keloids need to be considered separately. Many
authors have noted a lower rate of keloid recurrence in the
earlobe.44,45 Studies have shown a recurrence rate of only
41% after surgery alone.46 Studies utilizing both surgery and
steroids have shown recurrence rates of 1–20%.47–49 Surgery
with adjunctive RT has resulted in recurrence rates of
0–8.6%.47,50–52 With careful, aggressive therapy and using
multiple modalities, earlobe keloids rarely recur.
Better surgical results on earlobes are probably the result
of several factors. First-time earlobe lesions tend to be very
discrete, and easily separated from the surrounding dermis
and epidermis. Complete removal of all keloidal tissue is thus
easier to accomplish. Most earlobe keloids occur in women
who are profoundly motivated to wear earrings again, and are
far more compliant than the average keloid patient. The
fleshy tissue of the ear makes closure without tension easier
to accomplish. Postoperative pressure is easily applied with
the use of pressure earrings. These earrings are not particu-
larly cosmetically appealing, but the patients find them easy
to wear and comfortable. They also make an ideal postop-
erative dressing, obviating the need for bulky, and often inad-
equate pressure dressings.
Earlobe keloids come in five varieties, each of which is
approached differently: anterior and posterior buttons, dumb-
Figure 41.6  Anterior button earlobe keloid.
Figure 41.7  Posterior button earlobe keloid.

676
Part 4  Special Procedures
Laser surgery
After initial excitement over the demonstrated ability of the
carbon dioxide laser to decrease fibroblast activity in vitro,
its use in keloid therapy was a disappointment.54,55 Used in
the defocused mode, recurrence rate is extremely high.56 In
the focused mode, recurrence rate is similar to surgery alone
(50–70%).54,57 The Nd:YAG laser has been demonstrated to
cause an in-vitro selective bioinhibition of collagen produc-
tion, but recurrence rates are 53–100% in vivo.58 The combi-
nation of ultrapulse carbon dioxide laser and interferon
injections was reported by Conejo-Mir et al.59 Thirty lesions
were treated with 3 million units thrice weekly for 9 weeks
resulting in recurrences in 10 of 14 on the trunk and none of
16 on the ear at 3 years. Since truncal lesions are the more
difficult to treat than earlobes, this is not a major improve-
ment over surgery alone.
The pulsed-dye laser has been reported to improve hyper-
trophic scar symptoms, decrease scar height, and improve
skin texture. Alster & Williams showed a 57–83% improve-
ment with the 585-nm flashpump pulsed-dye laser in the
prevention of keloids in sternotomy scars.60 They noted the
importance of starting therapy early for the best results. It
has been proposed that the pulsed-dye laser decreases the
microvasculature in early keloids and hypertrophic scars,
resulting in anoxia. Several combination studies have shown
that pulsed-dye laser works better in combination with other
modalities including corticosteroids, interferon, and carbon
dioxide laser.27,61–64
Radiation therapy
The mechanism of action of RT on keloidal tissue and preven-
tion of keloids is unknown. Its preferential effectiveness in
early keloids suggests that it may decrease fibroblast collagen
synthesis.65 Alternatively, it may act by decreasing vascular
hyperplasia.66
RT alone is ineffective in existing keloids, although it may
resolve the pruritus associated with the lesion.65,67 In a study
anterior surface of the lobe and vertically on the posterior
lobe to prevent a pointed lobe.
Small lobular and wraparound keloids are best excised in a
wedge and closed primarily. Huge lobular keloids, wrapa-
round, and multilobular recurrent keloids are the most dif-
ficult to manage. Removal of the entire keloid is crucial, but
may well leave no functioning lobe. A perfectly keloid-free
ear is not a successful outcome if earrings are not wearable.
One option is to sculpt the lobe, removing as much keloid
as possible, leaving an earlobe-shaped keloid and relying on
postoperative techniques to prevent recurrence. This is not a
time for monotherapy or single adjunct therapy. Extensive
postoperative treatment with RT and silicone gel and
corticosteroid injections and interferon injection and pres-
sure often prevents the regrowth of the keloid. Once the
lobe-shaped keloid ages, it becomes stable and functional.
Pressure earrings may be necessary for 6–18 months (or even
permanently) after this technique, but the patients do not
seem to mind as they have some adornment on a functioning
lobe.
Figure 41.8  Wraparound earlobe keloid.
Figure 41.9  Dumbbell earlobe keloid.
Figure 41.10  Lobular earlobe keloid.

677
Chapter 41  Keloid Management
Pressure alone is ineffective in the treatment of existing
keloids. However, dressings which apply more than 24 mmHg,
worn 24 hours a day for 4–6 months, are often successful in
reducing keloid recurrence rates postoperatively. Not all
areas are amenable to pressure dressings, which in any
event are uncomfortable, hot, and unsightly. Ears are the
exception to this rule. Newer pressure earrings have large
compression plates and are easily worn all day long. In order
to accommodate the large surface area, the earrings are
necessarily broad and bulky. Young patients are often dis-
mayed by the cosmetic appearance of the ‘grandma earrings’
and most males will not wear them at all in public. The ear-
rings called ‘sleepers’ are smaller and more acceptable for
daytime use even though they have no adornments. Those
intended for heavy lobes are always more appropriate post-
operatively when the lobe is edematous from the procedure
and the healing process. Thin lobe earrings may become
necessary as time goes on in order to continue consistent
pressure.
The most complicated aspect of compression therapy is
determining when to discontinue. In this author’s opinion,
pressure can be stopped when the discontinuation does not
result in swelling of the affected area. This generally takes
4–6 months, but may occur earlier. It is useful to remind the
patient that this non-invasive technique is better used in
overkill than ‘underkill.’
Kosaka & Kamiishi recently reported an interesting com-
pression device for the more difficult areas.87 They created a
vest into which they sewed the balloon and rubber tubing
from a neonatal sphygmomanometer. The balloon was placed
over the area to be compressed, and inflated to the desired
pressure. They report that it is particularly good for the
anterior chest as it fits well over concave and uneven surfaces
without the use of tape. There is minimal pain and sweating
and the balloon does not displace.
Silicone products
SGS has been touted in many studies to be efficacious in
preventing the development of hypertrophic scars and
keloids.88–90 These studies are marred by the absence of blind-
ing and control, small patient numbers, retrospective design,
inadequate follow-up time, and the inclusion of both keloids
and hypertrophic scars within the same treatment group.
Keeping these confounding factors in mind, these studies
have shown that existing keloids may decrease in size by as
much as 30% when the gels are applied 24 hours a day con-
sistently for 2 months.88 SGS has been shown in small studies
to reduce hypertrophic scar formation by as much as 70%
when used consistently.90 The sheets must be worn over a
scar for 2–3 months, 12–24 hours a day to prevent keloid
development.91 Sheets are available in varying thicknesses and
consistency. Adhesive tape is necessary for consistent applica-
tion. A new formulation of silicone gel has recently been
reported.92,93 The gel is self-drying and forms a flexible and
transparent sheet after application, obviating the need for
tape. The mechanism of action of silicone gel sheeting is
unknown. SGS is known to retard epidermal water loss. The
drier agents have been shown to create static electricity
which some believe plays a role in its effectiveness. In a con-
trolled, prospective, non-blinded study, SGS was compared
to an occlusive dressing without silicone.94 SGS was not
found to be superior, leading the authors to conclude that it
of over 300 patients, RT alone at a total dose of 800–2400
rads over 2–5 months was only effective in reducing keloids
which were within 6 months of initiation.65–68 Mature, thicker
keloids require excision prior to radiation therapy.69,70
For prophylaxis in keloid-prone individuals, X-radiation,
electron beam, and interstitial radiation have all been reported
to result in similar cure rates (recurrence rates near 20%,
which are far superior to other modalities).71–73 Dosing sched-
ule and fractionation have varied greatly from one study to
another, but outcomes are similar. A minimum of 1000 rads
or equivalent appears to be the common consensus for suc-
cessful outcome.74 Kal & Veen concluded that radiation
therapy should be done within 2 days of surgical removal, and
that short treatment durations and ‘relatively high doses’ are
necessary.75 In a study of earlobe keloids, surgery plus RT was
compared to surgery plus corticosteroids.47 Recurrence rates
were 12.5% and 33%, respectively. Recurrence rates of 4.7%
with high-dose-rate brachytherapy,76 21% with interstitial
iridium-192,77 and 16–32% with electron beam78–80 have been
demonstrated. Recurrence rates have been shown to be
higher in areas of high tension such as the chest, scapula, and
suprapubic areas in three studies.79–81 The short treatment
plan required with RT may aid in patient compliance.
Despite its documented success in preventing keloid recur-
rence, RT is avoided by many clinicians due to largely
unfounded concerns regarding the long-term risks of malig-
nancy of the skin or underlying structures. Numerous large
studies report a carcinogenesis rate of 0%.74 Only one reported
case of squamous cell carcinoma arising in postkeloid radia-
tion site is evident in the literature, and the causality is
unclear.82 Botwood et al.74 attempted to put these concerns
into perspective. In more than 100 years in clinical use, there
are only three case reports of malignancies occurring post-RT
for a keloid. Breast cancer in a 57-year-old woman occurring
29 years after RT to a chest keloid was reported in 1999.74
Breast cancer in a 36-year-old woman 23 years after chest
wall keloid radiation was reported in 1988.83 In both cases,
confounding variables were also evident (7-year history of
hormone replacement therapy and evidence of unusually high
radiation doses, respectively). A single case report of thyroid
cancer occurring in a 27-year-old man 8 years after RT to a
keloid of the chin has also been reported.84 Histopathology
revealed a medullary carcinoma; radiation-induced carcino-
mas of the thyroid are exclusively papillary carcinomas.85
Based on dosimetry studies, RT in standard dosages to the
ear with proper shielding would expose the ipsilateral thyroid
lobe to only 2 rads.74 Studies, therefore, do not warrant a high
level of concern. Common side effects to consider are skin
atrophy, radiation dermatitis, abnormal skin pigmentation,
and local alopecia. RT is not recommended in children with
keloids, or metaphyses must be shielded to prevent retarda-
tion of bone growth, which may occur at doses of 400 rads
and less.86
Compression therapy
Compression therapy – applying pressure greater than that
of capillary pressure (24  mmHg) – causes a reduction in
soft tissue cellularity. Histopathology shows increased inter-
stitial space and collagen bundles that are more widely dis-
persed.87 It is theorized that pressure creates hypoxia,
resulting in fibroblast degeneration and subsequent collagen
degradation.

678
Part 4  Special Procedures
therapy was a logical continuance from injectable interferon.
Berman & Kaufman reported its use postoperatively in an
uncontrolled pilot study of 13 keloids removed from 12
patients.100 Applications were done twice daily, beginning on
the day of surgery and continuing for 8 weeks. At 24 weeks,
none of 11 keloids (10 earlobes, 1 trunk) evaluated had
recurred. The authors have subsequently reported one recur-
rence in the lesion removed from the back.
Since then, several other small, uncontrolled trials have
suggested that imiquimod is most effective on the earlobes.
Stashower showed no recurrence at 12 months in four
patients with eight earlobe keloids.101 Martin-Garcia & Bus-
quets reported a 25% recurrence rate in 8 earlobe keloids.102
Chaungsuwanich & Gunjittisomram showed an overall
6-month recurrence rate of 28.6% in 35 patients.103 Recur-
rences on the pinna were rare (2.9%) and those of the chest
common (83.3%). Malhotra et al.104 showed an improvement
after surgical excision of three presternal keloids in two
patients over the 8-week treatment phase, but recurrence 4
weeks later in all patients. In an ongoing study, we have found
a modest reduction in keloid recurrence in non-earlobe
keloids treated with imiquimod. In a placebo-controlled,
double-blind study of six patients with 12 non-adjacent
keloids, we found a 50% reduction in keloid reformation. The
recurrences in the imiquimod-treated areas occurred later
and were easier to treat than placebo-treated recurrences.
More controlled studies need to be performed to assess the
effectiveness of this treatment modality.
In all of the studies mentioned, there were few topical
and no systemic side effects noted. Application of imiquimod
to open wounds was mostly non-irritating. Discontinuation
for several days was adequate to control this unlikely side
effect.
Imiquimod application does not appear to result in an
improvement in existing keloids or hypertrophic scars, even
when applied under occlusion.
Cryotherapy
Many publications applaud the use of cryotherapy alone and
in combination with other products in the treatment of
keloids and hypertrophic scars.105–107 The proposed mecha-
nism of action is a combination of direct cell damage as well
as vascular damage that leads to further cell anoxia and death.
Most authors propose 30-second freeze times repeated 2–3
times per cycle with a 60–75% ‘good results’ outcome.105–107
Many papers suggest that younger lesions respond better to
treatment than more mature keloids.106 They do not, however,
comment on their method for differentiating hypertrophic
scar from young keloid.
Side effects of cryotherapy include pain and a prolonged
healing phase of more than 1 month. The likelihood of hypo-
pigmentation resulting from melanocyte sensitivity to cold
makes cryotherapy ‘less applicable in dark-skinned patients.’106
Unfortunately this is the population most likely to present
for therapy.
Recently, several authors have suggested unique methods
of cryosurgery with good results in small numbers of patients.
Gupta & Kumar suggest inserting a lumbar puncture needle
in one side and out the other side of the keloid.107 Liquid
nitrogen is then passed through the needle utilizing an IV drip
set. There were two freeze–thaw cycles of 20–30 seconds
was wound hydration, not the presence of silicone, that was
responsible for the clinical effect.
Interferon
As discussed previously, fibroblast activity increases dramati-
cally after wounding. Once the wound is adequately stabi-
lized, signals are sent to the fibroblasts to shut off this
excessive production of ground substance and collagen. Inter-
ferons are one of these signals. Berman & Duncan reported
that short-term intralesional interferon-α-2b treatment of a
keloid resulted in a selective and persistent normalization of
keloidal fibroblast collagen, GAG, and collagenase production
in vitro and a rapid reduction in the area of the keloid.95
Interferon has also been shown to upregulate native p53 that
is dysfunctional in keloidal fibroblasts.96 This might promote
the natural cell death of the overactive fibroblasts.
Both interferon-α and -g are available for use. Initial clinical
trials with interferon-g were disappointing and it is no longer
in use.97 Granstein has reported on an unpublished study
where 18 of 19 keloid re-excisions were accomplished
without recurrence at 1 year by two postoperative injections
of interferon.98 Berman & Bieley reported response in 11 of
12 recurrent keloids of the head and neck after surgical exci-
sion and interferon-α-2b.99 Berman & Flores reported a recur-
rence rate of 51.5% following surgery alone, 58.4% after
surgery and corticosteroids, and 18.7% when surgery was
combined with both interferon and corticosteroid injec-
tions.39 At King’s County Hospital, we have found that
interferon-α injections can be used to decrease keloid recur-
rence after earlobe keloid excisions in which keloidal tissue
was left behind.
We can predict from the in-vitro findings highlighted above
that interferon may work better in young keloids and in
keloid prevention than in mature older keloids where the
damage has already been done. Clinical investigations have
borne this out. Interferon injections do not result in an
improvement of existing mature and stable keloids.
Injections of interferon-α-2b are done on the day of surgery
and then 1 week postoperatively directly into the wound.
One million units per linear centimeter are injected into the
wound base and margins. In the case of a wound allowed to
heal by second intention, injections are given approximately
every square centimeter. Side effects are reduced by limiting
total dose to less than 5 million units per treatment.
Side effects of interferon-α-2b include a flu-like syndrome
which can be reduced or eliminated by the prophylactic
use of acetaminophen. One gram is taken 1 hour preopera-
tively, 3 hours postoperatively, and every 4 hours through
the first 24 hours. Patients are told to set alarms to assure
prompt and continued dosing. It is also helpful to time the
injections late in the afternoon so that mild febrile reactions
pass unnoticed during sleep. Patients are told to plan to be
free from obligations on the night of the procedure and
the next day, and to repeat these cautions in the following
week.
Imiquimod application
Imiquimod 5% cream is a potent and rapid inducer of inter-
feron after topical application. Topical application of imiqui-
mod to keloids has been shown to significantly alter gene
expression of markers of apoptosis.96 As such, its use in keloid

679
Chapter 41  Keloid Management
Vitamin E
The use of topical vitamin E on scars is believed to be highly
effective by the lay public. There is no evidence that vitamin
E improves or prevents hypertrophic scars, and there is clear
evidence that it is a frequent cause of cutaneous side effects.
In one study, it was found to be ineffective in scar improve-
ment; at the same time it caused cutaneous adverse reactions
in 33% of the patients.120
Bleomycin
Espana et al.121 describe the treatment of 13 patients with
bleomycin. Bleomycin 1.5 IU/mL is applied to the surface
of the keloid that is then punctured repeatedly with a
25-gauge needle. A total of two to five treatments at 1–4-
month intervals resulted in complete flattening of three of
seven keloids, and a thinning of the rest. Side effects included
pain, necessitating lidocaine anesthesia, and hyperpigmenta-
tion in all patients. There were two recurrences at 10 and 12
months.
Combination therapy
There is no medical reason to limit preventive treatment
to a single agent or modality. Prevention of recurrence or
occurrence can be greatly improved when all available modal-
ities are utilized simultaneously. Interferon injections at day
1 and day 8 combined with RT can deliver two adjunctive
therapies in the first 2 weeks postoperatively when patient
compliance is at its peak. Pressure dressings, if possible, imi-
quimod application, and continued corticosteroid injections
as previously delineated can be used in conjunction to maxi-
mize outcome.
Keloid avoidance behaviors
The first goal of therapy is, of course, prevention of unneces-
sary trauma. Cosmetic procedures should be discouraged.
Ears from which keloids have been removed should not be
repierced.
Early and aggressive treatment of accidental wounds or
non-elective surgeries is crucial in keloid-prone individuals.
Necessary surgical procedures should be closed parallel to
relaxed skin tension lines with minimal stress (Fig. 41.11).
Skin grafts, tissue expanders, and healing by second intention
should be considered to minimize wound tension. Wounds
should be covered with SGS and/or pressure garments when-
ever possible. Preventive intralesional corticosteroids should
be injected at the time of the procedure and regularly there-
after. Intralesional interferon and RT should also be consid-
ered. Often this must be coordinated in advance with the
patient’s general surgeon. Such interference is not always
appreciated and it is prudent to elicit the help of the patient
in discussing with the surgeon the importance of early
intervention.
Patients in whom acne lesions tend to form keloids must
be carefully monitored and treated (Fig. 41.12). They should
be educated to present at the first sign of an inflammatory
acne lesion for intralesional steroids. Multiple lesions are an
indication for oral antibiotics or a course of isotretinoin. Sim-
ilarly, in dark-skinned individuals with a family history of
keloid formation, varicella or zoster should be aggressively
treated with antiviral agents.
each. Patients were treated with 5–10 sessions. Although
hypopigmentation was evident in all patients, more than 75%
showed flattening. Har-Shai et al.108 reported a 51.4% reduc-
tion in scar volume after only one session of cryotherapy
utilizing a cryoprobe to completely freeze the keloid. Other
authors have suggested that the combination of cryotherapy
and corticosteroids is superior to either modality alone.38,109
The problem with hypopigmentation still remains a major
issue in darker-skinned patients.
5-Fluorouracil
5-Fluorouracil (5-FU) is the mainstay of therapy for one
author who has considerable experience with its use.110,111
There are no evidence-based data to support its use. Fitz-
patrick has reported on his experience in more than 5000
patients with hypertrophic scars and keloids.110 Small amounts
(0.05 mL of 50 mg/mL) are injected at 1-cm intervals along
the scar. The total dose per session ranged from 2 to 50 mg
and never exceeded 100  mg. Patients were treated once
weekly on average, but as high as thrice weekly in patients
with markedly indurated or symptomatic keloids. Fitzpatrick
found that the younger, more symptomatic scars improved
the most.110 Numerous small, uncontrolled studies have
shown similar results: modest improvement, superiority in
younger, smaller, virgin keloids. Side effects in all studies
included ulceration, pain, and hyperpigmentation in virtually
all patients.112–114
Fitzpatrick further found that the addition of TAC (0.1 mL
of 10 mg/mL TAC added to 0.9 mL of 5-FU mixture above)
both improved efficacy and decreased the pain of injection.111
Apikian & Goodman also showed superior results when bet-
amethasone was added.115
Like corticosteroids, the mechanism of action appears to
be the inhibition of fibroblast proliferation. Unlike cortico­
steroids, however, Fitzpatrick reports no side effect of tel-
angiectasia formation.110 The further addition of pulsed-dye
laser therapy to TAC/5-FU injections was even more success-
ful in Fitzpatrick’s hands.62 He hypothesizes that the pulsed-
dye laser causes selective damage of the microvasculature,
resulting in a reduction of erythema and improved wound
surface texture. Beranek & Masseyeff suggested that it is the
prolonged angiogenesis that is the cause of hypertrophic scar-
ring and that an interruption of this process results in lesion
improvement.116
Miscellaneous therapies
Intralesional verapamil
In vitro, verapamil increases procollagenase synthesis and
drives fibroblasts towards extracellular matrix degradation.117
Its low cost and good safety profile, when used intralesionally,
lead to its use in keloid therapy. Two studies have shown
it to be effective only for early hypertrophic scars.117,118 It
appears to be ineffective in sites other than earlobes.
Mederma
Mederma is a plant extract that has been shown to have a
wide range of effects in biological systems. It has antioxidant
and anti-inflammatory properties demonstrated in many in-
vitro studies.119 However, there is no well-designed study
showing any clinical utility.

680
Part 4  Special Procedures
 PITFALLS AND THEIR MANAGEMENT
 OPTIMIZING OUTCOMES
Figure 41.12  Acne merging imperceptibly with keloids.
Optimizing outcomes
 Consider the morphology and location of the lesion carefully
when planning therapy for existing keloids.
 Follow up for at least 1 year after therapy to monitor for
recurrence.
 For patients with a history of keloids:
n keep keloid prevention in mind when planning any
surgical incision and postoperative care
n treat viral exanthems aggressively
n monitor those with acne carefully and institute therapy
early if lesions start to form keloids.
 Consider postoperative compression therapy to reduce keloid
recurrence rates.
 Consider postoperative corticosteroid injections as an adjunct
to prevent recurrence.
Figure 41.11  Keloid resulting from placement of ventricular
shunt.
Pitfalls and their management
 Educate patients so that their expectations of therapy
for keloids are realistic – for example, it is important that
they understand that the lesion may become wider with
corticosteroid therapy.
 In children, avoid radiation therapy for reduction of keloid
recurrence – if it must be used, shield growth plates to prevent
growth retardation.
 When corticosteroid injection is used, to minimize atrophy and
hypopigmentation inject corticosteroid into the lesion rather
than the surrounding normal tissue.
 SUMMARY
Keloids are a challenging problem that have four distinct and
equally important features: discomfort, size, color, and dys-
function. All of these issues must be addressed with the
patient prior to embarking on a treatment plan to ensure that
what the physician feels is an optimal treatment goal is shared
by the patient. Since therapy is often inadequate and fraught
with complications, the patient must be fully prepared for a
long treatment course.
The future of keloid therapy rests with our better under-
standing of the pathogenesis of these fascinating lesions.
Keloids can be envisioned as incomplete tumors. They are
stuck in a proliferative phase and fail to proceed to the
maturation phase. Keloids have several characteristics of
malignancy: poor regulation of growth, proliferation beyond
the boundaries of the initial insult, and increased collagen
synthesis. Yet there has never been a reported case of a keloid
becoming malignant. These factors predict that future
advances in keloid therapy lie in the direction of an immuno-
logic approach rather than the slash and burn approach we
now pursue. Time will tell if interferons or other immune
response modifiers will be the magic wand for which our
patients are waiting.
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