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

333
Chapter 20  Scar Revision
A
B
C
Figure 20.9  V–Y repair. (A) Retracted lower lip. (B) ‘V’ incision made inferiorly and scar undermined. (C) The lip is pushed up and
the ‘V’ is converted into a ‘Y’.
is then pushed away from the incision to relieve the tension
and simultaneously lengthen the scar. The newly created
defect is then closed such that the two sides of the defect
are brought together to form a straight line along the initial
scar line (Fig. 20.9). V–Y repair is helpful for relatively
smaller contractions. Just as the V–Y repair can raise an ana-
tomic point, a Y–V repair can be used to lower it. The initial
incision is made in a Y shape and similarly converted to
form a ‘V’.
Trapdoor deformity repair
Mild trapdoor deformities can usually be managed with
intralesional steroids, beginning at approximately 1 month
postoperatively. If the wound edges blend well with the sur-
rounding skin, then the flattening that results from intrale-
sional steroids is all that would be required. If the deformity
is pronounced, however, surgical revision may be required.
An incision is made along the curvature of the flap. Because
the entire flap does not need to be lifted, the portion of the
scar that is the most uneven or spread is selected for place-
ment of the incision. The incised flap is then reflected back.
The undersurface is thinned and the base deepened (Fig.
20.10). A technical trick is to use a #69 Beaver blade (Bec-
ton-Dickinson, Franklin Lakes, NJ), rounded at the tip, to
remove the disc of fibrofatty tissue. The flap can be thinned
to a greater extent than it was at the time of the initial recon-
struction because there is reduced tension, better vascularity,
and less disruption of the flap base and pedicle. Any excessive
flap tissue is trimmed and the wound edges are undermined
to widen the scar base. The wound edges are widely under-
mined. The flap is then gently draped back and placed slightly
inset to the surrounding skin.23,24
Ectropion repair
Ectropion is a complication that deserves special mention.
Unlike most other scars, it has implications beyond the cos-
metic appearance. Patients with ectropion complain of irrita-
tion, tearing, and conjunctival injection, which demands
immediate consideration of scar revision. However, keep in
mind that a mild ectropion frequently resolves spontaneously
over several weeks postoperatively.
Ectropion can be difficult to repair; therefore, its preven-
tion through careful planning and surgical technique is para-
mount at the time of the initial surgery. Scars should
be oriented perpendicular to the lower lid margin. Grafts
should be oversized up to double the defect size to compen-
sate for the massive contraction that occurs with thinner
grafts in this region. Flaps should be sized generously in order
to push the inferior lid up, such as in an inferiorly based
rhombic transposition flap. The flap’s tension vector can
also be designed to pull up on the lower lid, as is seen in a
laterally based advancement flap that is incised above the level
of the lateral canthus in order to pull up on the lower eyelid.
Additionally, periosteal tacking sutures can be placed to
suspend flaps to the bony orbit to prevent pull on the lower
lid. If excessive lid laxity is present, then the lower lid should
be tightened preventatively by removing a full-thickness tri-
angular wedge of the lower lid.25 Additionally, canthoplasty
can be performed by making a horizontal incision several mil-
limeters lateral to the lateral canthus, exposing the lateral
canthal ligament, then tacking down this ligament to the
superior orbital rim, thereby resulting in a tightening of the
lower lid skin.
Once an ectropion has developed, however, other tech-
niques need to be performed to release the contracture
causing the ectropion. V–Y repair is helpful for a mild ectro-
pion.26 For more prominent ectropia, a full-thickness skin
graft is a good option to restore the lower eyelid. The ideal
donor site is the upper lid skin. The graft should be oversized
to up to double the defect size.27 If the original scar is present
Figure 20.10  Flap debulking. An incision is made along a
bulky flap. The scar is carefully trimmed to reduce the
bulkiness.

334
Part 2  Essential Surgical Skills
near the lower lid margin, then an incision is made through
the scar and undermined to lift the lower lid into proper
position, thus releasing the ectropion. The graft is then
inserted into the defect created by the release. If the original
scar is distant from the lid margin, then the incision is made
horizontally at the subciliary line. In severe cases, the lower
lid is tacked to the eyebrow in order to suspend the lower
lid in an elevated position for approximately 3 weeks. This
maneuver can be performed alone without a skin graft for
mild to moderate ectropia (Fig. 20.11).
Dermabrasion and ablative lasers
Spot dermabrasion is an ideal technique to improve subtle
textural abnormalities associated with scars. This can be per-
formed on a scar as the sole scar revision technique or used
in combination with a re-excision. The ideal timing for derm­
abrasion is 6–12 weeks postoperatively.
Dermabrasion superficially abrades the scar and the sur-
rounding skin to the level of the papillary dermis in a precise
and controlled manner. This results in a smoother texture and
evens out any irregularities along the scar surface. Dermabra-
sion can improve the appearance of uneven scar edges as well
as raised grafts and flaps by leveling the irregular contours.28,29
Even in aesthetically acceptable scars, dermabrasion can help
to blend the scar into the surrounding skin. Dermabrasion is
performed in multiple different ways. Larger areas usually
need a power dermabrasion device with local anesthesia and
freezing. Smaller scars, however, can be lightly dermabraded
to the point of pinpoint bleeding using sterile 300–400 grit
sandpaper wrapped on a dental roll. One must be cautious
not to go too deeply into the dermis, thus causing a depres-
sion that is difficult to repair. The margins along the scar
undergoing dermabrasion should be extended and feathered
into normal surrounding skin, including an entire cosmetic
unit or subunit, because pigmentary alteration occasionally
resulting from dermabrasion may lead to a more conspicuous
treated area (Fig. 20.12).
Pulsed ablative lasers (CO2 and Er:YAG) can provide
similar results as dermabrasion by superficially ablating the
scar.30 Each laser has its distinct advantages. Er:YAG has a
higher affinity for water, so it is more precise in ablating
raised scar edges. The CO2 laser causes more thermal necro-
sis and thus promotes more wound contraction and collagen
remodeling. Surgical scar revision and laser resurfacing can be
combined into a single-step procedure where the cosmetic
unit surrounding the scar is lasered first, immediately fol-
lowed by scar re-excision.
All ablative procedures, including both dermabrasion or
laser ablation, carry a slight risk of worsening a scar from
overly aggressive treatment or from pigmentary alteration.
Fractional laser resurfacing is a new and promising proce-
dure that may lower these side-effect risks seen with
dermabrasion or traditional laser ablation (see above). Nev-
ertheless, patients need to be fully informed and consent to
this potential risk.
 POSTOPERATIVE CARE
After scar revision, care is the same as that for other
skin incisions. For further details on wound healing, see
Chapter 7, and on dressings and postoperative care, see
Chapter 8.
A
B
C
Figure 20.11  Ectropion repair. (A) Severe ectropion. (B) The
retracted scar is excised and the surrounding area is
undermined to return it to normal position, is loosened, the
lower lid is tacked to the eyebrow, and an oversize full-
thickness skin graft from the contralateral upper eyelid is placed
into the defect. (C) Result: 2 months postoperatively.

335
Chapter 20  Scar Revision
 PITFALLS AND THEIR MANAGEMENT
A
B
C
Figure 20.12  Dermabrasion. (A) Bulky flap on the lateral nasal
ala. (B) The entire alar subunit is dermabraded. (C) Good
cosmetic blend 2 months postoperatively.
Pitfalls and their management
 Understand the time sequence for normal wound healing and
give adequate time for this remodeling process to occur – do
not institute invasive revision procedures prematurely.
 Proper suture technique with buried vertical mattress sutures
and meticulous epidermal sutures are paramount in creating
wound eversion and a desirable surgical outcome; a wound
that lacks eversion at the time of closure is more likely to
become wide and depressed.
 Avoid aggressive defatting when thinning a bulky flap, which
may compromise vascularity.
 Be cautious not to be overly aggressive with the quantity,
frequency, or strength of Kenalog injections, as significant
atrophy may occur.
 Ectropion can be difficult to repair; it is best to prevent this
undesirable outcome through careful planning and surgical
technique at the time of the initial surgery. If ectropion does
occur, a Z-plasty or full-thickness skin graft that is generously
oversized is the most common revision technique to correct
this potentially disabling condition.
 When dealing with contracted scars in locations that are highly
visible, consider multiple Z-plasties which will better hide the
‘Z’ shape along the scar line as well as distributing the tension
across multiple smaller transverse diagonals.
 When using dermabrasion, one must not treat deeper
than the papillary dermis as a depressed scar will develop.
Treatment should extend slightly beyond the scar into normal
surrounding skin to help create a more even appearance.
 All ablative laser procedures carry a slight risk of worsening
a scar from overly aggressive treatment and should be used
on select patients with modest fluence settings. Postoperative
care should be discussed with the patient in detail prior to
treatment and strict sun avoidance is imperative.
 SUMMARY
Meticulous planning and technique will lead to superior scars.
Even the best surgeons must confront scars that are aes-
thetically unacceptable. Often, just waiting may be the best
treatment, as wound healing is not a static process. Some-
times surgical intervention is needed to optimize the appear-
ance of the scar. With careful assessment of the scar, various
scar revision techniques can be applied to create an aestheti-
cally pleasing scar.
 REFERENCES
1. Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines.
Plast Reconstr Surg 1984;73:144.
2. Baker SB, Swanson NA. Local flaps in facial reconstruction. St Louis:
Mosby; 1995.
3. Koranda FC, Webster RC. Trapdoor effect in nasolabial flaps. Arch
Otolaryngol 1985;111:421.
4. Webster RC, Benjamin RJ, Smith RC. Treatment of ‘trapdoor deformity.
Laryngoscope 1978;88:707.
5. Borges AF. Principles of scar camouflage. Facial Plast Surg 1984;1:
181–190.
6. Goslen JB. The role of steroids in preventing scar formation. In: Thomas
JR, Holt GR, eds. Facial scars: incision, revision, and camouflage. St
Louis: Mosby 1989; 88–89.
7. Alster TS. Improvement of erythematous and hypertrophic scars by the
585 nm flashlamp pumped pulsed dye laser. Ann Plastic Surg 1994;32:
186–190.

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Part 2  Essential Surgical Skills
18. Thomas JR, Frost TW. Scar revision and camouflage. In: Baker SB,
Swanson NA, eds. Local flaps in facial reconstruction. St Louis: Mosby
1995; 587–595.
19. Webster RD, Davidson TM, Smith RC. Broken line scar revision. Clin
Plast Surg 1977;4:263–274.
20. Swanson NA. Atlas of cutaneous surgery. Boston: Little Brown & Co
1987; 118–123.
21. Borges AF. Z-plasty. In: Borges AF, ed. Elective incisions and scar revi-
sion. Boston: Little Brown & Co; 1973.
22. Frodel JL, Wang TD. Z-plasty. In: Baker SB, Swanson NA, eds. Local
flaps in facial reconstruction. St Louis: Mosby 1995; 131–148.
23. Hosokwawa K, Susuki T, Kikui T, et al. Sheet of scar deformity: a
hypothesis. Ann Plast Surg 1990;25:134.
24. Salache SJ. Complications of local flaps. In: Baker SB, Swanson NA, eds.
Local flaps in facial reconstruction. St Louis: Mosby 1995; 581.
25. Young VL, Bartell TH. Burns of the face. In: Thomas JR, Holt GR, eds.
Facial scars: incision, revision, and camouflage. St Louis: Mosby 1989;
238–239.
26. Tromovich TA, Stegman SJ, Glogau RG. Flaps and grafts in dermatologic
surgery. Chicago: Mosby Year Book 1989; 217.
27. Skouge JW. Skin grafting. New York: Churchill Livingstone; 1991.
28. Hill TG. Enhancing the survival of full-thickness grafts. J Dermatol Surg
Oncol 1984;10:639.
29. Robinson J. Improvement of the appearance of full-thickness skin grafts
with dermabrasion. Arch Dermatol 1987;123:1340.
30. Wheeland RG. Revision of full-thickness skin grafts using the carbon
dioxide laser. J Dermatol Surg Oncol 1988;14:130.
8. Alster TS, Williams CM. Treatment of keloid sternotomy scars with
585  nm flashlamp pumped pulsed dye laser. Lancet 1995;345:
1198–1200.
9. Manuskiatti W, Fitzpatrick R, Goldman M. Energy density and numbers
of treatment affect response of keloidal and hypertrophic sternotomy
scars to the 585 nm PDL. J Am Acad Dermatol 2001;45:557–565.
10. Nouri K, Jimenez GP, Harrison-Balestra C, et al. 585 nm pulsed dye laser
in treatment of surgical scars starting on the suture removal day. Derma-
tol Surg 2003;29:65–73.
11. Laubach HJ, Tannous Z, Anderson RR, et al. Skin responses to fractional
photothermolysis. Lasers Surg Med 2006;38:142–149.
12. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photother-
molysis for the treatment of atrophic scars. Dermatol Surg 2007;
33:295–299.
13. Cohen SR, Henssler C, Horton K, et al. Clinical experience with the
fraxel SR laser: 202 treatments in 59 consecutive patients. Plast Reconstr
Surg 2008;121:297e–304e.
14. Chapas AM, Brightman L, Sukal S, et al. Successful treatment of acnei-
form scarring with CO2 ablative fractional resurfacing. Lasers Surg Med
2008;40:381–386.
15. Glaich AS, Goldberg LH, Friedman RH, et al. Fractional photothermoly-
sis for the treatment of postinflammatory erythema resulting from acne
vulgaris. Dermatol Surg 2007;33:289–294.
16. Thomas JR. Scar analysis. In: Thomas JR, Holt GR, eds. Facial scars:
incision, revision, and camouflage. St Louis: Mosby 1989; 120–124.
17. Borges AF. Improvement of antitension lines scars by the ‘W’ plastic
operation. Br J Plast Surg 1959;12:29–43.

PART 3
Aesthetic Surgical
Procedures

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339
21
Psychosocial Issues and the Cosmetic
Surgery Patient
Dee Anna Glaser MD
Summary box
 Psychosocial factors are important in cosmetic surgery patient
selection.
 An appropriate preoperative psychiatric exam is essential.
 By recognizing the key features of common personality and
mental disorders, cosmetic surgeons can plan effective
treatment for each individual patient.
 Body dysmorphic disorder is one of the more common
psychological disorders seen in people seeking cosmetic
surgery.
 Surgical success rates are poor for patients who have body
dysmorphic disorder and cosmetic surgery is generally
contraindicated for such patients.
 INTRODUCTION
Over the past decade the number of cosmetic procedures has
increased dramatically. With more and more patients seeking
cosmetic enhancements, it is imperative that the physician
and staff be able to identify patients with psychological prob-
lems that may either require special counseling or postopera-
tive care, and especially those that would preclude cosmetic
procedures being performed at all. Over the years there has
been a growing interest in determining the actual rates of
psychiatric conditions present in a typical cosmetic surgery
practice. One such study indicates that just under half
(47.7%) of a sample of 415 patients seeking cosmetic surgery
suffer from at least one serious mental disorder.1 Among the
major diagnoses were schizophrenia, persistent delusional dis-
orders, major depressive episodes, neurotic disorders, hypo-
chondriacal disorder, paranoid personality disorder, and
histrionic personality disorder. In addition, over half of the
patients surveyed suffered from poor social adjustment
(56%), indicating that many patients are turning to surgery
as a way of obtaining social acceptance. The researchers also
found that men tended to suffer from a greater number of
mental conditions, including dysmorphophobia, a disease that
will be discussed in great length later in this chapter.
Of course, many people whom we would consider to be
typical cosmetic surgery patients suffer from at least one
diagnosable psychological disorder including – but not limited
to – social inhibition, moderate self-consciousness, anxiety,
and depression.2 In fact, aesthetic surgery would be contrain-
dicated for any patient whose psychological health could not
be improved in one way or another through the desired
operation. In most cases, upon completion of an appropriately
indicated treatment, and possibly some minor psychological
counseling, the patient should have a positive outlook on the
procedure and should be able to function as a normal member
of society. In some cases, however, patients may be much
more psychologically disturbed, suffering from severe depres-
sion, personality disorders, neurosis, and other psychoses. In
any of these cases, it is important that the surgeon is able to
recognize immediately the presence of these more severe
conditions so that appropriate treatment can be obtained.
 TECHNICAL ASPECTS
The psychiatric exam
The importance of obtaining the mental status of a patient is
unique in its ubiquity. It is a mainstay of every examination,
regardless of where the patient encounter takes place – the
exam table in the emergency room, or on the psychiatrist’s
couch. Even though the psychiatrist and the emergency room
physician will undoubtedly have very different goals for their
evaluations, the general structure of the exam and the infor-
mation obtained are generally the same. Here I will describe
the basic steps to the psychological evaluation of a patient
and the information that is necessary for the cosmetic surgeon
to obtain before proceeding with any cosmetic procedure.
The psychological exam is also unique as it begins the
moment the patient walks into the office. Often with bizarre
patients, nurses and office staff alert the physician that the
patient may be acting strangely or unusually. In any case, the
physician should begin to evaluate the mental status of
the patient from the moment they meet, throughout the
visit, until the moment the patient walks out the door. For
most physicians, and in particular cosmetic surgeons, this is
a simple task, as a highly developed power of observation is
warranted by their chosen occupation.
The first thing any physician will notice is the appearance
of the patient. Taken alone, appearance means next to nothing
in our society as fashion and grooming style are no longer
accurate indicators of occupation, intelligence, or mental
status. However, the appearance of a patient may give the
physician clues as to the line of questions that will be most
appropriate in obtaining information about this particular

340
Part 3  Aesthetic Surgical Procedures
response times. Other abnormalities may be noticed if the
patient is excessively concerned with details or is not inter-
ested in anything past an overly generalized description of the
procedure. Understanding the patient’s background may also
be helpful in investigating these attributes. The purpose of
evaluating the patients’ thought processes, judgment, and
insight is to determine if they are able to arrive at a rational
decision independently. In all these areas it is important for
the physician to focus on asking specific but open-ended
questions, so that more of the patient’s personality and char-
acter will come through in the answers.
With some procedures it may be worthwhile to evaluate the
patient’s intelligence and level of comprehension. If a patient
is to undergo an extensive procedure that may lead to dramatic
alterations of appearance, or that carries a risk of significant
untoward effects, the physician must be confident that the
patient possesses the intellect to process and understand the
details of the procedure. Most of the time the screening
described above will allow a reasonable assessment of cognitive
ability. If there is doubt, however, several mental status exams
have been developed that can be used by non-psychiatrists to
screen patients with limited cognitive function. One of the
more widely used is that developed by Folstein called the
Mini-Mental Status Exam.3 Tools such as these provide a
simple and efficient way for physicians to ensure that only
mentally fit patients are selected for procedures.
Using these techniques and by asking questions pertinent
to the requested procedure, the doctor should be able, by the
end of the appointment, to ascertain the following:
• How long the patient has been dissatisfied with the
relevant body part.
• Why the surgery is requested at this particular time.
• The motivation(s) for requesting the surgery.
• The patient’s expectations: what the surgery will do for
them and how it will influence their life.
• What surgeries or procedures have been done in the
past, and what these experiences were like; whether
there were real or perceived problems with the
procedures or physician.
• Whether the patient is having some form of life
crisis.
• Whether the patient suffers from any known psychiatric
condition that would preclude them from undergoing
the procedure.
• If the physician or office staff are suspicious of an
unreported or unrecognized psychiatric condition that
would reduce surgical candidacy.
• Whether family and friends support the surgery and
how they might react.
By taking the time to go through these aspects of the initial
interview and receiving relevant answers, the surgical team
will be able to reduce significantly the amount of complica-
tions due to psychiatric factors on behalf of the patient. The
very best time to screen patients for the presence of these
conditions is during preoperative consultation.
 OPTIMIZING OUTCOMES
Personality identification
Some may question the need to perform a thorough psychi-
atric screening in a cosmetic surgery setting. Under most
conditions the personality type of the patient will have little
patient. More often than not the most informative indicator
of appearance is clothing, which might be dirty or disheveled,
tight or flashy, grotesque or gothic, or seductive. For instance,
a female patient who is very neat and well dressed, with a
blouse that precisely matches her earrings, nail polish, and
shoes might be considered for screening for obsessive-com-
pulsive disorder. It is, of course, important to remember that
these are not concrete associations that can be stereotyped,
but such observations may lead a physician to specific lines
of questioning.
The next attribute the physician will typically notice is the
patient’s orientation to time and place. Normally orientation
is not an issue that needs direct questioning unless patients
appear to be noticeably confused or vague about their sur-
roundings.
Having noted appearance and orientation, the next and
possibly most important factor to consider is the patient’s
mood and affect. Occasionally, the patient may actually tell
you about their current mood if attention is paid to such
phrases as ‘I’ve been a little down’ or ‘I’m happier than I have
been.’ When not told directly, the physician must rely on
observation. In some cases, such as mania or severe depres-
sion, the behavioral signs are straightforward. With depres-
sion there may be signs of sadness, indifference to the
questioning with reluctance to answer questions at length, or
use of a monotonous voice. At the other extreme, those with
mania often express inappropriate happiness and extreme
eagerness to answer questions, sometimes preventing the
doctor from getting a word in edgewise. At this point, it may
be appropriate to question patients about their use of psychi-
atric services or other mental health services. This may seem
like a very direct personal question, but those who are not
being treated will simply say no, while those who are being
treated are usually no more embarrassed than someone
undergoing treatment for a disease such as diabetes or hepa-
titis. In any case, the information gained by asking this ques-
tion is far more valuable than any temporary embarrassment
or discomfort one would cause to the patient. It may be
useful to have questions on a medical intake form that assesses
current and past psychiatric conditions. Naturally, this would
not replace the techniques described above but would provide
some indication that something may be awry.
As mentioned above, depression and mania are usually
readily recognized by physicians. Other conditions, such as
schizophrenia, require a heightened level of psychiatric obser-
vational skill. To identify schizophrenics, the doctor should
look for what are called colorless affects. These affects include
monotonous speech and other non-reactive, non-responsive
behaviors. In these cases, it is very important to distinguish
between patients truly suffering from schizophrenia and those
who may be too scared or too nervous to ask many questions
or to respond appropriately. For this reason, it is important
that the physician does not guide the patient’s answers too
much, and close attention should be paid not just to the
content of the speech but also to how the patient speaks.
The next part of the psychiatric exam deals with establish-
ing the patients’ thought processing ability and judgment and
insight. Again, certain psychological diagnoses can be gleaned
from observed patterns of behavior. For example, those
affected by mania will often be very flighty and skip from one
idea to another, lacking the ability to stay focused on one
topic. On the other hand, severely depressed people typically
find it harder to answer questions and will have slower

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Chapter 21  Psychosocial Issues and the Cosmetic Surgery Patient
 PRACTICAL APPLICATIONS
Body dysmorphic disorder
Clinical vignette
BD is a 48-year-old white man who complained of ingrown
hairs on his neck and face, especially his middle and lower
cheeks. During his first visit to the office 4 years previously,
he was diagnosed with pseudofolliculitis barbae and under-
went treatment with a long-pulsed neodymium:yttrium alu-
minum garnet (Nd:YAG) laser to reduce hair growth in the
affected area. Historically, he had also been treated with
13-cis retinoic acid and was currently using topical clin-
damyin and oral doxycyline, prescribed by other physicians
with minimal improvement. BD stated that the laser helped
with darker hairs, but made the ‘bumps’ worse. He described
needing to ‘work’ every day for 1–2 hours with a needle in
order to get out the ingrown hairs. Upon examination, exten-
sive scarring and self-inflicted wounds were observed, the
most notable being a 1-cm laceration on his right mandible,
which had been closed with three white nylon sutures (Fig.
21.1). The sutures, rather large for facial repairs, were
actually done with fishing line and had been placed by the
patient himself. It was not uncommon for the patient
to require suturing due to the extent of the wounds he
induced.
One of the more common, if not the most common, psy-
chological disorder that presents in a dermatology office is
body dysmorphic disorder. This disorder, also known as dys-
morphophobia, was formally recognized as a distinct disorder
in 1987,4 even though the clinical features of body dysmor-
phic disorder were first described over a century ago.5 Since
that time, articles related to this disease have been published
under various categories including dysmorphic syndrome,
dermatologic hypochondriasis, dermatologic non-disease,
monosymptomatic hypochondriasis non-disease, and mono-
symptomatic hypochondriasis. According to the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV), the
current diagnostic manual of the American Psychiatric Asso-
ciation, a diagnosis of body dysmorphic disorder is based
upon three major criteria.6 First, the patient must show a
preoccupation and excessive concern with an imagined defect,
or a defect that is slight and unnoticeable at normal conver-
sational distance. Second, this preoccupation must cause
or no effect on the major outcome of the indicated proce-
dure. However, by identifying certain personality character-
istics in patients, the physician will be able to estimate what
level of care the patient will require throughout the course
of treatment, how to best handle any questions or problems
that may arise, and how to ensure that both doctor and
patient view the procedure as a success. Some common per-
sonality characteristics and generalizations about the type of
care each type of personality prefers or elicits are described
below.
Passive-aggressive patients
• These patients have an increased need for postoperative
nurturing.
• Whining and childish behavior may frustrate the nursing
and supporting staff.
• Physicians may need to direct staff to withdraw
somewhat from the patient to avoid indulging the
behavior.
Hostile and angry patients
• Paranoid patients will project feelings onto the doctor
and staff.
• In reality, the vast majority of these patients are simply
frightened.
• Strong and confident reassurance is needed in the
postoperative period.
• Honest and thorough answers should be given to all the
patient’s questions.
• Avoid statements such as ‘Everything will be alright.’
Give detailed information in a forthright manner.
Sociopathic patients
• The doctor must maintain an authoritative
presence.
• The doctor is in charge with regard to the surgical
treatment and postoperative management.
Obsessive-compulsive disorder patients
• The patients will need a concrete plan.
• The details are extremely important (How long? How
severe? How much?).
A
B
Figure 21.1  (A) Man with body
dysmorphic disorder has significant
scarring but no evidence of ‘ingrown
hairs’ or acne that drives him to spend
many hours ‘working’ on the hairs under
the skin. (B) Close-up view of the patient
with fishing-line sutures that he placed
himself.

342
Part 3  Aesthetic Surgical Procedures
ranging from 7% to 15%,11 while in dermatology, one of the
largest studies, which involved screening 268 patients for
body dysmorphic disorder, revealed a rate of 11.9% (95%
confidence interval, 8.0% to 15.8%).12 In addition, it is
believed that body dysmorphic disorder affects men at an
equal or slightly higher rate than women, although the pres-
entation of the disease varies slightly in men and women.
Affecting around 1 in every 10 patients, it is apparent that
dermatologists see a great number of patients suffering from
this disorder, many of whom continue to be undiagnosed.
In terms of their overall appearance, it is interesting that
cosmetic surgery patients are no more dissatisfied, critical, or
preoccupied than the general population.7 But when ques-
tioned about their perception of the specific body part for
which they seek cosmetic surgery, a much greater level of
dissatisfaction is found compared with non-cosmetic surgery
seeking counterparts. This finding has led some to believe that
it is not dissatisfaction with overall appearance that leads a
body dysmorphic patient to seek out cosmetic surgery, but
dissatisfaction with one particular cosmetic feature. This
hypothesis would also explain why patients with body dys-
morphic disorder often present to dermatologists with one
chief complaint, such as hair loss or severe acne.
Etiology and pathophysiology
As with most other psychological disorders, the exact physi-
ologic cause of body dysmorphic disorder has yet to be deter-
mined. For the most part, body dysmorphic disorder, like
other obsessive-compulsive disorders, is thought to result
from a neurochemical imbalance, mainly involving sero­
tonin.13 This explains the improvement that some patients
experience when treated with selective serotonin reuptake
inhibitors. However, recent studies have attempted to eluci-
date the pathogenesis of this disease. One such case describes
a 24-year-old man who began showing symptoms of body
dysmorphic disorder after suffering an inflammatory brain
process 3 years previously.14 During clinical evaluation and
treatment, neuroimaging determined that the patient had
suffered significant atrophy in the frontotemporal region of
his brain. Although this isolated case does not give absolute
proof, the correlation of this focal atrophy along with the
onset of body dysmorphic disorder has given credence to the
idea that a specific area of the brain is responsible.
In another study, magnetic resonance imaging was used to
compare the brains of eight women suffering with body dys-
morphic disorder with eight unaffected women.15 Imaging
some hindrance to the patient in terms of normal social or
occupational functioning; examples of this include poor per-
formance at school or work and difficulty in dating or main-
taining other relationships. Finally, this preoccupation must
not be explainable by another comorbid condition such as
anorexia nervosa or transsexualism. These criteria are sum-
marized in Box 21.1.
Although the DSM-IV criteria maintain that the patient
may be preoccupied with any part of the body, the most
common complaints tend to involve the skin, face, and nose7
(Table 21.1). Body dysmorphic disorder has been described
in many different cases and apparently has several variations.
For example, one such variation is known as muscle dysmor-
phia. In this type of dysmorphic disorder, usually seen in
men, the patient feels as though his body is weak and scrawny,
when in fact he is typically very large and muscular.9 Body
dysmorphic disorder is listed under the rubric of hypochon-
driasis, with the difference that there is no other underlying
mental disorder in this disease. Unfortunately, even though
this disorder is one of the most commonly seen, it can be one
of the most difficult to treat.
Epidemiology
Although several studies have been conducted to establish the
prevalence of body dysmorphic disorder, there is a tremen-
dous amount of disagreement. Because we have all been
concerned with a particular part of our bodies at one time or
another, determining what exactly qualifies one as suffering
from body dysmorphic disorder can be very difficult. The
best estimate for the presence of this disorder in the general
population is around 1% in the United States, although rates
ranging from 0.7% to 2.3% have been reported.10 As would
be expected, the overall rates of body dysmorphic disorder
appear to be much higher in dermatological and cosmetic
surgery settings. In cosmetic surgery, rates have been reported
Table 21.1  Common complaints in patients with body dysmorphic syndrome8
FACIAL
HAIR
NOSE
OTHER
Acne
Altered skin color
Altered skin texture
Asymmetry
Enlarged pores
Scars
‘Spots’
Telangiectasias/redness
Wrinkles
Abnormal growth
Abnormal texture
Thinning
Excessive hair
Impending baldness
Size
Shape, especially crooked
Texture
Contour, especially bumpy
Poor relationship to rest of face
Breasts
Genitals
Weight
Muscles
Eyelids
Box 21.1  Criteria for diagnosis of body
dysmorphic disorder
1. Preoccupation with an imagined or overemphasized defect.
2. Imagined defect is a source of severe social or occupational
dysfunction.
3. Patient engages in repeated behaviors such as picking in
order to improve the defect.

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Chapter 21  Psychosocial Issues and the Cosmetic Surgery Patient
seeking out surgical, dermatologic, or other medical treat-
ment, even though other people and physicians have explained
to them that there is nothing to treat.
Evaluation
The first step in diagnosing the disease lies in listening to the
patient. One of the most frequent initial warning signs is that
the patient has been to countless doctors for this same
problem. If after listening to the patient’s chief complaint you
can find no sign of the defect to which they are referring, the
best plan of action is to probe the patient by further question-
ing about what aspects of the defect bother them. Another
option is to have the patient complete a standard body dys-
morphic disorder questionnaire (BDDQ). Many forms of
questionnaires have been published, but most of the stand-
ards are aimed at establishing the presence of the criteria set
forth by the DSM-IV. An example of a typical BDDQ is
shown in Figure 21.3.
The results of this questionnaire in no way serve to defini-
tively diagnose body dysmorphic disorder. The survey simply
attempts to ascertain whether a severe physical preoccupa-
tion exists, what the extent of the severity is, and if the
severity can be attributed to another condition such as ano-
rexia nervosa. Upon completion, the physician should have a
fairly good understanding as to whether or not the patient
meets the DSM-IV criteria for body dysmorphic disorder,
and if treatment should be pursued. When there is a psycho-
logical disease such as body dysmorphic disorder, the patient
is most likely not going to be very amenable to any discussion
that makes them seem mentally ill. Therefore, great care
must be taken to ensure that enough evidence is present to
confront any patient with the possibility of this diagnosis
(Box 21.2).
Complications and psychiatric comorbidity
Although body dysmorphic disorder may sound fairly trivial,
the comorbid conditions associated with it are not only dam-
aging to the patient’s quality of life but also carry the risk of
physical harm to the patient and others. O’Sullivan et al.
revealed a predominate left shift in caudate asymmetry and
a greater amount of total white matter in the group with body
dysmorphic disorder when compared to the control group.
These findings are consistent with brain scans of those who
suffer from similar obsessive-compulsive disorders. Although
both of these studies have limited applications at this time,
it is hoped that similar studies will one day allow for the
development of more specific diagnostic tests and treatments
for this disease. The current treatments for body dysmorphic
disorder will be discussed later in this chapter.
Clinical features
The clinical presentation of body dysmorphic disorder can be
divided into two general areas: the preoccupation with the
imagined defect and the performance of repetitive compul-
sive behaviors. As mentioned earlier, the preoccupation has
been shown in several studies to be primarily with the skin,
followed by the hair and nose. Based on this preoccupation
with the skin and hair, most doctor-shopping by these patients
occurs within the field of dermatology. Interestingly, there
have been reports that sex differences exist in terms of the
nature of the complaints about the most often ‘obsessed over’
body parts. For example, regarding hair ‘defects,’ most
women might complain about their hair as being the wrong
color, being asymmetrical, too curly, or too straight, while
men are mostly concerned about hair thinning or balding.9 In
addition, women are more frequently concerned over the
presence of excess body hair than men are.9 In terms of
overall body appearance, women tend to be more preoccu-
pied with their weight and the size of their hips, while men
tend to suffer more from muscle dysmorphia (see above).
Furthermore, men appear to have a greater preoccupation
with the size of their genitals, mainly believing that their
penis is too small.9 Interestingly, women do not share the
same preoccupation with their genitals.9
Body dysmorphic disorder and its variants have been
described by physicians in all disciplines of medicine and in
all parts of the world. Two such interesting international
variants include a delusional belief that the penis is shrinking
(Koro) by people in the Chinese community, and the obses-
sion with eyelids seen in Japanese people.16 Regardless of the
specifics of the apparent ‘deformity,’ the underlying theme
in all cases is that the concern is trivial or non-existent, and
causes much more distress in the patient than it would if it
were present in the rest of the population.
The second manifestation of the disease, repetitive com-
pulsive behavior, can be directly attributed to the presence
of the imagined or exaggerated defect. For example, because
in most cases the preoccupation is with some blemish present
on the skin, a common behavior will be obsessive skin check-
ing in the mirror (Figure 21.2). Some patients may present
to dermatologists with excoriations, due to constant picking
and rubbing at their imagined blemishes. In these cases,
lesions on the patient’s skin will actually be present due to
the patient’s own destruction. Cases such as these often
complicate the physician’s physical assessment of the condi-
tion and make the diagnosis of body dysmorphic disorder
even more difficult. Other obsessive behaviors seen in cases
of body dysmorphic disorder include excessive grooming,
camouflaging the defect with make-up, hair, clothes, or
posture, measuring the disliked body part, persistent ques-
tioning of others about the defect, and, of course, constantly
Figure 21.2  A deep crater-like scar is noted in addition to a few
ice-pick type scars on the face of a woman. The crater-like scar
was induced by the patient’s persistent ‘attention to’ and
picking of the pimple and scar.

344
Part 3  Aesthetic Surgical Procedures
This questionnaire asks about concerns with physical appearance. Please read each question carefully
and circle the answer that is true for you. Also, write in answers where indicated.
NAME: TODAY'S DATE:
1. Are you very worried about how you look? Yes No
If yes: Do you think about your appearance problems a lot and wish you could think about them less? Yes No
If yes: Please list the body areas you do not like:
Examples of your disliked body area include: your skin (for example: acne, scars, wrinkles, paleness, redness); hair;
the shape or size of your nose, mouth, jaw, lips, stomach, hips, etc.; or defects of your hands, genitals, breasts,
or any other body part.
If the answer to either of the above questions was No, you are finished with this questionnaire.
Otherwise, please continue.
2. Is your main concern with how you look that you are not thin enough or that you might get too fat? Yes No
3. How has this problem with how you look affected your life?
Has it often upset you a lot? Yes No
Has it gotten in the way of doing things with friends or dating? Yes No
If yes, please describe how:
Has it ever caused problems with school? Yes No

If yes, what are they?
Are there things you avoid because of how you look? Yes No
If yes, what are they?
1
Body dysmorphic disorder questionnaire (BDDQ)
Figure 21.3  Body dysmorphic disorder questionnaire.

345
Chapter 21  Psychosocial Issues and the Cosmetic Surgery Patient
of feelings of frustration and retribution. Among these comor-
bidities, severe depression usually tops the list, often leading
to rates of suicidal tendencies that far exceed the general
population. In one study, 22% of patients who had presented
to a dermatology clinic with body dysmorphic disorder had
attempted suicide.12 Furthermore, when patients are evalu-
ated for mental health status, they frequently score lower
than patients suffering from a variety of severe chronic ill-
nesses such as diabetes, depression, and myocardial infarc-
tion.20 Along with suicide and depression, body dysmorphic
disorder has also been shown to be positively correlated with
other psychiatric and medical illnesses such as anxiety disorder,
heart disease, diabetes, panic disorder, obsessive-compulsive
disorder, substance use, and other manic-depressive ill-
nesses.20 In most cases, the social phobias develop prior to
body dysmorphic disorder, while depression and substance
use begin after the onset of the disease.21 Some studies have
also reported gender differences regarding specific comorbid
conditions. More specifically, women with body dysmorphic
disorder are often reported to suffer from panic attacks,
bulimia, and generalized anxiety disorder while men are more
likely to suffer from bipolar disorders.22
Along with risk to the patient there may be significant
danger to the patient’s family and treating physician. As
might be expected, the continuous doctor-shopping and
seeking out of treatments can often lead to a heightened level
of frustration for the patient. As treatments continue to fail,
patients can lash out at their loved ones, especially their
spouse or significant other, for being unable to help them find
the treatment they feel they need. In addition, surgeons who
have performed cosmetic surgery on these patients, especially
report of a woman with body dysmorphic disorder who self-
inflicted an almost mortal wound by skin picking.19 Self-
inflicted skin wounds, also called neurotic excoriations, are a
fairly common finding with body dysmorphic disorder, but
can also be present with various other conditions such as
trichotillomania and obsessive-compulsive disorder.19
Despite the danger body dysmorphic disorder patients pose
to themselves through skin picking and other compulsive acts,
there is also a significant level of psychiatric comorbidity that
can put the patient in mortal danger when the angst and
despair may lead to suicide. The treating physician may also
be at risk of being harmed by the disturbed patient because
4. How much time a day do you usually spend thinking about how you look? Please circle one.
a) Less than 1 hour a day
b) 1–3 hours a day
c) More than 3 hours a day
You're likely to have BDD if you give the following answers on the BDDQ:
Question 1: Yes to both parts
Question 3: Yes to any of the questions
Question 4: Answer b or c
2
BDDQ questionnaire (continued)
Figure 21.3, cont’d
Box 21.2  Resources for information on body
dysmorphic disorder
Internet sources
The Body Image Program:
Last accessed: 2 March 2009.
Body Dysmorphic Disorder Central:
Last accessed: 2 March 2009.
Books
Phillips KA. The broken mirror: understanding and treating body
dysmorphic disorder. New York: Oxford University Press;
1996.17
Poe HG, Phillips KA, Olivardia R. The Adonis complex: the secret
crisis of male body obsession. New York: The Free Press;
2000.18

346
Part 3  Aesthetic Surgical Procedures
this type of psychological condition. Once the presence of
body dysmorphic disorder is confirmed through question-
naires or other means, the most appropriate step is a referral
to a psychiatrist. What follows are some general guidelines
adapted from Phillips & Dufresne’s guide25 for dermatologists
and plastic surgeons as to how one should proceed with a
patient suspected of having body dysmorphic disorder:
Provide education
• Inform the patient of your suspicion of body
dysmorphic disorder, explaining in simple terms what
that means.
• Recommend reading material (e.g. fliers, the Internet)
where the patient may obtain more information (a list
of appropriate websites is given in Box 21.2).
• Do not downplay any of the patient’s concerns about
their appearance as this may have a significant negative
impact on their recovery.
• If appropriate, educate any family members who may
be involved or are able to help.
Behavior modification
• Do not try to talk patients out of picking their skin or
being worried about their appearance.
• Attempts to end a patient’s compulsive behaviors often
leads to further depression, frustration, and lack of
recovery.
• Do not encourage the patient to use make-up or any
other concealing methods to hide their deformity as this
has also been shown to interfere with recovery.
Appropriate referrals
• Explain to the patient that the disorder cannot be
effectively treated by dermatologists or with cosmetic
procedures.
• Attempt to refer the patient to a psychiatrist,
emphasizing the amount of time they spend worrying
about their appearance and how it affects their life.
• If the patient is worried about taking antipsychotic
medications, explain that therapies that do not include
the use of medications may be available.
• If the patient is suicidal or severely depressed, attempt
no other referral than to a psychiatrist, as treatment
with antipsychotic medications is the best
approach.
Once referred to a psychiatrist or other mental health special-
ist, the patient can expect to encounter two forms of treat-
ment: pharmacotherapy and cognitive-behavioral therapy
(CBT), a form of psychotherapy. For over 10 years the main-
stay of treatment for body dysmorphic disorder has been
pharmacological with selective serotonin reuptake inhibi-
tors.26 In most situations, dermatologists and plastic surgeons
are not qualified to monitor the patient’s progress under the
influence of these medications. If the physician feels that
treatment for body dysmorphic disorder is warranted, a refer-
ral to a qualified psychiatrist is most likely the best course of
action.
Although most research indicates that surgery should be
contraindicated in patients with severe psychological condi-
tions, there are some physicians who feel that surgeons are
bypassing these patients unnecessarily, and that they might
male patients, have reported cases of extreme violence after
being disappointed with the outcome of the surgery. In some
of these more tragic cases, the aggression toward the surgeon
has even resulted in murder.11
Treatment options
In most patients with body dysmorphic disorder, the rate of
surgical success is exceedingly poor. In addition, after the
surgery has taken place and the area has healed, the patient
will claim that the surgery failed to improve the defect. If,
by chance, the surgeon is able to convince the patient that
the surgery has ameliorated any imperfection the patient may
have had, the patient will not be convinced for long, and will
soon turn attention to another part of the body. This pattern
greatly contributes to the excessive doctor-shopping as seen
in many body dysmorphic disorder patients who continually
request surgeries and extensive work-ups that the physician
knows will do no good in fixing the patient’s apparent defect.
Because of the risks involved and this recurrent pattern of
dissatisfaction, the performing of any cosmetic surgery on
these patients is generally contraindicated. Even in cases
where a deformity has been present, such as a large nose or
an area of excessive body hair, the completion of surgery
rarely improves the patient’s outlook on the situation and
most will be unhappy with the results. There have been some
reports that these patients can be considered good surgical
candidates, but an extreme caveat must be taken to ensure
that the best interest of the patient and the physician is being
taken into consideration before any cosmetic procedure is
undertaken. In most cases, the performing of simple restora-
tive cosmetic procedures such as botulinum toxin injections
shows little risk of severe psychological complications when
compared to permanent structural change procedures such as
rhinoplasties, where the entire general appearance of the
patient is altered.23
On the other hand, there are physicians who believe that
many surgeons are ‘passing up’ patients who may actually be
helped by a combined surgical and medical approach. None-
theless, current research indicates, on the whole, that most
patients suffering from body dysmorphic disorder do not
benefit from cosmetic surgery and frequently suffer from a
worsening of symptoms as treatment proceeds.24
Interestingly, there is little research in evaluating the per-
centage of cases of body dysmorphic disorder that start out
as common cosmetic repairs or enhancement. For instance,
in rhinoplasty surgery a significant percentage of the popula-
tion would probably consider the patient’s nose structure to
be cosmetically unappealing. In these instances, cosmetic
surgery is almost always indicated, with the patient usually
approving the final outcome. However, there are some cases
where the first surgery is just the start. Once the repair has
been made, the patient will insist that more work needs to
be done until it seems they become addicted to the changes
and potential enhancements of cosmetic surgery.
In cases such as these, it is difficult to say whether the
patient suffered from body dysmorphic disorder before
undergoing the initial procedure or because of disapproval of
the initial surgical results. Clearly, more research will have to
be done to investigate the pathogenesis of body dysmorphic
disorder in these cases.
In most cases, dermatologists and cosmetic surgeons lack
the experience and training necessary to treat a patient for

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Chapter 21  Psychosocial Issues and the Cosmetic Surgery Patient
not visible during the consultation. For example, they may
claim that this particular defect can only be seen at a certain
time of day, perhaps under certain lighting. In my practice, I
have found that these patients tend to have higher dissatisfac-
tion rates with treatments.
It is crucial that a thorough history includes all past con-
sultations and treatments. It is important to find out if and
why so many different physicians have treated the patient
and, more importantly, if it was for the same problem. Be
wary of patients who speak poorly of or blame previous phy-
sicians. Ask about past treatments and their outcomes. Ask
‘Were there any problems or complications?’ It is valuable to
evaluate the results of past procedures, but be wary of making
judgment regarding the past procedures, physicians, or out-
comes. However, in situations where the outcome was satis-
factory but the patient perceived complications or a prolonged
postoperative course, you may anticipate similar perceptions
during the care that you provide.
Make sure you understand exactly what the patient expects
of the procedure. Despite a detailed consultation on the fine
points of a procedure, such as the risks and possible out-
comes, some patients have ongoing unrealistic expectations.
These patients may repeatedly ask their doctor questions
such as ‘But I will get results, won’t I?’ or ‘But I won’t have
any complications, right?’ These patients may be able to
develop a better communication pattern with another physi-
cian and it should be suggested that the patient obtain a
second opinion.
Be wary of the patient who demands one particular treat-
ment and who is unwilling to contemplate other options
suggested by the physician. This can often lead to a situation
where either the patient or physician will be disappointed
with the outcome, or other unforeseen complications arise.
For example, a patient insisting on laser treatment for leg
telangiectasia should not be treated with that modality if the
doctor feels a different option is superior or less risky.
Be wary of cosmetic surgery patients who are ‘price-shop-
pers’ and try to push you into performing a much less effec-
tive treatment because it costs less. This can lead to
dissatisfaction and it is important to counsel the patient on
the expected outcome and likely degree of improvement. A
60-year-old woman with significant jowling is not going to be
satisfied with a trichloroacetic acid (TCA) peel if she expects
to eliminate the laxity, even though it costs significantly less
than a face lift and is more suited to her budget. In these
cases, the best course of action is to not perform the requested
procedure, even if some benefit may be gained, because it
will not achieve what the patient desires. In the example
given here, the woman may have lentigines or other lesions
amenable to the peel, but if she continues to express concerns
about the jowling and skin laxity, these must be addressed in
the treatment plan. Physicians should refer such patients to
a colleague if they cannot provide a treatment that will affect
the deformity that the patient wants to improve. Most
patients will respect the physician’s integrity and honesty
when referred elsewhere for a superior treatment. I have
found that such patients will not only return to my office but
will refer their friends and family as well. Other examples
might include a referral for a surgical procedure that you do
not provide such as a face lift or blepharoplasty, or a referral
for a laser treatment that may be superior for treating a par-
ticular problem for which you lack the proper equipment or
expertise.
actually be benefited by combining surgical and psychological
therapies for treatment. In some studies, patients were
selected who screened positive for the presence of body
dysmorphic disorder or other psychological disturbances, and
then cosmetic surgery was performed. After being followed
for several years, only a small percentage of patients experi-
enced negative outcomes from the surgery, with no reports
of lawsuits, suicide, or further induced psychological compli-
cations.27 Thus, although most surgeons prefer not to perform
cosmetic procedures on psychologically disturbed patients, in
the end it is up to the individual surgeon to decide whether
or not the patient is a good candidate for the desired cosmetic
surgery.
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 Cosmetic surgery is a team effort.
 Be wary of the patient who cannot point out or verbalize the
defect or problem that they would like improved.
 Be wary of the patient who requires a magnifying mirror to pick
out the problematic defect.
 It is crucial that a thorough history includes all past
consultations and treatments.
 Make sure you understand exactly what the patient expects of
the procedure.
 Be wary of the patient who demands one particular treatment
and is unwilling to contemplate other options suggested by
the physician.
 Be wary of the cosmetic surgery patients who are ‘price-
shoppers’ and try to push you into performing a less effective
treatment because it costs less.
 Perhaps, most importantly, know yourself.
Most patients presenting to a dermatology practice have a
normal mental health history and have realistic expectations.
There are several helpful hints that I have found to be useful
from my experiences in the clinical setting.
Cosmetic surgery is a team effort. The physician should
listen to the concerns raised by those of the office and nursing
staff who have encountered the patient. The patient who
appears pleasant in the presence of the physician, but is
degrading or unreasonable with the staff, can easily turn this
same frustration and anger toward the physician or surgical
procedure. In cases such as these, it is important to take a
more detailed look at the patient before proceeding with
surgery.
Be wary of the patient who cannot point out or verbalize
the defect or problem that they would like improved. These
patients may make broad hand gestures around the face or
accusingly ask the physician questions such as ‘Can’t you see
the problem?’ A common scenario is the patient who enters
the office and says ‘I want to look better’ or ‘I want to look
younger.’ Despite well-performed procedures, these patients
frequently are unhappy with the results and feel that they do
not look any better or younger.
Be wary of people who require a magnifying mirror to pick
out the problematic defect. This is often encountered with
scars or wrinkles that are so obscure that neither the patient
nor the doctor can find them without great effort. These
patients may even make excuses as to why the deformity is

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Part 3  Aesthetic Surgical Procedures
stable over time or change with time. The latter is especially
true when feelings of self-esteem are primarily dependent on
the feedback of others.30 Studies suggests that body image
improves among teenagers as they mature and that satisfac-
tion with body image varies for teens as a function of age and
development stage.31 This has some implications when trying
to understand why adolescents want cosmetic surgery and if
the procedure will improve their self-esteem, and how much
the improvement in body image is related to a procedure or
a function of age and maturity.
In general, it is difficult to assess adolescent body image
because of the self-consciousness and dissatisfaction with
physical appearance that is so common during this period of
development. Teens seeking cosmetic surgery report greater
dissatisfaction with specific body parts29 and this raises ques-
tions as to the possibility of body dysmorphic disorder. Accu-
rate diagnosis is the key as with adult patients. And with any
age it is important to reject patients with unrealistic expecta-
tions or those having surgery to please others, such as parents
or a boyfriend.
Another issue germane to cosmetic procedures for adoles-
cents is that of informed consent. Although this is a concern
with adults, it may be especially problematic with teens.
Studies of brain development indicate that the region of the
brain that inhibits risky behavior is not fully developed until
age 25.32 Adolescents may be overly optimistic about the
benefits of cosmetic procedures and less knowledgeable about
long-term health risks. Legal guidelines should be followed as
with other medical consents and parental consent should be
obtained in addition to the adolescent patient. It is prudent
to include a discussion of the risks and benefits of the proce-
dure, as well as body image concerns and the likelihood of
improvement in these parameters even without surgery, and
expectations of surgery, both short and long term.
 SUMMARY
Evaluating the psychosocial status of a patient is a crucial
component of every medical specialty. However, dermatolo-
gists and cosmetic surgeons undoubtedly encounter patients
with certain psychological disorders at a much higher fre-
quency than many of their colleagues. At its most superficial
level, the underlying goal of any cosmetic surgery procedure
is to provide some sort of psychological benefit to the
patient.27 More specifically, the surgeon should be able to lead
the patient to greater emotional health.27 Because of this
inextricably intertwined relationship of cosmetic surgery and
psychology, the psychosocial health of every cosmetic surgery
patient must be thoroughly evaluated in order to ensure that
no serious underlying psychological disorders exist that would
preclude that patient from an aesthetic procedure. As such,
any doctor performing cosmetic procedures should have a
working knowledge of the presentation, etiology, and treat-
ment options for many of these common diseases that may
be encountered. Consequently, the team will be able to
develop the most appropriate plan of action for the treat-
ment, ultimately helping the patient to attain a more physi-
cally and emotionally appealing state. Furthermore, the
dermatologist will also be able to help identify patients in
need of counseling or psychiatric treatment, and avoid per-
forming surgeries that would otherwise be contraindicated
due to the presence of various mental conditions.
Caution is warranted when considering procedures for
patients in a life crisis. Life crises can include divorce, loss of
job or family member, loss of sexual identity, and even loss
of mental or physical functions secondary to illness or acci-
dent.28 These patients may be seeking procedures for the
‘wrong’ reasons and have unrealistic expectations on the
change that will occur and the impact on their life situations.
Patients may try to pressure the physician into action espe-
cially when divorce is imminent to ‘make the spouse pay’
before settlement is complete. It behooves the physician to
perform the best procedure for the patient when outcomes
are expected to be optimal.
Likewise, unhappy patients can present challenges.
Unhappy people tend to be pessimists who exaggerate the
negative impact of events and may not be happy with a result
of any kind.28 Generalized unhappiness may result from
mood disorders, depression, personality disorders, or may be
a pattern of thinking and mind set. The team needs to estab-
lish any underlying causes, and if it is elected to perform
cosmetic procedures, be sure that expectations are clearly
reviewed and documented. If unrealistic expectations are
anticipated, it is wise to avoid procedures.
Cross-cultural patients are another group that may need
special consideration by the cosmetic physician. Language
barriers are forefront and it should be very clear to the office
team that the patient comprehends the information dis-
cussed. But more subtle issues need to be reviewed in terms
of acceptance by the patient’s family and support group. A
change in appearance can be perceived by the family nega-
tively, as if the patient was trying to deny or renounce ethnic
traits. This kind of negative feedback and unhappiness from
families or friends can be transferred to the physician.
Perhaps most importantly: know yourself. Recognize your
own personality, strengths, and style. Some patients are
excellent candidates for cosmetic surgery but may simply
have a ‘better fit’ with a different physician. I frequently
suggest that patients have a second consultation with a col-
league for another opinion. This colleague could be another
dermatologist or cosmetic surgeon. I have found that in the
end this enhances the patients’ experiences – and my practice
– because patients who may not fare as well in my environ-
ment can be avoided. In addition, patients will usually respect
my honesty and the fact that I truly consider their welfare as
paramount – they may become my best referrer in the future.
 ADOLESCENTS AND
COSMETIC SURGERY
The number of adolescents requesting and undergoing cos-
metic procedures is increasing and presents a new challenge
for the cosmetic surgeon during the pre- and postoperative
periods.29 Breast augmentation and liposuction procedures
are becoming more popular with teens. There are several
issues that need to be addressed when considering cosmetic
surgery during teenage years.
The process of body image development begins at a very
early age and is influenced by many factors, including paren-
tal approval or criticism, attention or lack thereof by non-
parental individuals, media such as television, and cultural
surroundings. The adolescent body image continues to
develop while the physical changes of puberty occur.29 Self-
esteem and self-worth also develop early and can remain

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Chapter 21  Psychosocial Issues and the Cosmetic Surgery Patient
 REFERENCES
1. Ishigooka J, Iwao M, Suzuki M, et al. Demographic features of patients
seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;52:283–287.
2. Brawman-Mintzer O, Lydiard R, Phillips K, et al. Body dysmorphic dis-
order in patients with anxiety disorders and major depression: a comor-
bidity study. Am J Psychiatry 1995;152:1665–1667.
3. Folstein M, Folstein S, McHugh P. ‘Mini-mental state.’ A practical
method for grading the cognitive state of patients for the clinician. J
Psychiatr Res 1975;12:189–198.
4. Hollander E, Allen A, Kwon J, et al. Clomipramine vs. desipramine
crossover trial in body dysmorphic disorder: selective efficacy of a sero-
tonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry
1999;56:1033–1039.
5. Phillips K, Albertini R, Rasmussen S. A randomized placebo-controlled
trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry
2002;59:381–388.
6. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, 4th edn. Washington, DC: American Psychiatric Asso-
ciation; 1994.
7. Sarwer D, Wadden T, Pertschuk M, et al. Body image dissatisfaction and
body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconst
Surg 1998;101:1644–1649.
8. Malick F, Howard J, Koo J. Understanding the psychology of the cos-
metic patients. Dermatol Ther 2008;21:47–53.
9. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder.
J Nerv Ment Dis 1997;185:570–577.
10. Phillips K, Dufresne RJ. Body dysmorphic disorder: a guide for primary
care physicians. Prim Care 2002;29:99–111.
11. Phillips K, Grant J, Siniscalchi J, et al. Surgical and nonpsychiatric
medical treatment of patients with body dysmorphic disorder. Psycho-
somatics 2001;42:504–510.
12. Phillips K, Dufresne RJ, Wilkel C, et al. Rate of body dysmorphic disor-
der in dermatology patients. J Am Acad Dermatol 2000;42:436–441.
13. Slaughter J, Sun A. In pursuit of perfection: a primary care physician’s
guide to body dysmorphic disorder. Am Fam Physician 1999;60:
1738–1742.
14. Gabbay V, Asnis G, Bello J, et al. New onset of body dysmorphic disorder
following frontotemporal lesion. Neurology 2003;61:123–125.
15. Rauch S, Phillips K, Segal E, et al. A preliminary morphometric magnetic
resonance imaging study of regional brain volumes in body dysmorphic
disorder. Psychiatr Res 2003;122:13–19.
16. Cotterill J. Body dysmorphic disorder. Dermatol Clin 1996;14:
457–463.
17. Phillips KA. The broken mirror: understanding and treating body dysmor-
phic disorder. New York: Oxford University Press; 1996.
18. Pope HG, Phillips KA, Olivardia R. The Adonis complex: the secret crisis
of male body obsession. New York: The Free Press; 2000.
19. O’Sullivan R, Phillips K, Keuthen N, et al. Near-fatal skin picking from
delusional body dysmorphic disorder responsive to fluvoxamine. Psycho-
somatics 1999;40:79–81.
20. Phillips KA. Quality of life for patients with body dysmorphic disorder.
J Nerv Ment Dis 2000;188:170–175.
21. Gunstad J, Phillips K. Axis I comorbidity in body dysmorphic disorder.
Compr Psychiatr 2003;44:270–276.
22. Perug G, Akiskal H, Giannotti D, et al. Gender-related differences in
body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis
1997;185:578–582.
23. Castle D, Honigman R, Phillips K. Does cosmetic surgery improve psy-
chosocial wellbeing? Med J Aust 2002;176:601–604.
24. Sarwer D, Crerand C, Didie E. Body dysmorphic disorder in cosmetic
surgery patients. Facial Plast Surg 2003;19:7–18.
25. Phillips KA, Dufresne R. Body dysmorphic disorder. A guide for derma-
tologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235–
243.
26. Phillips KA, Najjar F. An open-label study of citalopram in body dysmor-
phic disorder. J Clin Psychiatry 2003;64:715–720.
27. Edgerton M, Langman M, Pruzinsky T. Plastic surgery and psychotherapy
in the treatment of 100 psychologically disturbed patients. Plast Reconst
Surg 1991;88:594–608.
28. Adamson P, Chen T. The dangerous dozen – avoiding potential problem
patients in cosmetic surgery. Facial Plast Surg Clin N Am 2008;16:
195–202.
29. Zuckerman D, Abraham A. Teenagers and cosmetic surgery: focus on
breast augmentation and liposuction. J Adolesc Health 2008;43:
318–324.
30. Harter S, Whitesell N. Beyond the debate: why some adolescents report
stable self-worth over time and situation, whereas others report changes
in self-worth. J Pers 2003;71:1027–1058.
31. Rauste-von Wright M. Body image satisfaction in adolescent girls and
boys: a longitudinal study. J Youth Adolesc 1989;18:71–83.
32. Simis K, Verhulst F, Koot H. Body-image, psychosocial functioning
and personality: how different are adolescents and young adults
applying for plastic surgery? J Child Psychol Psychiatry 2001;42:
5669–5678.

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351
22
Evaluation and Management
of the Aging Face
Lisa M Donofrio MD
Summary box
 Evaluation of the aging face must take into account changes
that occur in all levels of tissue.
 Young faces are characterized by arcs and fullness, not
merely by the absence of wrinkles.
 The morphologic changes that occur in the aging face are
due mostly to the redistribution of fat and changes in muscle
tone (both increased and decreased) but bony remodeling
also plays a role.
 Gravitational aging is in all likelihood a myth – it is elucidative,
not causative.
 Structural fat augmentation and other methods of soft tissue
augmentation can reapproximate the contours of the youthful
face; chemodenervation is a useful adjunctive treatment in
achieving this goal.
 INTRODUCTION
Evaluation of the senescent face requires that one look deeper
than the rhytides and dyschromia of photoaged skin, into the
structural alterations that occur below the skin surface.
Throughout life the face, like the body, changes shape. Cer-
tainly some of these changes are due to bony growth and
remodeling and changes in muscle mass and tone, but fat
seems to be the most substantial contributor to soft tissue
changes. When examining a face for rejuvenation procedures,
the physician must think of the face in ‘layers’ and approach
the aging changes in each layer separately. Aging occurs both
as an extrinsic and intrinsic phenomenon. External aging
occurs through ultraviolet (UV) and oxidative damage and
most characteristically takes the form of dyschromia, tel-
angiectasias, and textural changes. Internal aging is likely hor-
monally and genetically regulated and is responsible for bone
and soft tissue remodeling, including dermal changes. In
essence, ‘wrinkles’ occur secondary to intrinsic and extrinsic
aging.
 TECHNICAL ASPECTS
Epidermal and dermal aging
Cumulative UV exposure decreases skin collagen content,
aggregates elastic fibers, disrupts cutaneous immune surveil-
lance, stimulates melanogenesis and angiogenesis, and disor-
ganizes epidermal cell maturation.1–6 Clinically this translates
into coarsened pores, sebaceous hyperplasia, telangiectasias,
keratosis, and skin cancers. A clinical correlation can be
made between ultrastructural changes in the collagen and
elastin and textural changes such as a crepe paper-like appear-
ance and fine rhytides. Coarse rhytides or folds are more
reasonably explained by soft tissue atrophy or muscular
movement.
Mimetic muscle aging
Sarcopenia, or skeletal muscle wastage with age, is a selective
event affecting some but not all muscles of the body. For
instance, the quadriceps muscles lose up to 21% of their mass
with advancing age, but the muscles of the arm remain
unchanged.7,8 This loss is also somewhat attenuated by exer-
cise. While a widely recognized theory to explain aging, to
date there is no evidence to substantiate that the facial
mimetic muscles atrophy with age. In fact, evidence exists to
the contrary. For example, magnetic resonance imaging
(MRI) studies reveal that there is no significant change in
length or projection of the levator labii superioris or the
zygomaticus muscles between young and old subjects.9
The skin/muscle interaction
In youth, the mimetic muscles are separated from the overly-
ing cutis by a diffuse layer of subcutaneous fat. This serves
to attenuate the muscular ‘pull’ on the skin and acts as a glide
plane between the skin and muscle. Animation of a young
face is followed by a relaxation of the muscular impression
on the skin. In an old face, the undersurface of the dermis
lies in close juxtaposition to the mimetic musculature and
investing superficial musculoaponecrotic system (SMAS).
Trabeculae of the reticular dermis attach to the underlying
muscles.10 The skin is tugged along with each facial expres-
sion. Repeated facial animation over time in conjunction with
chronic sun exposure serve to permanently fibrose the skin
to the muscle and set in the dermal component of the
rhytides.4 A helpful analogy is to think of the face as a Roman
shade or blind. When young, the Roman shade is made of
foam, so any tugging on the cord only minimally raises and
wrinkles the shade. With age, the shade becomes like tissue
paper so even a minor pull on the cord produces a number
of creases (Fig. 22.1). Botulinum toxin halts the tugging on

352
Part 3  Aesthetic Surgical Procedures
Structural fat remodeling with age
An infant has a characteristic distribution of fat, displaying
jowls, tear trough deformity, and submental fullness. Inter-
estingly, these patterns are seen again in the adult face, but
all too often gravity is erroneously named as the culprit. It is
more likely that fat redistribution is responsible for the hall-
mark shape of the aging face, so that aging, like infancy, can
be considered a state of facial fat dysmorphism.
The face of the middle to late 20s is the standard in desir-
ability of aesthetics. The rounded fullness of the teenage
years is lost and the face becomes mildly sculpted in the
subzygoma area. Overall, there is a homogeneity to the fat
distribution. Topographically, the facial contour is like a
gently rolling plain and the facial fat appears balanced. There
is a seamless connection between the cosmetic units of the
face and a near absence of shadows. The upper third of the
face is broad with a convexity in the temples and a projection
of the forehead and brow away from the underlying frontal
bone. The lower lid is supported with ample fat and this fat
is contiguous with the anteriorly projecting malar eminence.
There may be fullness or slight flatness of the buccal fat area;
however, hollowing is not seen in most healthy young adults.
In profile, the cheek, like the forehead, arcs forward giving
the face a strong anterior projection (Fig. 22.3). The lower
third of the face is arced on with a sweep of the jawline from
ear to ear (Fig. 22.4). The jaw itself is full with an anterior
projection that then wraps inferiorly forming an obtuse angle
with the neck. The prementum is full and projects forward
and superiorly, thus shortening the distance between the lip
and the nose. Overall the shape of the young face is triangu-
lar with the apex of the triangle occurring at the mentum and
the base at the temples (Fig. 22.5).
The aforementioned contours occur because of ampleness
in the deep fat compartments. Recent anatomic research sug-
gests that the face is made up of separate fat compartments.
This may mean that the face does not age as a confluent mass,
but as individual fat compartments, and that facial aging is in
part due to how these compartments change with both aging
and fat storage.16 On a more subtle level, the presence of a
diffuse layer of subcutaneous fat lends suppleness and opacity
the cord, but only volume replacement can replenish the
thickness of the shade.
Craniofacial skeletal aging
Significant aging changes take place in the facial bones. These
include changes in contour of the maxilla, increase in vertical
maxillary dimension with retrusion of the lower maxillary
skeleton, a slight overall widening of the face, and a decrease
in the overall facial height. This causes a ‘concertina effect’
with compression of the soft tissue and relative redundancy
of skin. Skeletal remodeling in adulthood changes the facial
dimensions to that of an infant with an increase in the ratio
of the maxillary height to the orbital height (Fig. 22.2).11,12
These changes are even more dramatic in edentulous people.13
Aging also causes the orbital rim and anterior cheek to move
posterior relative to the cornea, changing the relationship of
the orbit to the mid-face and causing the eye to appear prop-
totic.14 In young adulthood, however, there is a balance
between the bony facial skeletal support and the soft tissue
envelope and so aesthetic harmony ensues.15
A
B
Figure 22.1  (A) Due to the thickness of
subcutaneous fat, animation in the
young face produces few wrinkles in the
overlying skin. (B) Lack of subcutaneous
fat in the aging face allows the mimetic
muscles to pull the skin along. (Courtesy
of Lisa M Donofrio.)
Figure 22.2  The facial fat distribution of an infant is similar to
the dysmorphism seen in aging adults. (Photo property of Lisa
M Donofrio.)

353
Chapter 22  Evaluation and Management of the Aging Face
flip-flops, with the apex lying at the level of the glabella and
the base at the jawline (Fig. 22.8).
Life as art
Painters and sculptors are cognizant of the structural changes
in the face that occur throughout life and use them as ways
to denote the age of their subject. A sculptor will groove in
shadowed areas and a painter will brush in a darker color to
represent the hill and valley contours. Seeing as artists, we can
surmise the age of a subject without seeing surface changes
such as wrinkling, lentigines, or telangiectasias because what
tells us how old someone is is the contours of their face. An
illustrator will have to make a two-dimensional representation
to a young face and hides the insertion and pull of the mimetic
musculature. In contrast, the aging face is a contradiction in
terms. There is unbalancing of the fat with areas correspond-
ing to fat hypertrophy and/or fat atrophy. This leads to a hill
and valley topography and an abundance of shadows. The
anterior projection of the forehead and cheek is lost, causing
these areas to flatten and result in a downward displacement
of tissues (Fig. 22.6). The temples become concave, as does
the lateral third of the face. The sweep of the anterior jawline
arc is replaced by an undulating curve due to submental fat
accumulations, with loss of definition with respect to the neck
(Fig. 22.7). The cosmetic units no longer flow but show
separation with demarcation at underlying bony landmarks.
The overall shape is ‘bottom heavy’ and the triangular shape
Figure 22.3  The profile arcs of the young face. (Photo property
of Lisa M Donofrio.)
Figure 22.4  The frontal arcs of the young face. (Photo property
of Lisa M Donofrio.)
Figure 22.5  Due to a generous distribution of fat in the upper
third of the face, a young face is like a triangle with the apex
lying at the level of the mentum. (Photo property of Lisa M
Donofrio.)
Figure 22.6  Loss of profile arcs in the aging face. (Photo
property of Lisa M Donofrio.)

354
Part 3  Aesthetic Surgical Procedures
of age by painting a flattened cheek and more angularity as a
subject ages. Conversely, a young nubile face is represented
by fullness, arcs, and many points of highlight (Fig. 22.9).
Human beings have evolved to ‘look their age.’ There must
have been a distinct advantage to looking different with every
decade for this trait to have survived Darwinian evolution. It
makes sense that if age could be assessed from a distance,
then the threat of the on-comer could effectively be evalu-
ated. Those who ‘looked older’ represented less of a threat
and therefore were left alive to pass on their genes. Pheno-
typically aging is a gross event, evident from 3 meters away,
not a microscopic one. That is why artist renditions are so
successful at denoting age.
Figure 22.7  Loss of frontal arcs in the aging face. (Photo
property of Lisa M Donofrio.)
Figure 22.8  Due to a preponderance of fat in the lower third of
the face and loss of fat in the upper third of the face, the aging
face is like a triangle with the apex lying at the level of the
glabella. (Photo property of Lisa M Donofrio.)
Pitfalls and their management
 The aging face must not be addressed superficially, by
treating only the epidermal and dermal components. Treat all
layers of the face as separate entities; e.g. bony changes of
aging are treated separately from those of fat. Titrate treatment
to the individual – and do not forget to treat the structural
components of aging (bone and fat remodeling).
 It is important to take into account the patient’s current weight
and how that affects the aging face; look at photos taken in
their youth and ask how their body weight compares to what it
once was. For some patients, weighing the patient, obtaining
fat measurements, and recommending exercise and dietary
behavioral changes to achieve weight loss may be indicated.
 It is wrong to assume that gravity is to blame for facial aging,
and to address skin as an ‘excess’ phenomenon; take into
account the alterations in three-dimensional projection and the
shape of the face, and how filling the face with autologous fat
can restore youthful projection.
 Fat does best as a pan-facial filler; recommendations to
predictably achieve longevity include blunt infiltration,
multilayer low-pressure injection, global, dynamic filling, and
under-correction with ‘touch-up’ procedures.
The myth of gravitational aging
To date, gravitational aging is the premise for all traditional
cosmetic surgery, but accepting gravity as a significant influ-
ence of sagging is probably erroneous. Since at least one-third
of our life is spent in a recumbent position, the downward
‘force’ should be somewhat mitigated by a perpendicular one.
There exist no animal models for gravitational descent of
tissues. Sagging occurs in the animal kingdom as a phenotypic
expression, not an age-related one. For instance, parrots in
their sixth decade show no signs of gravitational descent of
tissues, and baby elephants display convoluted sagging of skin.
In humans, aging leads to fibrosis of connective tissues and a
stiffening against the forces of gravity.17 With the exception
of ptosis of the reproductive organs in multigravida women,
advancing age does not bring about descent of internal organs.
The pericardium and diaphragm do not sag. Gravity has also
been blamed for the descent of the malar fat pad, as if
somehow standing upright allows fat to separate itself from
surrounding tissues and ‘slide’ inferiorly.1,18
If this was true then dependent areas of the body, such as
the dorsum of the hand, would ‘collect’ fat with age. Of
course the opposite is true with the posterior aspect of the
hands becoming devoid of fat with age. Therefore, if gravity
were the cause of sagging it would have to be selective.
Perhaps the strongest argument against gravitational aging is
the fact that we all age differently. If gravity was the cause
of sagging, then every 60-year-old should sag the same, but
in fact we all age very differently, with prominent cross-
cultural variation in sagging. Gravity is not causative in facial
aging but merely elucidative. The cause of morphologic aging
occurs within the soft tissues and especially subcutaneous
tissues which atrophy and hypertrophy relative to other
structures.
Facial fat mirrors body fat
A common mistake when evaluating a patient for rejuvenation
is to ignore their total body fat status. A 55-year-old with 46%

355
Chapter 22  Evaluation and Management of the Aging Face
Age 20
Age 40
Age 60
Shape of face at different ages
Figure 22.9  Merely by
changing the angularity of
the face and the shifting
depiction of light and
shadow, an artist can render
the age of their subject.
A
B
Figure 22.10  (A) The heavy aging face.
(B) The lean aging face. (Courtesy of Lisa
M Donofrio.)
body fat will have a very differently shaped face compared to
a 55-year-old with 20% body fat (Fig. 22.10). Similarly, two
30-year-old faces will look very different with overall body fat
of 20% versus 46%. The main difference between heavy faces
of different ages is where the fat goes. Patterns of facial fat
atrophy and fat hypertrophy are changes that are relative to
each other. A hypertrophic area only appears such because it
abuts a neighboring area of atrophy (Fig. 22.11).19 An over-
weight 30-year-old has the ability to gain fat diffusely in all
areas of the face. The facial fat is ‘balanced’ and so the face
becomes rounded and homogeneously full. In contrast, a
55-year-old with a high body fat percentage can only gain

356
Part 3  Aesthetic Surgical Procedures
the presence of good skin tone can markedly correct sagging
by removing the offending pocket of fat. With the breast, the
skin envelope develops a relative redundancy because glandu-
lar breast tissue, which grows during puberty, atrophies with
aging. The common complaint of breast sagging is often rem-
edied by ‘filling up’ the breast skin pocket with an implant.
This serves to increase the anterior projection of the breast
and take up the redundant tissue. In the same way, re-estab-
lishing the anterior projection of the cheek can serve to ‘lift’
the face forward and correct sagging (Fig. 22.13).Baseline
elasticity
There is an ‘optimal’ elasticity of skin, a point at which it
is neither stretched nor deflated, which is seen in youth when
the face is appropriately full of fat at an ideal body weight.
This is the point where the skin has the ability to ‘snap’ back
to its original position when stretched – referred to as elastic
recoil. Elastic recoil has been studied in pleural tissue and
molecularly corresponds to intact elastic fibers and organized
bundles of collagen.21 At this point, the underlying ‘tension’
on the skin relies on filling by soft tissues, especially subcu-
taneous fat, so that the overlying tissues appear taught. If a
young person loses this subcutaneous layer, the overlying skin
responds to the changes underneath by exhibiting ‘supercon-
traction’ and in essence shrinks to accommodate the changes
without slackening. This can be demonstrated in a young face
that has facial hemiatrophy, where the skin has an ability to
contract past its baseline elasticity clinging to the skeletal
framework below. However, an old face has lost this capabil-
ity. The contractile properties of the skin become impaired
such that it hangs in folds in response to underlying atrophic
changes in the fat. Atrophy in the adult face can be seen as
a normal part of the aging process or can also occur iatro-
weight in patterns that correspond to the hypertrophic areas
of the face. Cadaver and MRI studies have noted an increase
in fat lateral to the nasolabial and labiomental creases in aging
adults, consistent with a hypertrophic fat storage pattern.9
The areas that correspond to the atrophic areas stay as such.
The heavier the face, the more discrepancy between these
two areas. In contrast, a lean woman in her early 30s, while
having ample subcutaneous fat, will have a more ascetic look.
If she stays the same weight while she ages, her face will
experience little if any of the hypertrophic fat storage pat-
terns and instead show only atrophy. In this case, increased
shadowing is from bony demarcation and angularity. When a
60-year-old patient brings in a photo of herself when she was
45 with a desire to ‘turn back the clock,’ it is important to
evaluate the difference in weight that has occurred in the
previous 15 years. Since most North Americans gain weight
throughout life, this has a profound effect on the shape of the
face and what the patient can reasonably expect.
Paradoxically, both lean and heavy aging faces exhibit
sagging as a direct result of fat distribution. Fat accumulations
will hang in the direction of gravity. In the aging face of a
heavy person, this fat collects in the lower third of the face
leading to jowls and prominent submental fat. In contrast, a
lean aging face being devoid of fat will hang empty and col-
lapsed in the direction of the gravitational force (Fig. 22.12).
What is true of fat distribution on the face is also seen on the
body. With the abdomen, the skin is closely apposed to
underlying rectus fascia at birth, and only becomes pendulous
with excessive fat accumulation. A pendulous abdomen will
be displaced downward due to the sheer weight of the pan-
niculus. Liposuction of this area removes the fat so the skin
can retract.20 Similarly, suction of submental and jowl fat in
Areas prone to relative hypertrophy
and atrophy in the aging face
A
B
Figure 22.11  (A) Areas
prone to relative hypertrophy
in the aging face. (B) Areas
prone to atrophy in the aging
face.

357
Chapter 22  Evaluation and Management of the Aging Face
must be subcategorized into fine or coarse, superficial or
deep, and then further into those present at rest or only with
movement. Dynamic wrinkles that disappear at rest are best
treated with botulinum toxin. In those with an ‘at rest’ com-
ponent to the wrinkle, superficial augmentation (e.g. with
collagen or hyaluronic acid) or resurfacing are needed for
optimal results.22 Very fine wrinkles at rest that are superficial
in nature respond to intervention with tretinoin, glycolic acid,
or superficial resurfacing like that achieved with trichloroace-
tic acid (TCA) peels or fractional photothermolysis.23,24 Most
problems in the delegation of appropriate cosmetic proce-
dures come when treating coarse or deep rhytides. Coarse
rhytides resulting from severe elastotic solar damage are often
ashen or yellow in color and should be treated with deep
resurfacing such as wire brush dermabrasion, carbon dioxide
laser resurfacing, or deep peeling agents, such as with higher-
strength TCA or phenol. A clue to the etiology of this subset
of wrinkles is the presence of exaggerated pores and come-
dones in the periocular region and a history of carcinomatous
genically, secondary to overaggressive liposuction or removal
of buccal fat pad. Photoaging is at least partially responsible
for the inelasticity of aged skin, with its inability to respond
to atrophic insults in an aesthetic manner.
 OPTIMIZING OUTCOMES
Figure 22.14 summarizes how an aging face can be made to
look younger.
 PRACTICAL APPLICATIONS
Cosmetic management of the aging face
Cosmetic improvement of the changes that occur with aging
must be specific to the structure or level of skin in which the
aging occurred. Dyschromia and poikilodermatous changes
are epidermal and dermal events that must be treated with
resurfacing tools (lasers, peels, or topical therapies). Wrinkles
A
B
Figure 22.12  (A) Due to the loss of
support from deep fat atrophy, a lean
aging face will collapse in the direction of
gravity. (B) A young face with ample
subcutaneous and deep fat will hold its
shape regardless of the direction of
gravitational pull. (Photos property of Lisa
M Donofrio.)
A
B
Figure 22.13  (A) The profile arcs of the
young face. (B) The same patient as
seen in Figure 22.6 after structural fat
replacement. Note reapproximation of
arcs of face and restoration of forward
projection. (Courtesy of Lisa M Donofrio.)

358
Part 3  Aesthetic Surgical Procedures
cheeks are due to relative excess of skin secondary to shrink-
age of the framework of the face, and pulling from underlying
muscle with failure of the skin envelope to adapt. These
wrinkles are ameliorated by either traditional rhytidectomy
procedures that lift the skin, or structural augmentation pro-
cedures. Sagging, like folding of the skin, is an atrophic event,
occurring in the direction of gravity. Face and neck lifts and
skin-contracting lasers and radiofrequency devices are effi-
cient at shrinking the skin to again fit the face, but they can
unmask the bony framework of the face and accentuate the
angularity that is so uncharacteristic of youth (Fig. 22.15).
Care must be taken to reapproximate not only the texture
and color of youthful skin but also the shape and arcs of the
young face.
Structural facial rejuvenation
Structural facial rejuvenation is that which replaces the scaf-
folding of the face – the bone and soft tissue – so that the
skin can assume draping without redundancy.
True rejuvenation can only be accomplished by restoration
of the young arcs of the face and rebalancing the fat and
bony compartments. Options include mid-face-lifting pro­
cedures that re-establish forward cheek projection (see
Chapter 37), synthetic and injectable implants to approxi-
mate mid-face volume and jawline definition (see Chapters
23 and 25), and autologous fat transfer (see Chapter 28).
Implants available for augmenting the zygoma, maxilla, man-
dible, and chin, and injectable substances such as calcium
hydroxylapatite can reapproximate the shape of the young
bony facial skeleton. The former may ultimately become
demarcated and visible through the skin with age. Since
much of the loss of the young architecture of the face is
due to the redistribution of fat, autologous fat transfer is a
useful option and a versatile choice.25 Fat removed from
extra deposits on the body can be used to reconstruct youth-
ful facial contours (Figs 22.16–22.18). In addition, areas of
fat hypertrophy on the face can be suctioned out to level
off unevenly projected areas (Figs 22.19 and 22.20). This
requires the surgeon to think like a sculptor. Examination of
photographs of the patient when younger is an invaluable
tool that can help to plan a ‘blueprint’ of the surgery (Fig.
22.21). In this way, the fat compartments of the face can
be ‘rebalanced’ to the fat distribution of youth. Careful
staged fat transplantations can bring about a gradual improve-
ment and may enhance ‘take’ of the fat graft (see Chapter
28).26 Any suction performed on the face should be done
with microcannulae and hand-generated negative pressure.
Undercorrection via a staged removal of fat is advised to
minimize the risk of poor skin contraction secondary to an
atrophic insult in photodamaged skin.
 SUMMARY
Successful rejuvenation occurs when the physician takes
into account all of the changes that have occurred in the
aging face, and their etiologies. The clinician must remem-
ber that aging is an intrinsic event with shrinkage of the
underlying framework and an extrinsic event with alterations
in the dermis and epidermis. Creams that reduce the appear-
ance of fine lines are not appropriate when the concern of
the patient is the nasolabial fold or wrinkles that occur with
movement.
Poikilodermatous changes
No
No
Yes
Yes
Yes
No
Yes
No
Yes
No
No
Yes
No
Yes
Yes
Telangiectasias
Lentigos/melasma
Texture changes/fine wrinkles
Intense pulsed light
Lasers
Liquid nitrogen
Peels
Retinoids
+/- Bleaching agents
Wrinkles at rest
Loss of convex
facial arcs
Bone loss/edentulous
Fractionated lasers
Superficial fillers
Wrinkles in motion
Botulinum toxin
Folds/sagging
Soft tissue
augmentation
Mid-face lift
Skin contracting
devices
(CO2 + laser;
radiofrequency;
ELOS, etc.)
Structural
augmentation
(Implants;
bone grafts;
injectable
hydroxylapatite)
No treatment
Management of the aging face
Figure 22.14  Algorithm for management of the aging face.
changes of the skin. Most aging patients have some degree of
solar elastosis, but what separates those best treated with
resurfacing is that the wrinkles appear superficially as creases
in the skin, rather than causing skin involutions. Involutional
changes like the folds occurring in the nasolabial area or mid-

359
Chapter 22  Evaluation and Management of the Aging Face
A
B
Figure 22.15  (A) The youthful jawline is
full and rounded. (B) After lower face lift,
the jawline is ascetic with an acute
angularity. (Courtesy of Lisa M Donofrio.)
A
B
Figure 22.16  A 55-year-old lean-faced
woman (A) before and (B) after structural
fat augmentation. (Courtesy of Lisa M
Donofrio.)
A
B
Figure 22.17  (A) Before and (B) after structural fat augmentation of face and jawline without suction. Note how the jawline is full
and rounded and more closely approximates the shape of the young jawline seen in Figure 22.15A. (Courtesy of Lisa M Donofrio.)

360
Part 3  Aesthetic Surgical Procedures
A
B
Figure 22.18  (A) Before and (B) after structural augmentation of the jawline and face. Note how ‘excess skin’ has been redraped
over the new framework. (Courtesy of Lisa M Donofrio.)
A
B
Figure 22.19  Outlined areas of
hypertrophy (A) and atrophy (B) in an
aging woman’s face. (Courtesy of Lisa M
Donofrio.)
A
B
Figure 22.20  (A) Before and (B) after
facial fat rebalancing via a combination of
microsuction of the hypertrophic areas
and structural augmentation of the
atrophic areas seen in Figure 29.19.
(Courtesy of Lisa M Donofrio.)

361
Chapter 22  Evaluation and Management of the Aging Face
into an integrated model of midfacial aging. Plast Reconstr Surg 1998;102:
205–212.
12. Bartlett SP, Grossman R, Whitaker LA. Age-related changes of the
craniofacial skeleton: an anthropometric and histologic analysis. Plast
Reconstr Surg 1992;90:592–600.
13. Kingsmill VJ. Postextraction remodeling of the adult mandible. Crit Rev
Oral Biol Med 1999;10:384–404.
14. Pessa JE, Desvigne LD, Lambros VS, et al. Changes in ocular globe-to-
orbital rim position with age: implications for aesthetic blepharoplasty of
the eyelids. Aesthetic Plast Surg 1999;23:337–342.
15. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial aging:
nonlinear aspects of youthfulness and skeletal remodeling, and why,
perhaps, infants have jowls. Plast Reconstr Surg 1999;103:635–644.
16. Rohrich, RJ, Pessa JE. The fat compartments of the face: anatomy and
clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119:
2219–2227.
17. Lindner J, Grasedyck K. Age-dependant changes in connective tissue.
Arzneimittelforschung 1982;32:1384–1396.
18. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Rejuvenation of
the midface by elevating the malar fat pad: review of technique, cases,
and complications. Plast Reconstr Surg 2002;110:1526–1536.
19. Pessa JE, Garza PA, Love VM, et al. The anatomy of the labiomandibular
fold. Plast Reconstr Surg 1998;101:482–486.
20. Pollack SV. Liposuction of the abdomen. The basics. Dermatol Clin
1999;17:823–834, vii.
21. Lemos M, Pozo RM, Montes GS, et al. Organization of collagen and
elastic fibers studied in stretch preparations of whole mounts of human
visceral pleura. Anat Anz 1997;179:447–452.
22. Carruthers J, Carruthers A, Maberley D. Deep resting glabellar rhytides
respond to BTX-A and Hylan B. Dermatol Surg 2003;29:539–544.
23. Nyirady J, Bergfeld W, Ellis C, et al. Tretinoin cream 0.02% for the
treatment of photodamaged facial skin: a review of two double-blind
clinical studies. Cutis 2001;68:135–142.
24. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatment
of facial and nonfacial cutaneous photodamage with a 1550-nm erbium-
doped fiber laser. Dermatol Surg 2007;33:23–28.
25. Donofrio LM. Fat distribution: a morphologic study of the aging face.
Dermatol Surg 2000;26:1107–1112.
26. Donofrio LM. Structural autologous lipoaugmentation: a pan-facial tech-
nique. Dermatol Surg 2000;26:1129–1134.
Judicious tailoring of the procedure to treat the etiology
ensures the best outcome and a satisfied patient.
 REFERENCES
1. Bertazzo A, Favretto D, Costa CV, et al. Effects of ultraviolet irradiation
of melanogenesis from tyrosine, dopa and dopamine: a matrix-assisted
laser desorption/ionization mass spectrometric study. Rapid Commun
Mass Spectrom 2000;14:1862–1868.
2. Whitmore SE, Morison WL. The effect of suntan parlor exposure on
delayed
and
contact
hypersensitivity.
Photochem
Photobiol
2000;71:700–705.
3. Warren R, Garstein V, Kligman AM, et al. Age, sunlight and facial skin:
a
histologic
and
quantitative
study.
J
Am
Acad
Dermatol
1991;25:751–760.
4. Contet-Audonneau JL, Jeanmaire C, Pauly G. A histological study of
human wrinkle structures: comparison between sun-exposed areas of the
face, with or without wrinkles, and sun protected areas. Br J Dermatol
1999;140:1038–1047.
5. Kambayashi H, Yamashita M, Odake Y, et al. Epidermal changes caused
by chronic low-dose UV irradiation induce wrinkle formation in hairless
mouse. J Dermatol Sci 2001;27(Suppl 1):S19–S25.
6. Toyoda M, Nakamura M, Luo Y, et al. Ultrastructural characterization
of microvasculature in photoaging. J Dermatol Sci 2001;27(Suppl
1):S32–S41.
7. Reimers CD, Harder T, Saxe H. Age-related muscle atrophy does not
affect all muscles and can partly be compensated by physical activity: an
ultrasound study. J Neurol Sci 1998;159:60–66.
8. Morley JE, Baumgartner RN, Roubenoff R, et al. Sarcopenia. J Lab Clin
Med 2001;137:231–243.
9. Gosain AK, Amarante MT, Hydede JS, et al. A dynamic analysis of
changes in the nasolabial fold using magnetic resonance imaging: implica-
tions for facial rejuvenation and facial animation surgery. Plast Reconstr
Surg 1996;98:622–636.
10. Pierard GE, Lapiere CM. The microanatomical basis of facial frown lines.
Arch Dermatol 1989;125:1090–1092.
11. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative maxillary retrusion as
a natural consequence of aging combining skeletal and soft-tissue changes
A
B
Figure 22.21  (A) Surface changes such as wrinkles and lentigos best treated by resurfacing are easy to see in this 52-year-old
woman’s face. (B) It is not until examining a photograph of the same woman in her 20s that the striking change in facial contours is
appreciated. (Courtesy of Lisa M Donofrio.)

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363
23
Soft Tissue Augmentation
Emily Tierney MD, Roberta D Sengelmann MD FAAD FACMS, Gerhard Sattler MD and C William Hanke MD MPH FACP
Summary box
 The ideal soft tissue filler would be characterized by the
following properties: safety, efficacy, reproducibility, ease
of administration, low abuse potential, non-carcinogenicity,
non-teratogenicity, non-migratory, cost-effective, physiologic,
semi- or non-permanent, and government sanctioned.
 A large diversity of materials are currently available worldwide
for dermal filling
 The available fillers have varying levels of particle size,
desired placement depth, biodegradability, allergenicity, and
durability.
 Indications for soft tissue augmentation include atrophic
scarring, rhytides, volume loss, lip atrophy, and contour
defects.
 Setting appropriate patient expectations is essential for
treatment of volume loss, acne scarring, contour deformities,
wrinkle reduction, and enhancing lip fullness.
 It is critical to understand the technique and substrate of each
filler substance and potential side effects in order to achieve
the most optimal outcomes.
 INTRODUCTION
As people live longer and healthier lives, more seek physicians
to help them maintain and restore a more youthful appear-
ance. A large component of the skin’s natural aging process
is manifested by volume loss with contour changes and
rhytides secondary to atrophy of soft tissues, including both
muscle and subcutaneous fat and loss of skin resistance as
dermal collagen, hyaluronic acid, and elastin are depleted.
Traditionally, rejuvenation has been achieved with surgical
resection of redundant skin, namely through ‘face-lift’ or
‘eyelid-lift’ procedures. Today, a multitude of minimally
invasive procedures, of which soft tissue augmentation is one,
produce significant rejuvenation without the risks, downtime,
and expense of major surgery. In addition, the development
of botulinum toxin injections (Botox Cosmetic, Allergan, Inc,
Irvine, CA and Dysport, Medicis, Inc, Scottsdale, AZ) has
opened the door for equally non-invasive adjunctive treat-
ments for rhytides and other signs of facial aging.
Smooth, symmetric facial contour may become disrupted
by either natural disease, such as acne, by environmental
causes, such as sun exposure, by trauma, or merely by the
process of aging. Scars caused by acne or trauma leave depres-
sions of various depths which can be improved using soft
tissue fillers. Atrophy of an entire cosmetic subunit may be
caused by diseases such as HIV lipodystrophy or morphea.
Fine rhytides, particularly perioral and periocular lines, can
be caused by excessive actinic damage. Normal lines of facial
expression become accentuated with age.
Restoration of facial symmetry and volume, as well as a
smooth contour and homogeneous skin tone, are the goals of
the dermatologic surgeon. Soft tissue augmentation plays a
major role in this process. The appropriate filler can restore
symmetry and volume and recreate a smooth skin surface.
Particularly, in combination with other treatments, such as
botulinum toxin and non-ablative resurfacing, fillers may
provide satisfying and prolonged results.
Injectable soft tissue augmentation materials available for
use in the United States have proliferated during the past 5
years. In addition to bovine collagen and autologous fat, phy-
sicians can now choose between numerous other options,
including hyaluronic acid derivatives, poly-L-lactic acid
(PLLA), injectable calcium hydroxylapatite, polymethyl-
methacrylate (PMMA) microspheres, and human, bovine,
and porcine collagen. While these materials are generally safe
and versatile, each has specific features that govern its best
use, which will be discussed in detail in this chapter.
Significant progress has been made toward the develop-
ment of an ideal filler/implant, which is characterized by the
following properties: safety, efficacy, reproducibility, high use
potential, low abuse potential, non-carcinogenicity, non-tera-
togenicity, non-migratory, cost-effective, physiologic, semi-
permanent, and approved for use by US government agencies.
This chapter provides an overview of the currently available
dermal fillers that are used for augmentation of superficial
contour irregularities and subdermal fillers and soft tissue
implants that correct contour defects where more volume is
needed.
 HISTORICAL ASPECTS
The search for an ideal soft tissue filler for the correction of
facial lines and wrinkles has spanned a century. The first
organic injectable filler was injectable paraffin, first used at
the turn of the 20th century. This material was characterized
by the appearance of paraffinomas and was thus abandoned.1

364
Part 3  Aesthetic Surgical Procedures
developed by Serono Laboratories in 1985. It was later mar-
keted by Mentor Corporation. Fibrel is a mixture of
ε-aminocaproic acid, gelatin powder, and plasma from the
patient. The gelatin forms a scaffolding upon which new col-
lagen synthesis occurs. The enzyme inhibitor ε-aminocaproic
acid blocks fibrinolysin, which decreases collagen degrada-
tion, thus increasing collagen production to fill the clot
matrix. Blood plasma provides a supplemental source of
fibrinogen and other clotting factors that enhance the collagen
matrix. Although venipuncture and centrifugation of the
patient’s blood made Fibrel preparation tedious, reported
results were generally favorable.25–27 Nonetheless, a corporate
decision was made by the Mentor Corporation to discontinue
marketing of the product, which at the current time remains
unavailable.
The search for an ideal, injectable, soft tissue filler contin-
ues. A number of new products have appeared worldwide in
the last two decades and new additions to the repertoire of
dermal and subdermal fillers continue to grow each year.
Many of the currently available injectable fillers include bio-
logically compatible agents, such as hyaluronic acid gels
(Restylane, Perlane, Juvéderm, Hylaform, Puragen), human
fibroblasts (Isolagen), fibroblast-derived human collagen
(Cosmoderm, Cosmoplast), fascia lata (Fascian), acellular
human collagen (Alloderm, Cymetra), elastin, and other
human dermal products. Others have introduced substances
such as Dextran (Reviderm Intra), polyethylene beads
(Profill), silicone polymers (Dermagen), PMMA (Artecoll),
calcium hydroxylapatite (Radiesse), or PLLA (New-Fill/
Sculptra) to increase duration of correction.
Balazs and Denlinger established that insoluble, injectable,
cross-linked hylan gels derived from hyaluronic acid exhibited
a prolonged residence time in soft tissues and were as bio-
compatible as natural hyaluronan.28 Hylan B, first developed
in the mid-1980s, is produced by introducing sulfonyl-
bis-ethyl cross-links between hydroxyl groups of the polysac-
charide chain of hyaluronan. Intra-articular injections of this
material were found to be helpful for knee pain associated
with osteoarthritis.29 Subsequently, it was evaluated and used
for soft tissue augmentation. Hylan B gel has a number of
attributes that make it a favorable intradermal injectable
implant material. It is water insoluble, resists degradation,
and is unlikely to migrate. The high water content mimics
the natural hydrating function of native hyaluronan in the
skin. The elastic properties of the gel render it soft and
natural feeling and provide elastic protection (shock absorp-
tion) to the cutaneous soft tissue.30 The physical properties
of hyaluronic acid gels are controlled by the molecular weight
and the concentration of the material and by the degree of
cross-linking.31 The most commonly used source of hyaluronic
acid are rooster combs (Hylaform), bacterial cultures (Resty-
lane), human umbilical cord, vitreous humor, tendons, and
skin.32
PMMA was first synthesized in 1902 by the German
chemist Rohm and was patented as Plexiglas in 1928. It has
had medical applications since 1945, and is commonly used
in bone cement, intraocular lenses, dental prostheses, and
repair material for craniofacial surgery. In addition to being
biocompatible and immunologically inert, PMMA has never
demonstrated degradation or carcinogenicity. Professor Gott-
fried Lemperle (St Markus Hospital, Frankfurt, Germany)
developed the concept of using PMMA microspheres for
tissue augmentation.33,34 The initial product tested, Arteplast,
Subsequently, in the 1960s, the Dow Corning Corporation
(USA) introduced a form of liquid silicone (medical grade
360) for the correction of facial deformities, lines, and wrin-
kles.2 Between 1960 and 1990, various forms of liquid sili-
cone were utilized in the treatment of tens of thousands of
patients. Complications were minimal with the use of the
‘microdroplet’ technique, where silicone was injected in small
aliquots through a fine-bore needle. Unfortunately, the lack
of uniformity in silicone preparations, with the use of impure
and adulterated silicones, resulted in several severe complica-
tions.3 These complications, as well as the lack of approval
for silicone by the Food and Drug Administration (FDA),
significantly limited silicone use in the US. More recently, in
2002, when the FDA approved the use of 1000 centistoke
liquid silicone for intraocular injections, off-label use of this
injectable silicone oil as a permanent soft tissue filler for facial
rejuvenation has increased in the US.4
In the 1970s, research into collagen production led to a
bovine formulation that could be placed into a syringe and
injected. Injectable bovine collagen was introduced into the
market in 1981 by the Collagen Corporation (Palo Alto,
CA).5–8 Bovine collagen is currently marketed by Inamed
Aesthetics (Santa Barbara, CA) as Zyderm and Zyplast and
is characterized by easy administration, and safe and effective
short-term tissue augmentation. Injectable bovine collagen
equivalents are also available in Japan (Kokenatelocollagen
implant, Koken Co, KTD, Tokyo) and Europe (Resoplast,
Rofil Medical International BV, Bredia, Netherlands), all of
which have similar indications to Zyderm and Zyplast colla-
gen. However, the incidence of allergic responses to bovine
collagen products and their limited longevity have fueled the
continual search for a more ideal dermal filler product.9–11
Human collagens which are analogous to Zyderm and Zyplast,
namely Cosmoderm and Cosmoplast (Inamed Aesthetics),
which obviate the need for skin testing, have largely replaced
treatment with bovine collagen.
A readily available augmentation substance is the patient’s
own dermis and fat. Early in the 20th century, fat grafts were
utilized to fill volume after trauma. However, excising and
transplanting fat still represented a major procedure, which
in many cases did not have long-lasting effects.12–17 Neuber
was the first to report use of autologous tissue for subcutane-
ous augmentation through the use of dermis and fat.18 Dermis
and fat both have varying degrees of resorption after implan-
tation, rendering unpredictable outcomes.19 The modern use
of fat as a filling substance dates to its reintroduction by
Fournier with the ‘microlipoinjection’ technique in the late
1970s.20 The longevity of contour correction after autologous
fat injection is highly variable. Duration of correction is
dependent on a variety of factors, including whether fat is
fresh or frozen, viability of fat cells, technique utilized,
amount of fat injected, location of recipient site, and type of
defect treated. Recent data by Coleman suggest improved
duration of correction with autologous fat transfer.21 Although
early results with fat transfer are promising and there is an
inherent intuitive benefit to using an autologous agent for soft
tissue augmentation, it is not clear that autologous fat is an
ideal soft tissue filling agent, particularly given its highly var-
iable duration of correction.22 A complete discussion of fat
transfer is presented in Chapter 28.
In 1957, Spangler first published his studies on the use of
‘fibrin foam’ to treat depressed scars.23 Based upon this work
and modifications by Gottlieb,24 a new product, Fibrel, was

365
Chapter 23  Soft Tissue Augmentation
nasolabial folds and marionette lines (Figs 23.1 and 23.2).
Advanta (Atrium Medical Corporation, Hudson, NH)43 is one
of the newer versions of these products. It is a dual-porosity
e-PTFE which is marketed as a softer, smoother implant
which comes in a larger diversity of shapes and sizes. It has
been available since 2001, with studies by Hanke44 demon-
strating encouraging results in the treatment of marionette
lines (the vertical grooves extending downwards from the oral
commissures to the mental area), nasolabial folds, and lip
augmentation.
Alloderm (LifeCell Corporation, Palo Alto, CA) is acellular
human cadaveric dermis which has been freeze dried. Allo-
derm is processed as sheets and has been widely used in the
treatment of full-thickness burns, blistering conditions such
as epidermolysis bullosa, and in reconstructive surgery for
patients with urinary incontinence. It is also used as an
implant in soft tissue augmentation procedures such as rhi-
noplasty, lip augmentation, glabellar contouring, and scar
revision.45,46 Cymetra (LifeCell Corporation, Palo Alto, CA)
is the injectable form of Alloderm. Both Cymetra and Allo-
derm have been available since the mid-1990s.
was heterogeneous, containing various PMMA monomers,
spheres of various sizes, and even some impurities. It led to
several cases of granuloma formation, with swelling and
inflammation. Artecoll (formerly Artefill), which has been
available in Europe for a decade, contains only smooth micro-
spheres of 30–40 µm in size and 99% of the remaining mon-
omers have been removed during processing. These changes
in the product size and uniformity of particle composition
have resulted in a significantly decreased incidence of granu-
loma formation.35
In 1971, Robert and William Gore developed expanded
polytetrafluoroethylene (e-PTFE) as an expanded fibrillated
form of Teflon (PTFE). Teflon was first used as a vascular
prosthesis in bypass surgery36–42 but rapidly found uses in a
variety of other surgical procedures, such as the treatment of
facial lines and wrinkles and lip augmentation. It was approved
for use in facial and reconstructive surgery in 1993. Softform
and its softer, more pliable second-generation counterpart,
Ultrasoft (Tissue Technologies, Inc, San Francisco, CA) are
sheets, strips, and tubes of e-PTFE used as facial implants to
treat depressed scars, lip atrophy, and deep furrows such as
A
B
Figure 23.1  (A) Pre and (B) post bovine collagen (Zyderm I) injections to fine perioral rhytides, bovine collagen (Zyplast) to deeper
perioral furrows. (Courtesy of C William Hanke MD.)
A
B
Figure 23.2  (A) Pre and (B) post bovine collagen (Zyderm II) injections to acne scarring on cheek. (Courtesy of C William Hanke
MD.)

366
Part 3  Aesthetic Surgical Procedures
Most recently, two novel filling substances, Radiesse and
Sculptra, which are considered stimulatory fillers, have been
introduced into the filler market. These two fillers are con-
sidered ‘stimulatory fillers’ as they induce a fibroblastic
response that results in the formation of new collagen and
connective tissue. This allows the clinical effects to last for a
prolonged duration, which has been reported to range from
12 to 36 months. Radiesse (Bioform, Franksville, WI) is com-
posed of calcium hydroxylapatite microspheres suspended in
polysaccharide gel. It has been utilized as a soft tissue filler
for augmentation of the nasolabial folds, zygomatic region,
lips, under-eye region, and as a non-surgical rhinoplasty treat-
ment to improve nasal contouring. PLLA (Sculptra) was ini-
tially approved by the FDA in 2004 for the correction of
facial lipoatrophy in patients with HIV infection; since that
time PLLA has been used investigationally, and off-label
clinically, as a soft tissue filler. It has been utilized for the
correction of fine lines, wrinkles, folds, and creases as well as
for augmentation, repositioning, and contouring of the cheeks,
chin, and lips. The PLLA microparticles are absorbed slowly
over a period of several weeks after injection, but the newly
generated collagen and clinical effects have been reported to
last for at least 18–24 months.
A comprehensive list of injectable soft tissue fillers available
at the time of writing is given in Table 23.1. Of these prod-
ucts, those deemed by the authors to be of most immediate
importance to the reader are discussed below and presented
in Table 23.2.
 INDICATIONS
Fillers either replete defects or augment existing facial struc-
tures. Beginning with the upper third of the face, fillers can
be used to fill in depressions in the forehead from acne scars.
Temporal depression that is associated with age may also be
augmented, and lines of expression such as glabellar frown
lines can be diminished. Filling the upper third of the face is
potentially more challenging because of the concurrence of
dynamic creases in this region. In the periorbital region, fillers
may be used for ‘etched-in’ crow’s feet, with some practition-
ers advocating using fillers under the lateral eyebrow as a
substitute for surgical brow lift. In the lower eyelid, restoring
this subunit’s volume rather than removing fat has become a
guiding principle in restoration of the upper face. The appro-
priate use of a filler can remove the ‘double bubble’ between
the lower eyelid and the upper cheek as well as camouflage
the nasojugal groove.
In the mid-face, fillers can be used to correct traumatic or
acne scars. The types of acne scars most amenable to treat-
ment are either atrophic or rolling scars. Sinking and efface-
ment of the malar eminence and hollowing of the cheeks can
also be corrected with fillers. While the malar region can be
directly built up, often merely adding volume diffusely to the
cheeks will increase the malar prominence. Cheek hollowing
is commonly treated with fillers in patients with HIV lipo­
atrophy. While the thinness of nasal skin may lead to a higher
rate of complications or unsatisfactory results with the use of
fillers, experienced practitioners can effectively fill scars and
alter the profile of the nasal dorsum.
The most popular anatomic areas for injectable soft tissue
augmentation, and the ones with the most prolonged results,
are the nasolabial folds and the marionette lines, also known
as ‘smile’ lines. Deepening of the nasolabial folds, which are
Table 23.1  Table of commercially available products
PRODUCTS
TRADE/BRAND NAME
Animal derived
Bovine
Endoplast-50
Resoplast
Zyderm I
Zyderm II
Zyplast
Porcine
Permacol
Surgisis
Hyaluronic acid
AcHyal
Acrylic Hydrogel
Hyal-System
Hylaform Fine Line
Hylaform
Hylaform Plus
Hylan Rofilan Gel
Juvéderm (18,24,30)
MacDermol
Macrolane
Restylane Fine Line
Restylane
Perlane
Rofilan
Polyacrylamide gel
Amazing Gel
Aquamid
Argiform
Bio-Alcamid
Bioformacryl
Dermalive
DermaDeep
Evolution
Formacryl
Outline (fine, regular, ultra)
Polymethylmethacrylate
Artecoll
Meta-Crill
Silicone based
AdatoSil 5000
Bioplastique
Dermagen
Silikon 1000
Biocatalyst
Dermacellagen
New-Fill/Sculptra
Reviderm Intra
Other injectable
synthetic
Kopolymer (sterile plastic fatty acid gel)
Profill (polyethylene beads)
Radiance/Radiesse (calcium
hydroxylapatite)
Autologous
Autologen
Autologous grafts (fat, dermis,
dermis-fat, tendon, scar, fascia)
Isolagen
Plasmagel
Human derived
Alloderm
Biocell Ultravital
Cosmoderm I
(Cosmoderm II)
Cosmoplast
Cymetra
Dermaplant
Fascian
Human placental collagen
Recombinant human collagen
Synthetic implants
(e-PTFE)
Advanta
Gore-Tex (strings, strands)
Softform/Ultrasoft

367
Chapter 23  Soft Tissue Augmentation
Table 23.2  Most commonly used products (by
injection/implant level)
PRODUCT
TRADE/BRAND NAME
Dermal fillers
Superficial/mid-dermis
Cosmoderm I
Zyderm I
Mid-dermis
Autologen
(Cosmoderm II)
Hylaform
Restylane
Zyderm II
Deep dermis
Artecoll
Cosmoplast
Dermalive
Hylaform Plus
Perlane
Reviderm Intra
Zyplast
Versatile dermal levels
Fascian
Hylan Rofilan Gel
Isolagen
Juvéderm (18,24,30)
Subdermal fillers
Cymetra
Radiesse (calcium hydroxylapatite)
Dermadeep
New-Fill/Sculptra
Subdermal implants
Advanta
Alloderm
Gore-Tex
Softform/Ultrasoft
Autologous grafts (fat, dermis,
dermis-fat, tendon, scar, fascia)
Box 23.1  Pitfalls of soft tissue augmentation
Discomfort
Bruising
Vasovagal reactions
Incomplete correction
Bluish discoloration (Tyndall effect)
Beading
Granuloma formation
Swelling
Hematoma
Asymmetry
Hypersensitivity
Palpability in skin
Scarring
Infection
Extrusion
Neuropraxia
Skin necrosis (intra-arterial injection)
Blindness
in the transition zone between the mid-face and lower face,
creates an abnormal demarcation between these two major
facial regions. The desire of even young patients to fill these
lines reflects the aesthetic aspiration for a smooth facial
contour. A secondary effect of filling these lines is to increase
the prominence of the medial cheeks in profile view.
The lower face is dominated by the lips. Fine vertical
rhytides of the upper lip can be diminished with judicious
use of fillers. Age-related effacement of both the upper and
the lower lip margins, as well as thinning of the lips, can also
be corrected. Many types of fillers can be used in the lips to
achieve a natural fullness, and other fillers can be used to
redefine the effaced vermilion border. Marionette or ‘drool’
lines are a combination of expression, aging, and genetics.
While a variety of fillers can be used to reduce them, in older
individuals or those with advanced actinic damage and sagging,
filling them may create ripples lateral to the injection area.
A sign of aging in the lower face is unevenness of the
jawline. This is caused not only by loss of skin elasticity and
gravity but also because of resorption of the mandible. Selec-
tive injection of the appropriate filler can create a smooth and
robust mandibular line. Although permanent implants are the
procedure of choice for increasing chin projection, using
fillers can temporarily create a prominence at this point. Use
of fillers for this indication may also be useful in allowing the
patient to determine if he or she desires a permanent implant.
  PREOPERATIVE PREPARATION
Minimal preoperative preparation is required for soft tissue
augmentation. With the diversity of products available, the
physician should advise the patient of the strengths and
potential pitfalls of various products. Patient and physician
should come to a mutual agreement regarding which product
would best suit the patient’s needs, downtime, and risk toler-
ance. Physicians should set realistic patient expectations for
adverse reactions, postinjection side effects, and duration of
correction, prior to deciding on the substance to be utilized
for soft tissue augmentation (Box 23.1).
The cosmetic consultation should prioritize the patient’s
concerns and devise an overall treatment plan. During this
discussion, a distinction should be made between lines of
expression, static wrinkles, and sagging, and the appropriate
therapies for each should be explained. When it is deter-
mined that fillers are the best therapy for a given cosmetic
concern, several alternative approaches and materials should
be considered. It should be explained to the patient why the
practitioner believes that that particular filler and injection
technique is the best choice. Reviewing common postopera-
tive sequelae such as bruising is important; rare but serious
potential adverse effects should also be discussed, if appropri-
ate. If the filler is being used off-label, this fact should be
disclosed to the patient.
A complete medical history, including medication list,
should be elicited. When medically appropriate, patients
should discontinue non-steroidal anti-inflammatory drugs
(NSAIDs), aspirin, high-dose vitamin E, and most herbal
medications prior to injection to decrease risk of ecchymosis.
This is particularly important prior to injection of the thin
skin of the eyelids and lips. As with any invasive procedure,
the patient may be asked not to take aspirin for at least 8
days, or NSAIDs for at least 5 days, unless discontinuation
of these poses a significant risk to the patient. If the patient
is on warfarin therapy, the prothrombin time (PT) may be

368
Part 3  Aesthetic Surgical Procedures
patients have been treated.68 The results typically last 3–4
months. The desire for substances with a longer duration of
correction has led to novel filler substances which have
decreased the current use of collagen injections as a dermal
filler substance. The material is derived from the hides of an
isolated herd of domestic cattle.69
Given the 1–3% risk of hypersensitivity, bovine collagen
requires pretesting for hypersensitivity reactions. Internal
postmarketing surveillance by Inamed showed a 3% preva-
lence of circulating antibodies to bovine collagen. Two skin
tests, performed at 2–4 weeks, is the standard assessment
recommended.70,71 Positive skin test is defined as erythema,
induration, tenderness or swelling that persists more than 6
hours after implantation and typically arises 2–3 days after
implantation as a delayed hypersensitivity reaction. As
patients are typically very upset in the event of a hypersen-
sitivity reaction, skin testing and waiting the entire duration
of follow up prior to injection are imperative prior to treat-
ment. Treatments for hypersensitivity reactions include: int-
ralesional steroids, topical tacrolimus 0.1% ointment b.i.d,
systemic steroids, or systemic cyclosporine.72,73
Contraindications to injectable bovine collagen include ana-
phylactic event of any cause, prior hypersensitivity to bovine
collagen, lidocaine sensitivity, pregnancy or lactation, and any
signs of infection at the injection site.
Zyderm I consists of 3.5% bovine collagen suspended in
sodium chloride with 0.3% lidocaine. It contains 95–98%
type I collagen and 2–5% type III collagen. It is designed to
be injected into papillary dermis for superficial rhytides and
is useful around the eyes, lips, glabellar region, and cheek
(Fig. 23.3). It is particularly useful in depressed acne scars
and can be overlaid on a more viscous substance, such as
Zyplast or Cosmoplast. Overcorrection by 100% is required
to offset the absorption of the saline.
Zyderm II consists of 6.5% bovine collagen suspended in
sodium chloride with 0.3% lidocaine and is slightly more
viscous than Zyderm I. It is injected deeper than Zyderm I
(into upper reticular dermis) for the treatment of more
coarse rhytides as well as for acne scarring and lip augmenta-
tion (Fig. 23.4). Less overcorrection (50%) is required than
Zyderm I, because of a higher concentration of collagen and
less saline absorption
Zyplast, like Zyderm I, is composed of 3.5% bovine col-
lagen suspended in sodium chloride with 0.3% lidocaine.
Zyplast is cross-liked with glutaraldehyde to form a lattice-
work and a more viscous compound. It is less immunogenic
than either Zyderm I or II and is more resistant to degrada-
tion. Zyplast is injected into the mid to deep reticular dermis
for treatment of deeper rhytides and contour defects, includ-
ing marionette lines and significant volume lip augmentation.
Unlike Zyderm I and II, with Zyplast, no overcorrection is
required. It is important to note that Zyplast is not recom-
mended for the glabellar region due to the possibility of
intravascular injection causing local tissue necrosis and a rare
risk of partial blindness.
Human collagen
Cosmoplast and Cosmoderm are human-derived collagen
products from long-standing fibroblast culture lines. They are
similar to bovine collagen in injection technique; however,
the significant advantage of human collagen includes the lack
of antigenicity which makes skin pretesting unnecessary.
checked; generally if the PT is under 2.0, then the risk of
hematoma or excessive bruising from injection is low. Herbal
medications (e.g. ginkgo biloba, St John’s wort, vitamin E,
garlic, ginseng, fish oil) that predispose to bleeding should be
held, if possible. Complete lists of herbal anticoagulants are
available in two references: by Broughton et al.47 and Dine-
hart and Henry.48 Preoperative ingestion of some homeo-
pathic medications (e.g. arnica) may reduce bruising, although
further investigations are needed to substantiate this effect.
Some physicians find that preoperative photos from the
frontal, oblique, and profile angles are useful for documenting
the results of an injection procedure. There are very few
absolute contraindications to prepackaged injectable fillers. A
patient with a known allergy to a specific filler would not be
a candidate for the procedure.
Injectable fillers
Some products, for example Zyderm, Zyplast, Cosmoderm,
Cosmoplast, Elevess, Prevelle Silk, contain local anesthesia,
obviating the need for local anesthesia. The pain of needle
sticks, even in products with local anesthesia, can still be
significant. The pain can be decreased by pretreatment with
topical anesthesia, such as Betacaine (Betacaine, Tampa, FL)
or LMX (Ferndale Laboratories, Inc, Ferndale, MI). Periop-
erative cold packs can help to decrease discomfort and bruise
formation. Infraorbital and mental nerve blocks, which
decrease sensation around the mid-face and upper and lower
lips, are particularly helpful. One per cent lidocaine without
epinephrine should be utilized for nerve block injections.
Robust local infiltration of anesthesia is not recommended as
it causes tissue swelling, which makes it difficult to assess the
end point of treatment. Swelling associated with local
anesthesia may also cause the patient undue anxiety about
the immediate outcome.
All make-up should be removed prior to treating the desired
sites. Areas to be treated should be prepared with an antisep-
tic such as isopropyl alcohol, Betadine, or benzalkonium chlo-
ride solution. For injectable fillers, patients should be seated
comfortably with a head support, either upright or at an angle
of no more than 45°. This position allows the physician to
appreciate the effects of gravity on soft tissue.
For soft tissue implants, anesthesia is infiltrated throughout
the region to receive the implant. Regional nerve blocks are
encouraged whenever possible with minimal local anesthesia
for vasoconstrictive field effect. Minimal sedation is recom-
mended when vigorous manipulation of soft tissues are
required for implantation. Perioperative antibiotics should be
given any time that a foreign body, such as a solid implant-
able device, is used. Antiviral prophylaxis should be given for
patients with a history of recurrent orolabial herpes virus
infection.
  TECHNICAL ASPECTS AND OVERVIEW
OF COMMONLY USED PRODUCTS
A larger variety of injectable dermal fillers is now available
worldwide. Regulation of use in some countries, notably the
US, limits their use by clinicians (Table 23.3).
Bovine collagen
Bovine collagen was the first device approved in 1981 for soft
tissue augmentation in the US; since this time over 1 million

369
Chapter 23  Soft Tissue Augmentation
Table 23.3  Injectable dermal fillers available worldwide
CATEGORY AND
MANUFACTURER
UNITS, SHELF
LIFE, STORAGE,
AND COST (US$)
AVAILABILITY
AND FDA
APPROVAL
COMPOSITION
AND MECHANISM
DURATION
OF EFFECT
INDICATIONS AND
CONTRAINDICATIONS (CI)
PRETESTING
RELATED
STUDIES
Superficial dermal fillers
Zyderm I
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

0.5-, 1.0-, 1.5-mL
syringe
Shelf life 3 years
Refrigerate
$156 for 1 mL
Worldwide
3.5% bovine dermal
collagen and lidocaine
3–4 months
For superficial rhytides, scars,
layering
CI: Hypersensitivity to bovine
collagen, lidocaine
Two skin tests
2–4 weeks apart
Wait 4 weeks
from time of
second skin test
to treatment
Klein49
Cosmoderm I
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

1-mL syringe
Shelf life 3 years
Refrigerate
$175–205
USA
Canada
Europe
South America
Asia
Human collagen and
plain lidocaine
3–4 months
For superficial rhytides, scars,
layering
CI: Lidocaine hypersensitivity
None
N/A
Hylaform Fineline
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

0.4-mL syringe
Shelf life 2 years
Refrigerate or room
temperature
$250–750
Europe
Canada
USA (pending)*
Hyaluronic acid derived
from rooster comb
3–6 months
For superficial rhytides, scars,
layering
CI: None
None
N/A
Restylane Fine Line
US: Medicis
Scottsdale, AZ
+1 602 808 8800

Europe: Q-Med
Laboratories
Uppsala, Sweden
+46 18 474 9000

0.4-mL syringe
Shelf life 18 months
Refrigerate or room
temperature
$250–500
Europe
UK
Canada
Australia
South America
USA (pending)*
Hyaluronic acid
(20 mg/mL) in small
gel particle size
derived from bacterial
fermentation
3–6 months
For superficial rhytides, scars,
layering
CI: None
None
Friedman
et al.50
Mid-dermal fillers
Zyderm II
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

0.5-, 1-mL syringe
Shelf life 3 years
Refrigerate
$150 for 1 mL
Worldwide
6.5% bovine dermal
collagen and plain
lidocaine
3–4 months
For mid-dermal rhytides, layering
CI: Hypersensitivity to bovine
collagen and lidocaine
Two skin tests
2–4 weeks apart
Wait 4 weeks
from time of
second skin test
to treatment
Klein49

370
Part 3  Aesthetic Surgical Procedures
CATEGORY AND
MANUFACTURER
UNITS, SHELF
LIFE, STORAGE,
AND COST (US$)
AVAILABILITY
AND FDA
APPROVAL
COMPOSITION
AND MECHANISM
DURATION
OF EFFECT
INDICATIONS AND
CONTRAINDICATIONS (CI)
PRETESTING
RELATED
STUDIES
Hylaform
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

0.7-mL syringe
Shelf life 2 years
Refrigerate or room
temperature
$145–199
Europe
Canada
USA
Hyaluronic acid (small
particle) derived from
rooster comb (5.5 mg/
mL)
3–6 months
For moderate rhytides, layering,
early folding, lip augmentation
CI: None
None
Pollack51
US Food and
Drug
Administration52
Restylane
US: Medicis
Scottsdale, AZ
+1 602 808 8800

Europe: Q-Med
Laboratories
Uppsala, Sweden
+46 18 474 9000

0.4-, 1-mL syringe
Shelf life 18 months
Refrigerate or room
temperature
$230–250
Europe
UK
Canada
Australia
South America
USA
Hyaluronic acid
(20 mg/mL) in small
gel particle size
derived from bacterial
fermentation
4–6 months
For moderate rhytides, folds, and
lips
CI: None
None
Pollack51
Olenius53
Narins54
Autologen
Collagenesis, Inc
Beverly, MA
Tel +1 978 23 9333
3-mL syringe
Shelf life ≤5 years with
manufacturer
$1200–4000 for 3 mL
Stored frozen with
manufacturer until
needed
Storage costs: free,
$500 for first ice, $100
additional ices
USA
Canada
Europe
Autologous human
collagen derived from
patient’s skin
Harvested during
cosmetic or
reconstructive
procedure
Processed by the
manufacturer
4–9 months
For rhytides, lip and fold
augmentation, sensitivity to
bovine collagen
CI: None
None
Sclafani and
McCormick5
Deep dermal fillers
Zyplast
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

1.0-, 1.5-, 2.0-, 2.5-mL
syringes
Shelf life 3 years
Refrigerate
$165 for 1 mL
Worldwide
3.5% bovine collagen
cross-linked with
glutaraldehyde and
plain lidocaine
3–5 months
For deep rhytides and folds, lip
augmentation, layering
CI: Hypersensitivity to bovine
collagen and lidocaine
None
Klein49
Table 23.3  Injectable dermal fillers available worldwide—cont’d

371
Chapter 23  Soft Tissue Augmentation
CATEGORY AND
MANUFACTURER
UNITS, SHELF
LIFE, STORAGE,
AND COST (US$)
AVAILABILITY
AND FDA
APPROVAL
COMPOSITION
AND MECHANISM
DURATION
OF EFFECT
INDICATIONS AND
CONTRAINDICATIONS (CI)
PRETESTING
RELATED
STUDIES
Cosmoplast
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

1.0-, 1.5-mL syringe
Shelf life 3 years
Refrigerate
$199–235 for 1 mL;
$270 for 1.5 mL
Worldwide
Human collagen
cross-linked with
glutaraldehyde and
plain lidocaine
3–4 months
For deep rhytides and folds,
off-label lip augmentation
CI: Lidocaine hypersensitivity
None
N/A
Hylaform Plus
Inamed Corp
Santa Barbara, CA
Tel +1 800 766 0171

0.7-mL syringe
Shelf life 2 years
Refrigerate or room
temperature
$165–219
Europe
Canada
USA
Hyaluronic acid
(medium particle)
derived from rooster
combs
3–6 months
For deep rhytides and folds, lip
augmentation
CI: None
None
US Food
and Drug
Administration56
Perlane
US: Medicis
Scottsdale, AZ
+1 602 808 8800

Europe: Q-Med
Laboratories
Uppsala, Sweden
+46 18 474 9000

0.7-mL syringe
Shelf life 18 months
Refrigerate or room
temperature
$250–500
Europe
UK
Canada
Australia
South America
USA (pending)*
Hyaluronic acid
(20 mg/mL) in large
gel particle size
derived from bacterial
fermentation
3–9 months
For deep facial lines, folds and
lips
CI: None
None
Friedman
et al.50
New-Fill/Sculptra
US: Dermik Laboratories
Berwyn, PA
Tel: +1 800 340 7502

Europe: Biotech Industry
SA
Luxembourg
Tel: +352 26 259 462

150-µg powder for
reconstitution with
3–5 mL sterile water
and 1 mL lidocaine
Room temperature
$480
Europe (New-Fill)
USA (Sculptra)
Poly-L-lactic acid in gel
carrier
Permanent
For rhytides of variable depth, lip
augmentation, lipoatrophy
(New-Fill)
For HIV-associated lipoatrophy
(Sculptra)
None
Berry57
Artecoll
Artes Medical, Inc
San Diego, CA
Tel +1 858 550 9999

com
0.5-mL syringe
Shelf life 2 years
Refrigerate
$400–900 per 1 mL
(4-pack of 1-mL
syringes filled with
0.5 mL product)
Europe
Canada
Mexico
South America
USA (pending)*
Homogeneous
polymethylmethacrylate
beads in 3.5% bovine
collagen suspension
Mixed with plain
lidocaine
Permanent
For deep rhytides and folds,
acne scars, lip augmentation
CI: Hypersensitivity to bovine
collagen and lidocaine
One skin test
30 days before
treatment
Pollack51

372
Part 3  Aesthetic Surgical Procedures
CATEGORY AND
MANUFACTURER
UNITS, SHELF
LIFE, STORAGE,
AND COST (US$)
AVAILABILITY
AND FDA
APPROVAL
COMPOSITION
AND MECHANISM
DURATION
OF EFFECT
INDICATIONS AND
CONTRAINDICATIONS (CI)
PRETESTING
RELATED
STUDIES
Dermalive
Derma Tech
Paris, France
Tel +33 1 49 24 06 86

0.8-mL syringe
Shelf life 3–5 years
Room temperature
$400–600
Europe
South America
Africa
Middle East
40% acrylic hydrogel
suspended in 60%
hyaluronic acid
Permanent
For deep rhytides
CI: Autoimmune diseases,
healing disorders, areas with
another filling material present
None
Bergeret-Galley
and Illonz58
Reviderm Intra
Rofil Medical International
Broda, The Netherlands
Tel +31 76 531 5670

1-mL syringe
$300–750
Europe
Canada
Flexible dextran
microbeads
suspended in
supercoiled, stabilized
hyaluronic acid (non-
animal origin)
12–18 months
For deep rhytides
CI: Keloids, autoimmune
diseases
None
Lemperle
et al.59
Variable dermal fillers
Juvéderm (18,24,30)
LEA Derm
Paris, France
Tel +33 1 49 24 06 86

Two 0.6-mL syringes
$250–500
Europe
USA (pending)*
Viscoelastic hyaluronic
acid gel (18 mg/g,
24 mg/g, or 30 mg/g)
3–6 months
For superficial (18), mid-level
(24), and deep (30) rhytides, lip
augmentation, layering
CI: Autoimmune diseases
None
Bergeret-Galley
and Illonz58
Fascian
Fascia Biosystems LLC
Beverly Hills, CA
Tel +1 888 3 FASCIA

0.25-, 0.5-, 1.0-,
2.0-mm particulate
size in 80-µg, 3-mL
syringes
Hydrated to 3 mL with
saline or lidocaine
Shelf life 2 years
Room temperature
$500–2000
Worldwide
Injectable irradiated
human cadaveric
preserved particulate
fascia lata (varying
particle size)
3–6 months
For rhytides of variable depth (by
particulate size), acne scars, lip
augmentation
CI: Hypersensitivity to polymyxin
B sulfate, bacitracin, gentamicin
None
Burres60
Hylan Rofilan Gel
Rofil Medical International
Broda, The Netherlands
Tel +31 76 531 5670

1-mL syringe
Shelf life 2 years
Refrigerate or room
temperature
$250–500
Europe
Canada
USA (pending)*
Viscoelastic stabilized
non-animal hyaluronan
gel
3–6 months
For rhytides of variable depths,
lip augmentation
CI: None
None
N/A
Table 23.3  Injectable dermal fillers available worldwide—cont’d

373
Chapter 23  Soft Tissue Augmentation
CATEGORY AND
MANUFACTURER
UNITS, SHELF
LIFE, STORAGE,
AND COST (US$)
AVAILABILITY
AND FDA
APPROVAL
COMPOSITION
AND MECHANISM
DURATION
OF EFFECT
INDICATIONS AND
CONTRAINDICATIONS (CI)
PRETESTING
RELATED
STUDIES
Isolagen
Isolagen
Houston, TX
Tel +1 713 780 4754

3-mm punch biopsy
sent to lab for
fibroblasts culture
Frozen and stored for
future culturing
Live cultured
fibroblasts injected
≤48 h of leaving lab
$1000–1500
Europe
USA
Australia†
Cultured autologous
human fibroblasts
Unclear
(months or
years)
For rhytides, acne scars, lip
augmentation
CI: None
One test dose 2
or more weeks
before treatment
Watson and
Lask61
Subdermal fillers
Cymetra
Life Cell Corp
Branchburg, NJ
Tel +1 908 947 1100

330 mg dried acellular
particulate dermal
matrix in 5-mL syringe
Reconstituted to 1 mL
Shelf life 2 years
Room temperature
$600–900 per 1 mL
Worldwide
Micronized acellular
human cadaveric
dermis
3–6 months
For deep rhytides, acne scars, lip
augmentation
CI: Hypersensitivity to
gentamicin, collagen vascular
disease, avascular or infected
recipient site
None
N/A
Radiesse
Bioform
Franksville, WI
Tel +1 262 835 9800

com
1-mL syringe
Shelf life 2 years
Room temperature
$500
Europe
USA§
Calcium
hydroxylapatite
microspheres
suspended in aqueous
polysaccharide gel
9 months–5
years
For deep rhytides and folds, lip
augmentation, acne scars,
lipoatrophy
CI: None
None
Drobeck et al.62
Subdermal implants
Alloderm
Life Cell Corp
Branchburg, NJ
Tel +1 908 947 1100

Freeze-dried sheets of
variable size/thickness
1 × 2 cm to 4 × 12 cm
Shelf life 2 years
Room temperature
$135–1500 per sheet
Worldwide
Acellular human
cadaveric dermis
12–24 months
For deep rhytides, acne scars, lip
augmentation, skin grafting,
rhinoplasty
CI: Hypersensitivity to
gentamicin, collagen vascular
disease, avascular or infected
recipient site
None
Sclafani et al.63
Advanta
Atrium Medical Corp
Hudson, NH

com
Implants of variable
shape and size with
or without preattached
trocars
Shelf life 5 years
Room temperature
$310–420 per implant
Europe
Canada
USA
Dual porosity e-PTFE
Permanent
(easy to remove
if placed within
90 days)
For nasolabial folds, marionette
lines, lips
CI: Infection at recipient site
None
Truswell64

374
Part 3  Aesthetic Surgical Procedures
CATEGORY AND
MANUFACTURER
UNITS, SHELF
LIFE, STORAGE,
AND COST (US$)
AVAILABILITY
AND FDA
APPROVAL
COMPOSITION
AND MECHANISM
DURATION
OF EFFECT
INDICATIONS AND
CONTRAINDICATIONS (CI)
PRETESTING
RELATED
STUDIES
Gore-Tex (strings,
strands)
Gore Advanced
Technologies Worldwide
Newark, DE
Tel +1 410 506 7787 or
888 914 4673 (US)

Tubes and strings of
variable size
Shelf life 5 years
Room temperature
$300–350 per implant
Worldwide
e-PTFE (expanded
polytetrafluoroethylene)
Permanent
(easy to
remove)
For deep rhytides, lip
augmentation
CI: Infection at recipient site
None
Maas &
Denton65
Softform/Ultrasoft
Tissue Technologies
San Francisco, CA
Tel +1 415 771 7960

tissuetechnologies.com
Tubes of variable
length and thickness
Shelf life 5 years
Room temperature
$300–500 per implant
Worldwide
Tubular e-PTFE
Permanent
(easy to
remove)
For deep rhytides, lip
augmentation
CI: Infection at recipient site
None
Miller et al.66
Autologous grafts
(fat, dermis, dermis-fat,
tendon, scar, fascia)
$2000–5000 per
treatment
N/A
Fat with or without
dermis, tendon, scar or
fascia
Harvested from the
patient
Fat 6–24
months; tendon
potentially
permanent;
dermis
unknown;
fascia unknown
For lipoatrophy, lip augmentation,
folds
CI: None
N/A
Krauss67
*Pending FDA approval in the USA.
†Australia currently not accepting biopsy specimens from new patients until FDA approved.
§Available off-label in the USA.
Table 23.3  Injectable dermal fillers available worldwide—cont’d

375
Chapter 23  Soft Tissue Augmentation
punctures are generally made, along or adjacent to the wrinkle
being treated, with small aliquots of material injected through
each puncture site. Gentle massage can mold the collagen at
the treatment site to ensure that the final result is even and
smooth. For deeper rhytides, the needle may be placed per-
pendicular to the skin surface. Care must be taken to ensure
placement at the base of the furrow rather than at the shoul-
der of overhanging redundant skin. With the threading tech-
nique, a longer needle may be used and advanced for some
distance under the rhytide with injection as the needle is
withdrawn. Threading is utilized more routinely with
hyaluronic gels as well as more viscous products, including
Zyplast and Cosmoplast.
If a patient is prone to bleeding, an ice pack should be
applied for 5 minutes postoperatively. Injections at the
Cosmoplast and Cosmoderm contain lidocaine, which
decreases discomfort associated with injection.
The mechanism of manufacture of these products includes
expanded human fibroblast cultures that are placed onto a
nylon mesh and placed inside special bottles, called bioreac-
tors, which simulate in-vivo conditions. Cells are grown until
the nylon mesh is covered and tissue develops. Tissue is then
removed from the bottles and tested for pathogens and con-
taminants. Collagen is isolated from the tissue, treated with
viral inactivation, and purified for injection.
For the injection of Cosmoplast and Cosmoderm, the skin
should be held taut by the free hand with the patient’s head
supported by a back/neck rest. The needle should be angled
parallel to the skin for superficial lines and wrinkles with a
gradually greater angle for deeper lines and grooves. Serial
A
B
Figure 23.3  (A) Pre and (B) post e-PTFE implant (Advanta) to upper and lower lips for volume restoration. (Courtesy of C William
Hanke MD.)
A
B
Figure 23.4  (A) Pre and (B) post ePTFE implant (Advanta) to upper and lower lips for volume restoration. (Courtesy of C William
Hanke MD.)

376
Part 3  Aesthetic Surgical Procedures
chains form highly hydrated random coils that entangle and
interpenetrate each other, producing highly elastoviscous
solutions.37–39
The amount of hyaluronic acid in the skin progressively
decreases with age,76 and loss results in reduced dermal
hydration and increased skin folding.77 With its unique elas-
toviscosity, immunologic compatibility, and natural role as a
structure-stabilizing, space-occupying, cell-protecting con-
nective tissue matrix filler, hyaluronan would at first sight
appear to be an ideal material for soft tissue augmentation.30
However, with a tissue half-life of only 1–2 days, hyaluronan
turns over too quickly to be of value in this regard.78 Exog-
enous hyaluronic acid is rapidly cleared from the dermis and
degraded in the liver to carbon dioxide and water. For this
reason, investigators sought modifications of hyaluronan that
would render it more stable following injection while preserv-
ing its properties of biocompatibility.
Stabilized hyaluronic acid gel fillers, first evaluated in 1998,
provide good efficacy with a considerably longer duration of
action than the first generation of dermal fillers, namely
bovine and human collagen (Figs 23.5–23.9). The first inject-
able stabilized hyaluronic acid filler approved by the FDA, a
non-animal stabilized hyaluronic acid (NASHA) 100 000 gel
particles/mL filler, was introduced in the US in 2003 and has
been shown to be safe and effective while providing a much
medial side of the nasolabial fold and marionette lines should
be performed to avoid further heaviness laterally. Crow’s feet
should be approached with caution to avoid overfilling and
lumpiness. The orbital area is highly prone to bruising; placing
the needle tip just barely below the skin before injecting and
thorough massage will help to prevent bruising.
Hyaluronic acid
Hyaluronic acid (hyaluronan) is a naturally occurring gly-
cosaminoglyan biopolymer which is a component of all con-
nective tissues. It exhibits no species or tissue specificity
because the chemical structure of the polysaccharide is
uniform throughout nature. Therefore, there is no potential
for immunologic reactions to hyaluronan in humans. In
nature, the primary biologic function of hyaluronan is to
provide stabilization to the intercellular structures and to
form the elastoviscous fluid matrix in which collagen and
elastic fibers become embedded.74 In addition, the hyaluro-
nan matrix regulates cell movement and functions, and plays
a role in developing and remodeling tissues.75 Hyaluronan has
a very large average molecular weight (4–5 million daltons in
all human tissues) and consists of repeating disaccharides of
D-glucuronic acid and N-acetyl-D-glucosamine arranged in
long, unbranched polyanionic chains.37–39 These molecular
A
B
Figure 23.5  (A) Pre and (B) post hyaluronic acid (Restylane) injections to upper and lower lips for lip augmentation. (Courtesy of C
William Hanke MD.)
A
B
Figure 23.6  (A) Pre and (B) post hyaluronic acid (Restylane) injections to upper and lower lips. (Courtesy of C William Hanke MD.)

377
Chapter 23  Soft Tissue Augmentation
received treatments at 2-week intervals to achieve ‘optimal’
results. The total number of treatments ranged from 1 to 3
with a mean of 1.4 for both fillers. Once this outcome was
achieved, patients were considered to be at ‘baseline.’ Assess-
ments at 6 months after baseline indicated that hyaluronic
acid gel was superior in 56.9% and 62.0% of patients, respec-
tively, while Zyplast was rated as superior in 9.5% and 8.0%
of patients, respectively. Additionally, the mean total injec-
tion volume required to achieve optimal results was 1 mL of
Restylane compared to 1.6 mL of Zyplast.
In an analogous study performed comparing Perlane with
Zyplast for the treatment of nasolabial folds,80 Perlane, a
similar hyaluronic acid-based filler to Restylane, demon-
strated similarly significantly greater improvement in wrinkle
severity as well as increased duration of correction. The con-
centration of hyaluronic acid in Perlane is the same as Resty-
lane (20  mg/mL); however, the particle size of Perlane is
much larger than that of Restylane (Perlane 700–1000 µm vs
Restylane 250–500 µm). A total of 68 patients with promi-
nent nasolabial folds were randomized to intradermal treat-
ment with NASHA gel (Perlane) and bovine collagen
(Zyplast) on contralateral sides of the face. According to
investigator-based Wrinkle Severity Rating Scale assessments
at 6 and 9 months after baseline, Perlane was superior in
50.0% and 48.8% of patients, respectively, whereas Zyplast
was superior in 10.3% and 14.0% of patients, respectively (P
< 0.0004). ‘Optimal cosmetic result’ was achieved with
nearly half the volume of Perlane relative to Zyplast (mean
1.2 mL vs 2.1 mL). Local injection-site reactions (redness,
swelling, pruritus, and induration) were less frequent with
Perlane than with Zyplast. Thus, Perlane offered significantly
longer-lasting aesthetic improvement than Zyplast.
Similarly, Juvéderm Ultra and Ultra Plus injectable gel
(hyaluronic-based filler) were compared with Zyplast in a
study by Pinsky et al.81 for the treatment of rhytides in the
nasolabial folds. In this multicenter study approved by the
FDA, subjects were randomized to treatment with Juvéderm
Ultra or Ultra Plus in one nasolabial fold and Zyplast collagen
in the other. After optimal correction was achieved (treat-
ment plus up to two touch ups at 2-week intervals), effective-
ness was assessed on a 5-point scale through the 6-month
study period. An additional poststudy visit provided long-
term effectiveness data. A total of 292 subjects were rand-
omized and treated, with 146 in each cohort. Clinically
longer duration of action than that of collagen fillers. The use
of hyaluronic acid gel fillers has increased considerably since
that time, with several other stabilized hyaluronic acid gel
fillers introduced to the US market. They are currently the
most commonly used injectible fillers by a wide margin.
According to the American Society for Aesthetic Plastic
Surgery, hyaluronic acid gels accounted for approximately
80% of the nearly 2 million soft tissue filler injections per-
formed in 2006.
The prolonged efficacy of stabilized hyaluronic acid gel
fillers is attributed to the cross-linking between hyaluronic
acid polymers and to the gradual absorption of water as the
filler degrades. Some data suggest that stabilized hyaluronic
gels stimulate collagen synthesis and inhibit collagen break-
down, which may contribute to their effectiveness and long
duration of action.79 Despite their long duration of action,
retreatment is typical because the efficacy of the filler declines
as it is naturally resorbed by the body.
Key publications: hyaluronic acid
In the pinnacle study that earned Restylane its FDA approval
for the treatment of nasolabial folds, Restylane was compared
to Zyplast.54 One hundred and thirty-eight patients were
randomized to receive either Restylane or Zyplast and
A
B
Figure 23.7  (A) Pre and (B) post hyaluronic acid (Restylane) has been injected over the periosteum to correct infraorbital hollows.
(Courtesy of C William Hanke MD.)
Figure 23.8  Preoperative markings before hyaluronic acid
(Restylane) injections to nasolabial folds. (Courtesy of C William
Hanke MD.)

378
Part 3  Aesthetic Surgical Procedures
In an Italian study of the efficacy of Restylane,84 158
patients received intradermal Restylane injection for correc-
tion of facial wrinkles/folds or for lip augmentation. Patients
reported a 73.4% incidence of marked or moderate improve-
ment after 8 months, independent of treatment area. Treat-
ment reactions of a localized and transient nature occurred
after 12.5% of treatments. The most commonly reported
were bruising, tenderness, discomfort, edema, and erythema
at the treatment site. Thirteen patients complained, particu-
larly after lip augmentation, of intermittent swelling of the
implanted material.
Kono et al.85 performed a comparative split-face study of a
single cross-linked hyaluronic acid (SCHA; Restylane) versus
a double cross-linked hyaluronic acid (DCHA; Puragen) in
the treatment of glabellar lines. Glabellar lines rather than
nasolabial folds were utilized in this study by the authors as
they reported it is difficult to define complete improvement
of nasolabial folds whereas with glabellar lines, it is signifi-
cantly easier to achieve complete rhytide effacement. At 6,
9, and 12 months post treatment, a higher proportion of
patients showed over 50% improvement with Puragen than
with Restylane. At 12 months post treatment, Puragen was
considered superior in 70% of patients whereas Restylane was
only superior in 10% of patients. Both SCHA and DCHA are
equally effective in producing an optimal cosmetic result in
effacement of glabellar lines; however, DCHA provides a
more durable aesthetic improvement in the treatment of
glabellar lines.
A recent study by Narins et al.86 presented the results of
duration of correction with hyaluronic acid, with an 18-month
analysis of the efficacy of Restylane comparing two different
retreatment protocols. This multicenter, randomized, evalu-
ator-blinded study enrolled 75 patients with moderate to
severe nasolabial folds. Patients were randomized to retreat-
ment of one nasolabial fold at 4.5 months and the contralat-
eral fold at 9 months. Wrinkle Severity Rating Scale scores
improved significantly (P < 0.001) from baseline, with mean
improvements ranging from 1.1 to 1.7 grades. Almost all
patients (97%) responded satisfactorily. The improvements
seen after initial treatment with NASHA 100 000 gel parti-
cles/mL filler persisted for up to 18 months with one retreat-
ment. Interestingly, the duration of correction was equivalent
significant mean wrinkle correction (= 1 point improvement)
was still evident at >9 months for both Juvéderm formula-
tions but not for Zyplast. At >9 months, 75% of Juvéderm
Ultra- and 81% of Juvéderm Ultra Plus-treated nasolabial
folds maintained a clinically significant correction. Moreover,
78% of nasolabial folds treated with Juvéderm Ultra Plus had
a clinically significant improvement beyond 1 year. Local
treatment site reactions were comparable for Juvéderm and
Zyplast. Next-generation hyaluronic acid dermal fillers can
be reliably expected to provide long-term correction, with
Juvéderm Ultra lasting more than 9 months and Juvéderm
Ultra Plus lasting for a year or more.
In 2005, Rao and colleagues82 reported a split-face com-
parison study of two hyaluronic acid derivatives, Hylaform
and Restylane in the treatment of nasolabial folds. Hylaform
is an animal-sourced, single cross-linked hyaluronic acid,
where the concentration is 5.5  mg/mL. Each subject was
randomized to receive Restylane 0.7 mL to either the right
or the left nasolabial fold and Hylaform 1.0 mL to the con-
tralateral side. The average patient satisfaction score was 3 of
5 for Hylaform and 3.78 of 5 for Restylane. The blinded,
independent reviewer panel attributed an average improve-
ment score of 2.86 of 5 for Hylaform and 3.78 of 5 for
Restylane.
Similarly, a randomized controlled trial by Carruthers et
al.83 compared the efficacy and safety of a NASHA gel
(Restylane Perlane) with that of a hylan B gel (Hylaform), a
cross-linked hyaluronic acid from chicken combs, for treat-
ment of nasolabial folds. While the two products were equally
effective in producing an optimal cosmetic result, fewer
treatment sessions were required with Restylane Perlane. At
6 months post treatment, a higher proportion of patients
showed a 1-grade improvement in Wrinkle Severity Rating
Scale score with Restylane Perlane (75%) than with Hyla-
form (38%). Restylane Perlane was considered superior in
64% of patients, whereas Hylaform was superior in 8% of
patients. Local injection-site reactions were generally tran-
sient and mild or moderate in intensity and were no more
frequent after Restylane Perlane treatment than after Hyla-
form treatment. Restylane Perlane provided a more durable
aesthetic improvement than Hylaform and offered accepta-
ble patient tolerability.
A
B
Figure 23.9  (A) Pre and (B) post hyaluronic acid (Restylane) injections to correct nasolabial folds. (Courtesy of C William Hanke MD.)

379
Chapter 23  Soft Tissue Augmentation
each site. The goal is to fill the defect in the dermis such that
bleeding is minimized and the resulting visible contour is
smooth and atraumatic.
Some injectors prefer to inject while advancing the needle
into the skin, and some inject as they withdraw the needle
after having previously advanced it to the farthest point of
injection.91–93 Both methods can provide satisfactory and safe
correction. During injection, an effort should be made to
provide continuous pressure to the plunger and to smoothly
advance or withdraw the needle at a constant rate; these
precautions reduce the risk of unintended bolus injections
that can cause contour irregularities and nodules. Needles
may be inserted at a shallow, near-parallel angle to the skin
(0–45°) or at a steep, near-perpendicular angle (46–90°). The
angle of the needle will determine the depth of correction,
and thus it is important that the needle tip be at the correct
depth when injectant is delivered.
Hyaluronic acid injectables can be used in conjunction with
other injectable prepackaged fillers. Fillers that are more
appropriate for superficial correction can be layered above
(e.g. Cosmoderm, Cosmoplast, Zyderm, Zyplast, placed in
the papillary dermis) hyaluronic acid derivatives, and fillers
that are more appropriate for deeper correction can be
layered below (e.g. in the deeper dermis or subcutis). Addi-
tionally hyaluronic acid derivatives themselves can be layered,
with some (e.g. Perlane, Juvéderm Ultra Plus) placed deeper
and some (e.g. Restylane, Juvéderm Ultra) more superficially.
Very superficial placement can also be achieved by using a
finer needle, commonly of 32 gauge. As novel fillers are intro-
duced, it should be verified that they can safely be combined
with hyaluronic acid derivatives before they are used in such
adjacency.
For the treatment of nasolabial folds, the triangular-shaped
concavity at the upper aspect (isthmus of the lip) should be
treated with a fan-like array of 2–3 threads of implantation,
to ensure uniform filling of this area.91–94 The lower portion
of the nasolabial fold is treated with threads of injected mate-
rial, placed one below the next (always staying medial to the
crease of the nasolabial fold) in a continuous row. For a par-
ticularly wide nasolabial fold, two parallel rows of implanta-
tion may be made, with gentle massage after each thread.
Treatment of marionette lines, oral commissures, and glabel-
lar frown lines can be performed in the same manner. As was
demonstrated in the study by Carruthers & Carruthers87 for
glabellar frown lines, combination treatment with botulinum
injections can be particularly advantageous.
For lip enhancement, the technique should include first
defining the lip margin by gently injecting along the vermilion
border.95–97 A row of successive aliquots of hyaluronic acid
should be administered in 5–6 treads for the lip margin (total
volume of 0.3–0.4 mL should be used for lip definition). The
remainder is injected, with the threading technique, along the
wet line of the red lip (the line at which the dry outer mucosa
meets the moist inner mucosa). Spreading is noted as the
hyaluronic acid spreads through the plane of injection. Gentle
massage should be performed throughout the treatment to
ensure uniformity and smoothness of the correction.
For treatment with hyaluronic acid products under the eyes
and in the glabellar space, injections should be performed
slowly, with limited injectant, to avoid intravascular injection
that can result in vascular occlusion as well as bruising.98,99
Significant edema can occur for several days after injection,
and patients should be apprised of this prior to injection.
for retreatment at 4.5 and 9 months. The authors postulated
that one of the reasons the level of correction was the same
with earlier or late retreatment was that earlier retreatment
may slow the rate of resporption of the gel, by maintaining
tissue expansile tension. Fibroblasts that are stretched by
mechanical tension may stimulate new collagen production
and inhibit collagen breakdown. These effects on stimulation
of collagen production may persist longer than the space-
filling effects of the injected gel.
One of the unique treatment approaches with fillers which
has evolved in the last 5 years is the combination of dermal
fillers with botulinum toxin to treat glabellar rhytides as well
as rhytides of the lower half of the face. A study by Carru-
thers & Carruthers87 compared the efficacy of BTX-A com-
bined with intradermal NASHA, Restylane, with the efficacy
of Restylane alone in females with moderate to severe glabel-
lar rhytides. They performed a prospective randomized study
of 38 subjects with moderate to severe glabellar rhytides,
where half of the subjects were treated with BTX-A and
Restylane and the other half with Restylane alone. By com-
parison with the Restylane-alone group, the BTX-A plus
Restylane group showed a better response both at rest and
on maximum frown, and this response was maintained for a
significantly longer duration of correction. The median time
for return to preinjection furrow status occurred at 18 weeks
in the Restylane-alone group compared with 32 weeks for the
BTX-A plus Restylane group. Thus, significantly greater dura-
tion of correction of glabeller rhytides can be achieved
through combination treatments with botulinum toxin and
hyaluronic acid relative to hyaluronic acid alone.
Injection technique
In general, hyaluronic acid products are injected into the
dermis or close to the dermal–subcutaneous junction.88–90
Injections high in the skin, near the interface of the epidermis
and papillary dermis, are usually avoided as superficial injec-
tion technique can result in visible white, yellow, or blue
nodules, which may be persistent. Injections deep into the
subcutaneous fat may result in decreased efficacy of correc-
tion with the subsequent need for larger-volume injections.
One injection technique for hyaluronic acid is the linear
threading technique.91–93 Injections are administered using a
threading technique with the needle advanced along the line
to be treated with injection made with constant pressure on
the syringe plunger as the needle is withdrawn and advanced.
The needle should be kept superficial in the dermis, with the
goal being to inject in the mid-dermal space. If injected too
superficially, a bluish discoloration will be seen through the
skin (Tyndall effect) which may require needle puncture to
extrude the product. With injection, the material will be
noted to spread through the upper dermal tissue plane, pro-
viding a natural-appearing ‘plumping’ of the treated area.
Successive threads of injected material are placed adjacent to
previous injections until the entire fold or wrinkle has been
treated. After injection, massage of the product along the line
of injection can be performed to ensure that the implant is
smooth and uniform.
Some injectors prefer to deliver injectant in a continuous
linear stream in the threading technique as described
above.91–93 Another technique, the linear puncture technique,
involves reinserting the needle a few times via multiple pricks
along the length of the defect, with a small bolus injected at

380
Part 3  Aesthetic Surgical Procedures
Significant overcorrection is not necessary with injectable
hyaluronic acid derivatives and should be avoided. However,
all facial anatomic sites, and especially the lips and periocular
space, are subject to some immediate swelling upon injection.
This postinjection swelling should be taken into account when
determining the appropriate degree of correction. In general,
undercorrection is preferred over overcorrection as patients
can return for a touch-up procedure to address any incom-
pletely treated areas. Maintenance of symmetry is important,
regardless of how much material is delivered. The physician
should always check to ensure that approximately equal
amounts are placed into corresponding structures on each side
of the face. At the same time, given that most anatomic facial
structures are slightly asymmetric at baseline, visual inspec-
tion after initial correction is the most important procedure
to verify that both sides look comparably filled.
One uncommon but significant undesired effect that is
related to placement of filler materials is injection-site necro-
sis.98,99 Inadvertent injection of the angular artery (nasolabial
fold area) or supratrochlear artery (glabellar area) can induce
an ischemic response with violaceous bluish–grey discolora-
tion, pain, erosion, and ulceration.98,99 Resolution without
significant scarring is routine except with large-volume injec-
tions and resultant full-thickness necrosis. Treatment with
immediate application of nitroglycerin paste may help to
reduce the size of the area affected by ischemia. Treatment
of impending necrosis may be assisted by reviewing key arti-
cles in the literature on early signs of filler-induced necrosis
and appropriate treatment modalities.104–106 Injections at the
glabella with hyaluronic acid derivatives have not been associ-
ated with retinal artery thrombosis, an embolic phenomenon
reported in the distant past following use of injectable
collagen.
Nodule formation after hyaluronic acid injections manifests
as a blanched, bluish or white papule, or as a palpable lump
of visible injectant.107 Lowe et al.108 reported the results of a
retrospective cohort study of 709 patients treated with
Restylane and Hylaform between 1996 and 2000. They
found that both substances were associated with sporadic
cases of injection site skin nodules. Nodules appear to emerge
immediately after treatment, likely a result of superficial
injection or excessive injection to a given location. Alterna-
tively, they may emerge several weeks later, as a result of
local inflammatory or granulomatous foreign body reactions.
Nodules can be treated by (off-label) injection of hyaluroni-
dase. Most nodules will eventually remit with time in the
absence of treatment. The most conservative management
entails gentle at-home massage, reassurance of the patient,
and close follow up. However, this conservative approach to
managing nodules presupposes that there is no associated
hypersensitivity response.
A few cases of local hypersensitivity after injections of
hyaluronic acid derivatives have been reported; these may be
due to residual proteins, given that hyaluronic acid is derived
either from cocks’ combs of domestic fowl or fermentation
using streptococci bacteria.109 Red indurated bumps over
areas treated with hyaluronic acid derivatives may appear up
to 3 months after treatment.104 Lasting several months, they
usually clear up spontaneously, but remission may be acceler-
ated by topical application of tacrolimus ointment, intrale-
sional steroids, or incision and drainage.104
Itch, acne, and herpes labialis have been reported in a few
cases and may be associated with inadvertent skin irritation
Laser resurfacing procedures are often performed in com-
bination with hyaluronic acid injections. Patients receiving
injections of hyaluronic acid derivatives may also subse-
quently undergo laser, light, and energy treatments over the
same area. Preliminary data suggest that energy treatments
over areas previously injected with hyaluronic acid do not
disrupt the filler or cause adverse events like bruising, nodule
formation, or thermal injury;100 however, additional investiga-
tion into the impact of non-ablative and ablative traditional
and fractionated resurfacing on the efficacy and duration of
hyaluronic acid derivatives are needed.
Safety and adverse effects of hyaluronic acid
Injectable hyaluronic acid derivatives are currently the most
widely used class of soft tissue augmentation materials in the
US. Despite this, there are few reports of adverse events.
While individual formulations differ slightly, minor and
serious adverse events are similar across formulations.
Short-term effects of injectables include discomfort upon
injection as well as postinjection skin redness, swelling, and
bruising.101–103 Thicker needles tend to injure more tissue
upon injection, and thus to cause greater injection discomfort.
Perioral injections, injections of the lip, and injections of the
periocular skin, especially the lower eyelids, are among the
most painful due to the increased sensory innervation at these
sites. Among the mechanisms that can be used to decrease
injection pain are preinjection application of ice, vibration
devices, topical anesthetics, local anesthetic infiltration, and
nerve blocks. It should be noted that a small subset of sensi-
tive patients find nerve blocks more distressing than filler
injections without anesthesia, and thus these patients should
be offered other anesthetic techniques in conjunction with
dermal filler injections.
Redness and swelling tend to occur immediately after injec-
tion; they are local effects of injection trauma as well as the
hygroscopic properties of the filler being used. Redness will
usually persist for a few hours to overnight, but swelling can
last up to 1–2 days. When the lip is injected, swelling may
be more noticeable and usually lasts 1–3 days. In general, the
greater volume of hyaluronic acid that is injected, the greater
the duration and extent of swelling. Minimizing the number
of skin punctures and applying ice packs for 5–10 minutes
post injection may reduce redness and swelling. Make-up
with a greenish tint is also helpful in camouflaging red discol-
oration.
Bruising is an inadvertent and occasional effect of soft
tissue augmentation. Causes of bruising include needle-
associated perforation of vessels and crushing vessels second-
ary to the pressure of the injected substance. In patients
taking aspirin and other platelet disaggregating agents, bruis-
ing may be delayed. Resolution may be gradual, over approx-
imately 5–10 days. Side lighting and cleansing the skin with
alcohol pads can help to highlight bluish dermal vessels
prior to injection. When bruising does occur, pressure and
ice can both help to decrease the extent of the bruise.
Common locations for bruises are the perioral rhytides and
the lower eyelids, the upper third of the nasolabial fold, the
upper lip, and the lateral edge of the lower lip. Another
adverse effect is frank bleeding, which can result when a
vessel of moderate caliber is perforated by an injection needle.
Firm pressure for 1–5 minutes will usually control local pin-
point bleeding.

381
Chapter 23  Soft Tissue Augmentation
at 6 months and between 12 and 24 months after injection.
Treatment satisfaction was based on a scale of 1 (least satis-
fied) to 5 (most satisfied) using subjective self-evaluation of
preoperative photographs. The average satisfaction rating at
6 months was 3.94. Eighty-nine per cent of patients at 6
months and 74% at 12 to 24 months stated that they would
use the treatment again. The only side effect observed was
the development of easily treated nodules, reported by 42 of
338 lip mucosa augmentation subjects (12.4%) and 6 of 163
subjects (3.7%) who had treatment for radial lip lines. Inter-
estingly, the proportion of subjects with lip nodules decreased
to 8.8% when the implant volume was decreased, suggesting
that lower-volume injections in the lip are needed to prevent
nodule formation.
Moers-Carpi et al115 in 2007 conducted a multicenter,
blinded, randomized study comparing patient satisfaction,
efficacy, and durability of CaHA gel versus hyaluronic acid
for correction of nasolabial folds through 12 months after
initial injection and a 4-month touch up. Two hundred and
five patients were randomized to receive either CaHA gel or
hyaluronic acid for treatment of nasolabial folds. More CaHA
gel-treated patients were satisfied or extremely satisfied than
the hyaluronic acid-treated patients. At 8 months, signifi-
cantly more CaHA gel-treated nasolabial folds were improved
on the Global Aesthetic Improvement Scale than those
treated with hyaluronic acid. In addition, the volume of
CaHA required for full correction (2.2  mL) was signifi-
cantly lower than that for the three hyaluronic acid materials
(2.9–4.8  mL; P < 0.005). CaHA was more effective and
longer lasting than hyaluronic acid in maintaining nasolabial
augmentation.
Smith et al.116 reported a comparative trial in 2007 with
CaHA gel versus human collagen in the treatment of nasola-
bial folds. Seventeen subjects with moderate to deep nasola-
bial folds were enrolled and patients received CaHA on one
side of the face and human collagen on the other, and up to
two touch-up injections were permitted. Seventy-nine per
cent of subjects had superior improvement on the CaHA
side through 6 months (P < 0.0001). For optimal correction,
significantly less volume and fewer injections were needed
for CaHA than for collagen (P < 0.0001). Adverse event
rates were comparable, with some increase in bruising and
edema for CaHA-treated sides. Adverse event duration
was similar for both groups and generally resolved within
14–21 days.
Sadick et al.117 reported the results of a 47-month study of
the safety and efficacy of CaHA for soft tissue augmentation
in both the nasolabial folds and other facial sites. One hunderd
and two patients received 1.0 mL of CaHA per session and
12 received 2.0 mL per session. In terms of product safety,
of 113 patients, only 7 reported minor adverse events that
were short term and resolved within 1 month, including:
transient ecchymosis (3); non-granulatomous submucosal
nodules of the lip (2); and inflammation and edema (2). On
a scale of 1 to 5 (1 = unsatisfactory; 5 = excellent), the mean
patient evaluation score for look and feel of the implant
immediately after injection was 4.6; the mean physician
scores for the look and feel of the implant were 4.5 and 4.6,
respectively. At the 6-month follow-up visit, patients’ mean
ratings of the look and feel of the implant were 4.8 and 4.9,
and the mean physician’s ratings were 4.5 and 4.9. Both the
high efficacy and the high patient satisfaction (90% of patients
reported very good or excellent results) reported in this study
during the injection process. To avoid herpes outbreaks asso-
ciated with hyaluronic acid injections, particularly for injec-
tions into the lip or perioral region, many recommend
antiviral prophylaxis regimens prior to and immediately fol-
lowing injections. In addition, for acne flare-ups or bacterial
infections post injection, treatment with oral antibiotics is
essential to promote rapid healing, ensure product duration
of correction, and to prevent scarring.
Calcium hydroxylapatite
Radiesse (Bioform, Franksville, WI) is composed of calcium
hydroxylapatite (CaHA) microspheres suspended in a
polysaccharide carrier which holds the microspheres in place
until resorbed and fibroblast-driven collagenation takes
place.93,110 Injectable CaHA consists of a 30% concentration
of 25- to 45-µm CaHA spherical particles suspended in a
sodium carboxymethylcellulose gel.93 CaHA microspheres
remain in place to act as a scaffold that promotes soft tissue
ingrowth. Fibroblasts lay down a collagenous extracellular
matrix.93 As the matrix is deposited, the implant becomes
integrated into the surrounding soft tissue, which provides
for its long-lasting effects.93 Implant palpability diminishes
over time as CaHA is integrated into the surrounding
soft tissue.93 It is FDA approved for two facial soft tissue
augmentation indications: treatment of moderate to severe
facial lines and folds, such as nasolabial folds, and for correc-
tion of facial soft tissue loss resulting from HIV-related
lipoatrophy.93
In previous studies of soft tissue augmentation in facial
applications, Radiesse has been demonstrated to last up to a
year or more in most patients.111,112 Collagen proliferation
combined with the slow breakdown of the CaHA is believed
to account for the prolonged effects observed when CaHA is
utilized for soft tissue augmentation.112 Over many months
to years, the spherical CaHA particles themselves are gradu-
ally phagocytosed and degraded via normal body metabolic
processes and eliminated as calcium and phosphate ions via
the urinary system.112 This process is similar to the turnover
of bone mineral.
The CaHA used in Radiesse is synthetic in origin. It is
inherently biocompatible because it is identical in composi-
tion to bone mineral. Radiesse has been demonstrated to be
non-obstructive in X-rays, and when placed in soft tissue has
not demonstrated any heterotopic bone growth.113 CaHA is
the synthetic equivalent of bone and teeth, and has been
utilized in dentistry and ENT since 1972.113 In 2006, Radiesse
gained FDA approval for use in facial aesthetics and in treat-
ing facial lipoatrophy associated with HIV.113 CaHA is radio-
paque when injected as a bolus, but when utilized for soft
tissue augmentation, the material is spread throughout the
targeted area, making the material invisible on routine
X-rays.113 It can, however, be easily detected on MRI scans.114
Longevity of correction with CaHA is attributed to the slow
rate of dissolution, rapid rate of soft tissue ingrowth, and slow
rate of particle dislocation.113
Key publications: calcium hydroxylapatite
Jansen & Graivier114 conducted a long-term patient satisfac-
tion survey study in 2006 of 609 patients who received CaHA
injections in several facial areas, including the nasolabial folds,
marionette lines, oral commissure, cheeks, chin, lips, and
radial lip lines. Patient satisfaction surveys were conducted