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

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Chapter 23  Soft Tissue Augmentation
complete correction. After 9 and 12 months, 95.3% and
76.5% of subjects, respectively, met the criteria for persist-
ence of the corrective response. No unexpected, severe, or
serious injection-related adverse events were experienced.
Thus, the effectiveness of Dermicol-P35 was maintained for
up to 1 year after achieving full correction, both for touch-up
and for non-touch-up patients. However, it is important to
note that the results of Dermicol-P35 at 9 and 12 months
were not compared with Restylane, due to the lack of statis-
tical power at the 9 and 12 month data collection points.
Thus, no conclusions can be drawn in regards to the com-
parative efficacy of Dermicol-P35 relative to hyaluronic acid
beyond 6 months’ follow up.
Safety of cross-linked porcine collagen
Evolence is contraindicated in patients with a known hyper-
sensitivity to any collagen products or planning to undergo
desensitization injections to porcine products, as these injec-
tions can contain porcine collagen. It is also contraindicated
in patients with a history of anaphylactic reactions or history
or presence of severe recurrent allergic reactions. Based on
preclinical studies, the use of Evolence in individual patients
shall be limited to 10  mL over a 1-year period.120,121 The
safety of injecting greater amounts has not been established.
In clinical trials using a split-face design, patients were
injected with up to approximately 4  mL of Evolence in a
single injection site over a 1-year time period.
Poly-L-lactic acid
Sculptra (PLLA) is a stimulatory filler designed to be injected
into the deep dermis or dermal–subcutaneous junction to
treat lipoatrophy of the face and hands, HIV lipodystrophy
(only current FDA-approved indication) (Figs 23.10 and
23.11), and liposuction contour deformities. PLLA received
FDA approval in 2004 for treatment of HIV-associated
lipoatrophy. It is a non-animal-derived poly-L-lactic acid
for skin test prior to treatment.120 Evolence is designed to be
injected deeper into the dermis where it forms a three-
dimensional cellular matrix – replacing the skin’s depleted
collagen with new collagen.120 It is designed for correction of
moderate to deep facial wrinkles, such as nasolabial folds and
marionette lines.120
Key publications: cross-linked porcine collagen
A study in 2007 by Narins et al.120 aimed to compare the
efficacy and safety of Dermicol-P35 (Evolence) and single
cross-linked hyaluronic acid (Restylane) in the correction
of nasolabial folds. A total of 149 subjects with moderate
nasolabial folds were randomized to receive Dermicol-P35
and Restylane on contralateral sides of the face. If needed,
subjects could receive a repeat injection 2 weeks later to
obtain an optimal cosmetic result. Significant (P < 0.001)
improvement in the Modified Fitzpatrick Wrinkle Scale
scores relative to screening was observed after treatment
with both Dermicol-P35 and Restylane. Mean scores increased
(P < 0.001) over time, but there were no significant differ-
ences between treatments (+0.39 and +0.37 at 6 months;
P = 0.626). Greater proportions of subjects experienced
swelling, bruising, and pain at the hyaluronic acid site.
Several subjects had more induration at the Dermicol-P35
site. Thus, the effectiveness of correction by Dermicol-P35
is maintained for at least 6 months and was equivalent to
hyaluronic acid (Restylane) for the correction of nasolabial
folds.
A more recent follow up to this original study was pub-
lished in 2008 by Narins et al.,121 presenting data evaluating
the 12-month corrective response with Dermicol-P35 (Evo-
lence) relative to the hyaluronic acid filler Restylane. The
same cohort of subjects with moderate to deep nasolabial
wrinkles (n = 149) were randomized to injections of either
Dermicol-P35 or Restylane on one side of the face and the
alternative preparation on the contralateral side. If necessary,
one touch-up injection could be given after 2 weeks to obtain
A
B
Figure 23.10  (A) Pre and (B) post series
of six treatment sessions with poly-L-
lactic acid (Sculptra) for HIV lipoatrophy
of the malar region. (Courtesy of C
William Hanke MD.)

384
Part 3  Aesthetic Surgical Procedures
The postulated mechanism of action includes a foreign body
tissue response, leading to an increase in fibroblasts and sub-
sequent neocollagenesis.
PLLA has been utilized off-label for the treatment of
lipoatrophy associated with aging (Fig. 23.12). Patients should
be advised that between three and six treatment sessions will
likely be required, with a definable photographic difference
occurring between two and three treatments. Although the
precise duration of volumetric correction is unknown, results
seen after injection with PLLA have been demonstrated to
last for up to 2–3 years. Gradual resorption is thought to
occur over a 2–3-year period with eventual breakdown of the
material to lactic acid, found naturally in the body.
which is biocompatible, biodegradable, and immunologically
inert. PLLA is distributed freeze dried and can be stored at
room temperature and reconstituted 2–24 hours prior to
injection with sterile water. Importantly, it is not intended
for direct injection of rhytides; rather, it is intended to recon-
tour the face, causing a three-dimensional augmentation
which serves to lift the face, and stretch rhytides and soft
tissue redundancies.
PLLA is a sterile freeze-dried preparation composed of
24.5% sodium carboxymethylcellulose (an emulsifying agent),
34.7% non-pyrogenic mannitol (promotes osmosity), and
40.8% poly-L-lactic acid microparticles. Injection of PLLA
into the subcutis results in subcutaneous volume restoration.
A
B
Figure 23.11  (A) Pre and (B) post series
of three treatment sessions with poly-L-
lactic acid (Sculptra) injections for HIV
lipoatrophy of the malar region. (Courtesy
of C William Hanke MD.)
A
B
Figure 23.12  (A) Pre and (B) post series
of three treatment sessions with poly-L-
lactic acid (Sculptra) injections for
lipoatrophy of aging. (Courtesy of C
William Hanke MD.)

385
Chapter 23  Soft Tissue Augmentation
ciated with HIV and lipoatrophy of photoaging. Of these
patients, 27 were HIV positive and 38 were HIV negative.
The HIV-positive patients had more severe facial lipoatrophy
at presentation and improved more given their level of sever-
ity. The HIV-positive patients required more treatment ses-
sions and more PLLA to reach full correction than the
non-HIV patients. Ninety-four per cent of all patients had no
complications and the effects of PLLA were similar in both
groups. All complications were temporary and resolved over
time. Remarkably, patient satisfaction metrics indicated that
all patients were ‘very satisfied’ with their treatment. The
HIV lipoatrophy patients also indicated significant quality of
life improvement associated with their treatment.
Piquet et al.128 published the results of a prospective study
of 25 patients with HIV lipoatrophy treated with PLLA.
Facial lipoatrophy was classified in four clinical stages (stage
I, mild; stage II, moderate; stage III, important; stage IV,
severe) after a clinical examination. The PLLA solution was
prepared according to the manufacturer’s recommendations
(5 mL dilution) with one 5-mL vial injected per side, with an
interval of 1 month between treatments. The severity of the
lipoatrophy was stage I in two patients (8%), stage II in 12
patients (48%), stage III in nine patients (36%), and stage IV
in two patients (8%). The mean number of sessions was 5.2.
The mean follow-up time was 26 months. In 76% of the cases,
a complete correction of lipoatrophy was observed (100% of
stage I, 92% of stage II, 66% of stage III, 0% of stage IV).
However, among stages II, III, and IV that were incompletely
corrected, an improvement was noticed in all patients. The
mean satisfaction rate was 8/10 by patients and 7.2/10 by
surgeons. The painfulness of injections was rated at 3.3/10 by
patients. One single case of visible and palpable subcutaneous
granuloma was noticed in a patient at the end of the follow-up
period (18 months). PLLA was a safe and efficient procedure
for the treatment of facial HIV lipoatrophy, and it is effective
for all clinical stages of HIV lipoatrophy.
Levy et al.129 in 2008 published a prospective 3-year follow-
up study of 65 patients treated with PLLA for HIV lipoatro-
phy and lipoatrophy of aging. HIV-positive patients had a net
impro­vement of 2.5 points (P < 0.01) and HIV-negative
patients had a net improvement of 1.11 points (P < 0.01) on
the Facial Lipoatrophy Grading Scale. Subgroup analyses
revealed no statistically significant difference in facial lipo­
atrophy score between years 2 and 3 among patients who did
not receive treatment during the third year. Complications
were rare and included subcutaneous papule formation,
which improved spontaneously and partially responded to
subcision in one patient.
Salles et al.130 in 2008 published a 3-year follow-up inves-
tigation into the effect of PLLA implant injection for the
treatment of sunken nasolabial folds. All patients underwent
three injections: one injection per month for 3 months. Eval-
uation of the results based on clinical examination and pho-
tography was performed at each session, at 6 months, and
then 36 months after the third session. Injectable PLLA was
able to correct nasolabial folds successfully with a more
lasting result than absorbable fillers commonly used in clinical
practice, such as hyaluronic acid and collagen.
Injection technique
The appropriate reconstitution of the material and continu-
ous mixing are essential for obtaining optimal results with
Key publications: poly-L-lactic acid
In 2004, Woerle et al.122 reported the results of a retrospective
review of PLLA acid for correction of facial lipoatrophy and
wrinkles in a cohort of 300 patients. The authors reported that
PLLA acid is an effective, resorbable filler material for soft
tissue augmentation, especially in the lower half of the face.
The aesthetic results were excellent and long lasting; however,
clinical results and side effects are generally technique depend-
ent. The clinical results obtained in this series with PLLA for
soft tissue augmentation were comparable to autologous fat
grafting; however, surgical fat harvesting is not necessary,
making the treatment significantly more generalizable to a
broad patient population, including elderly individuals and
patients with infectious diseases who have little body fat.
Burgess & Quiroga123 in 2005 performed a study in 61 HIV
patients with lipoatrophy treated with an average of three
treatment sessions of PLLA. On long-term follow up (18
months), 48 of 61 (79%) required an average of three visits to
achieve the desired enhancement and 13 of 61 (21%) patients
requested additional treatment sessions beyond the initial
three sessions. Although all patients were very pleased with
their results, two patients developed persistent asymptomatic
palpable intradermal papules in the infraorbital region as a
result of the site of placement and concentration of PLLA.
A study from London in 2006 in the infectious disease
literature by Moyle et al.124 reported the long-term safety and
efficacy of injectable PLLA for correction of HIV-associated
facial lipoatrophy. Thirty patients were randomized to imme-
diate or delayed PLLA treatments, administered as three sets
of bilateral injections 2 weeks apart. Long-term efficacy was
assessed at a recall visit using visual analogue scales (VASs)
to record patient satisfaction, and by the Hospital Anxiety
and Depression Scale (HADS). At week 12, immediate-
treatment patients had significantly better VASs (7 vs 1; P <
0.001) and lower anxiety scores (6 vs 9; P = 0.056) than
delayed-treatment patients. Benefits on VAS and HADS
scores persisted until week 24. Improvements in VAS scores
for facial appearance were sustained from baseline to the
recall visit in both randomization groups (P < 0.05 and P <
0.001). Trends in improvement in HADS scores were also
noted, with patients in the delayed group experiencing sig-
nificant improvements in depressive symptoms (P < 0.05).
One case of injection-site induration and nine cases of injec-
tion-site nodules were noted at the recall visit, none of which
was described as serious or severe. Importantly, the study
documented both the physical and psychological benefits of
PLLA which was sustained over the 18-month follow-up
period.
Given the reports of the technique-dependent nature of the
results and avoidance of adverse effects with PLLA, in 2006
Leonard & Hanke125 reported specifics on a protocol
for injection of PLLA into the submalar and buccal regions.
The protocol includes both specific parameters for dilution of
PLLA and the use of a laboratory vortex.126 The authors rec-
ommended that the material be reconstituted with 3 mL of
sterile water on the night before the procedure. On the day
of the procedure, an additional 2 mL of lidocaine is added for
a total 5  mL dilution. The vortex should be utilized on a
medium setting speed prior to and during the injection pro-
cedure to ensure homogeneous mix of the diluted PLLA.
In 2007, Hanke & Redbord127 reported the results of a
series of 65 patients treated with PLLA for lipoatrophy asso-

386
Part 3  Aesthetic Surgical Procedures
in the sites of injection have been reported. Their occurrence
is likely technique dependent and may increase with superfi-
cial injection into the upper dermis. It should be emphasized
that injection of this filler should only occur at the dermal–
subcutaneous junction or subcutaneous fat. Vigorous post-
treatment massage also may reduce formation of nodules by
optimizing distribution of material.
Polymethylmethacrylate
Injectable PMMA is composed of a suspension of 20% non-
resorbable PMMA and 80% bovine collagen. PMMA is a
chemically inert and biocompatible synthetic implant mate-
rial widely used in bone implants, intraocular lenses, and
dental implants. In the prepackaged injectable filler, PMMA
is present as 30- to 50-µm spherical particles. There are
approximately 6 million PMMA microspheres in each mil-
liliter of injectable material. The injectable filler consists of
20% by volume PMMA microspheres suspended in a water-
based carrier gel composed of partially denatured 3.5% bovine
collagen, 92.6% buffered, isotonic water for injection, 0.3%
lidocaine hydrochloride, 2.7% phosphate buffer, and 0.9%
sodium chloride. The bovine collagen source is from an iso-
lated, US-bred calf herd monitored according to both FDA
and United States Department of Agriculture guidelines. The
collagen gel and the PMMA microspheres are both manufac-
tured and then combined in a dedicated US facility. Inject-
able PMMA implants are provided in syringes containing
0.8- and 0.4-mL fill volumes. Skin tests of the bovine collagen
gel only are provided in syringes containing a 0.3-mL fill
volume for allergy prescreening.
After injection, the collagen carrier is degraded by the body
within 1–3 months, and then new collagen is deposited by
the host to encapsulate and engulf the remaining scaffold of
PMMA particles. The PMMA microspheres are non-biode-
gradable and too large for macrophage phagocytosis. The
in-vivo persistence of PMMA particles is extremely long
lasting to permanent.
Injectable PMMA is FDA approved for the correction of
nasolabial folds. Other off-label indications for this material
are deep facial wrinkles at other sites on the face, as well as
other soft tissue contour deficiencies or deformities. Inject-
able PMMA is most appropriate for patients with well-defined
deeper facial wrinkle lines and little excess skin laxity.
Patients with sebaceous skin and large pore size, or those with
extremely thin and loose skin, are poor candidates, in whom
the implant may be palpable, result in a shiny skin appear-
ance, or even be directly visible after placement.
In October 2006, the FDA approved injectable PMMA
(ArteFill) for the correction of nasolabial folds in men and
women. The efficacy and safety evaluation period in the data
submitted for FDA evaluation was 12 months. Further data
on longer-term efficacy and safety were submitted to the
FDA in March 2007.
Key studies in the literature
for polymethylmethacrylate
In 2006, Cohen et al.131 reported the results of the pivotal
FDA study consisting of 251 subjects at eight centers who
received injections of ArteFill or bovine collagen dermal filler
(control) in 1334 wrinkles of the glabella, nasolabial folds,
radial upper lip lines, and corners of the mouth. The efficacy
data demonstrated a significant improvement with ArteFill
PLLA injections. We recommend that the material be recon-
stituted with 3  mL of sterile water on the night before
the procedure. On the day of the procedure, an additional
2  mL of lidocaine is added for a total 5  mL dilution. The
material is drawn into a 3-mL syringe with an 18-gauge
needle, which is then changed to a 25-gauge 1.25-inch needle
for injection.125,126
Prior to injection, the material is vigorously shaken (prefer-
ably with the use of a vortex device) to obtain a uniform
translucent suspension. This should be done immediately
prior to injection and at any point during the procedure when
the product appears to have settled out of suspension.125,126
The physician’s non-dominant hand is utilized to stretch
the skin, avoiding hand positioning in target of the advancing
needle. The suspension is injected into the outlined areas
using several of the predrawn dots as injection points. The
needle is advanced in even fan-like sweeps in the upper sub-
cutaneous fat layer just below the dermal–subcutaneous junc-
tion. The material should be injected as evenly as possible
during needle withdrawal. Movements should be fluid and
expeditious with constant motion until injection is complete
to minimize needle blockage of unevenly dispersed material.
Of the 6–8 marked anesthesia injection sites, only 3–4 need
to be utilized for the injection of PLLA. As injection of PLLA
into the dermis can result in dermal nodules, injection should
cease prior to pulling the needle upward from the dermal–
subcutaneous junction in the mid to superficial dermis. Focal
blanching and outpouching of the skin may be a sign that
injection is too superficial and should be followed by firm
focal massage if observed. Treatment is followed by 10
minutes of firm massage to the treated areas to ensure a
smooth and natural-appearing correction.125,126
On average, a patient with moderate to severe HIV lipo­
dystrophy will require approximately one vial of PLLA
injected to each cheek per injection session; however, treat-
ment volumes vary significantly from patient to patient. A
patient with minimal subcutaneous loss due to lipoatrophy of
aging may only require one-half vial to each side. A total of
three to six treatment sessions is typically required for
patients with both HIV lipoatrophy and lipoatrophy of aging
to achieve full correction.
Contraindications and adverse effects of
poly-L-lactic acid
Contraindications for PLLA injections include the use of
blood thinners (relative contraindication) as their use has been
associated with adverse events, including bruising, bleeding,
and hematoma formation. PLLA injection should be avoided
with active skin infections or inflammation in the treatment
area. Because the material is derived from synthetic, non-
animal origin, no skin testing is required prior to use.
The most common treatment-related side effects are bruis-
ing, erythema, swelling, and hematoma formation at the sites
of injection. Pretreatment screening for use of blood thinning
medications and supplements and ice-pack application can
minimize these risks. Asymmetry of volume can result when
one vial is split between two sides and the product settles out
of suspension during reconstitution. This unintended side
effect is easily corrected with distribution favoring the under-
corrected side at the next treatment and can be minimized
with vigorous shaking of the vial prior to injection (i.e. use of
vortex device). Delayed occurrence of subcutaneous papules

387
Chapter 23  Soft Tissue Augmentation
its long-lasting effect, PMMA is less forgiving of faulty tech-
nique than other injectable fillers. If gaps are apparent in the
initial correction, such uneven distribution may be correcta-
ble by subsequent injections into the gaps. Excessively deep
injection results in ineffective treatment, and further treat-
ments may be required to create adequate correction. Implan-
tation done too superficially may cause, in addition to visible
disfigurement, pruritus and erythema, which can be treated
with topical corticosteroids or intradermal corticosteroid
injections.
Papules and areas of excessive fullness due to incorrectly
placed or excess injectant, as well as true granulomas, have
been reported. Both of these may respond well to injection
of triamcinolone acetonide (Kenalog, up to 20 mg/mL). The
corticosteroid should be injected with care to avoid atrophy
and to ensure that only the locus of surfeit PMMA is targeted.
It is reportedly prudent to administer very small amounts of
low-concentration triamcinolone acetonide (e.g. 0.05–0.1 mL
per treatment session of 10 mg/mL triamcinolone acetonide)
directly into the area of excess fullness or inflammation. Use
of a small syringe and fine needle (e.g. a BD-II 0.3-mL syringe
with a swadged-on 31-gauge needle) can provide maximal
control of injection rate and minimal discomfort to the
patient. Treatment can be repeated every 3–4 weeks until the
desired result is achieved.
Areas of undesired fullness due to excess injectant or due
to treatment sessions more frequent than every 8–16 weeks
are especially common in the lips, and for this reason treat-
ment of the lips is contraindicated.
Granulomas have been described with Artecoll more so
than ArteFill. Because of the reduction in the number of
small particles in ArteFill, it is hypothesized that granulomas
will be less frequent with ArteFill than with Artecoll. Gran-
ulomas show a characteristic clinical appearance. They typi-
cally occur a number of years after Artecoll injection,
sometimes associated with a procedure, affect all the treated
areas eventually, and have a hard texture and bluish appear-
ance if superficial. Sometimes they respond well to intrale-
sional triamcinolone acetonide but at other times they are
very persistent and resistant to therapy. The possible occur-
rence of this complication is the main potential drawback to
therapy with ArteFill. It is wise to obtain a biopsy in all cases
where a granuloma is suspected, to confirm the diagnosis,
and to determine whether the granuloma, if present, is related
to ArteFill or to another filler (e.g. silicone or Dermalive/
Dermadeep) or to another cause, such as injection. The
biopsy report will also help to guide the most appropriate
treatment.
Injection technique for polymethylmethacrylate
The FDA currently requires a skin test prior to PMMA. Four
weeks prior to treatment, the patient should receive a 0.1-mL
intradermal injection of collagen into the volar forearm to
determine sensitivity to the treatment material. The patient
should observe the test site daily during the 4-week test
period and notify the physician immediately if any possible
positive or equivocal responses occur. A positive response
consists of erythema of any degree, induration, tenderness,
and swelling, with or without pruritus. Patients developing a
positive response should not be treated. An equivocal response
is one in which there is no localized skin reaction, but the
patient does develop a possible systemic reaction such as a
compared with collagen at 6 months (P < 0.001) in the
nasolabial folds. In the ArteFill group, follow up was obtained
at 12 months for 111 subjects (86.7%) and demonstrated
persistence of wrinkle correction. A subgroup of 69 patients
who received ArteFill were contacted 4–5 years later. Five
patients reported six late adverse events that occurred from
2 to 5 years after the initial injection; four of the adverse
events were mild cases of lumpiness and two were severe.
The total number of late adverse events was six of 272 (2.2%)
wrinkles injected. Among the 272 wrinkles evaluated at 5
years, two events (0.7%) in one patient were rated as severe
(a nodular, minimally inflammatory to non-inflammatory
reaction in both nasolabial folds). Investigator Facial Fold
Assessment ratings at 4–5 years were improved from baseline
by 1.67 points (P < 0.001).
Cohen et al.132 reported the long-term 5-year safety and
efficacy of PMMA filler, where safety was assessed by stand-
ard adverse-event reporting and efficacy was determined
using a validated 6-point grading scale. One hundred and
nineteen patients demonstrated significant improvement in
nasolabial folds comparing baseline to 5 years after their last
treatment (P < 0.001). Notably, subjects also demonstrated
continued improvement between 6 months after their last
treatment and year 5 (P = 0.002). No serious unanticipated
device-related adverse events were reported. These authors
noted that PMMA is the first soft tissue filler to demonstrate
continued improvement and persistence of correction over a
5-year period post treatment.
Bagal et al.133 reported a retrospective review of 72 patients
(62 females and 10 males) who underwent Artecoll implanta-
tion between 1997 and 2002. Artecoll was implanted into
different facial sites, including the philtrum, acne scars,
corners of the mouth, upper and lower lips, melolabial folds,
and other facial creases to attain permanent soft tissue aug-
mentation. Via completion of an anonymous survey, patients
performed subjective evaluation of the aesthetic results.
Among 72 patients, 40 returned a completed patient satis­
faction survey (56% response rate). Five of 40 patients
reported persistent problems with Artecoll (firmness of the
lip in one patient, increased sensitivity of the lip for 6 months
in one patient, and lumps in their lips in three patients).
Eighty-five per cent of patients (34 of 40) reported that the
treatment met or exceeded their expectations, 13% (5 of 40)
reported that the treatment was less satisfying than expected,
and 3% (1 of 40) reported that the treatment was much less
satisfying than expected. A medical record review confirmed
that 5 of 72 patients had complications after Artecoll implan-
tation (nodule formation in four patients and persistent lip
pain in one patient). Sixty-two of 72 patients (86%) achieved
favorable soft tissue augmentation with a total Artecoll
implant volume of 3.0  mL or less. The authors concluded
that Artecoll was a satisfying treatment for the majority of
patients with lip augmentation and facial creases, for patients
who were seeking a more permanent method correction.
However, it should be noted that implantation success is
highly technique dependent. Conservative gradual implanta-
tion in the subdermal plane provides favorable results and
few complications.
Adverse events with polymethylmethacrylate
The most common short-term side effects include injection-
related bleeding, bruising, erythema, and edema. Because of

388
Part 3  Aesthetic Surgical Procedures
Autologous collagen
Autologous collagen is performed with a microlipoinjection
technique developed by Fournier. Extracted adipose tissue
contains intracellular fat contents, adipose cell wall, and inter-
cellular fibrous septae. Harvested autologous fat is processed
by mixing with sterile distilled water and frozen, leading to
rupture of adipocytes. Solid fraction, representing lipocyte
cell walls and connective tissue, is utilized for soft tissue injec-
tion. The disadvantages of this technique include that the
injected material is highly viscous, thus requiring large needles
(25-gauge or higher); extensive local anesthesia is required
prior to injection, and needle marks and swelling from local
anesthesia can persist for several days; it is difficult to place
precisely autologous collagen at the required dermal level; and
there is a greater degree of bruising with autologous collagen
relative to bovine/human collagen injected with a finer needle.
Isolagen
Isolagen consists of an in-vitro culture of autologous fibro­
blasts in an extracellular matrix that replenishes the dermis
and subcutaneous tissues which have lost collagen as a result
of photodamage, aging, or scarring. With this technology, a
3-mm punch biopsy is obtained from the patient and then
sent to the manufacturer to be grown in culture. Processing
takes 6 weeks and a test dose is sent back to the physician.
If no reaction occurs 2 weeks after the test injection, Isolagen
can be administered. Expansion of the implant can be seen
for many months after injection, due to new collagen produc-
tion from the fibroblasts. Isolagen should be injected at mul-
tiple levels of the dermis for best results in scars and rhytides.
The product needs to be injected within 24 hours of receipt,
posing significant logistical challenges to both physicians and
patients.
A study performed with Isolagen by Watson et al.134 dem-
onstrated that this technique involving intradermal injection
of autologous fibroblasts was an effective treatment option
for facial rhytides and depressed scars. Ten adults (age range
24–69 years) with prominent rhytides or depressed facial
scars were treated with this technology. A 3-mm postauricu-
lar skin biopsy specimen from each participant was sent to
Isolagen Technologies, Inc, laboratories, where a fibroblast
cell line was developed. Three injection sessions were per-
formed at 2-week intervals; target areas were the study site
as well as the postauricular fold. Nine of 10 patients noted a
60% to 100% improvement with the treatment; clinicians
made similar observations. Size reduction of 10% up to 85%
of the study site was demonstrated by optical profilometry
for every patient. Microscopically, there was evidence of
increased thickness and density of dermal-layer collagen.
 OPTIMIZING OUTCOMES
Both clinicians and patients must recognize advantages as well
as limitations and disadvantages of injectable therapy in the
treatment of facial lines and wrinkles. Injectables cannot be
expected to counter the effects of gravity and are entirely
ineffective in treating ‘jowls’ or other problems associated
with excessive skin laxity. In such cases, liposuction, rhytid-
ectomy, and lifting procedures should be recommended to
patients. Deep dynamic rhytides will be improved better with
concomitant use of filler with botulinum toxin. Deeper lines
and folds may require subcutaneous fillers, such as Sculptra
rash, arthralgia, or myalgias that occur at any time during
the 4-week observation period. If an equivocal response is
observed, a second injection in the opposite arm is required.
Patients demonstrating a positive or equivocal response in the
second test should not be treated.
Since injectable PMMA contains 0.3% lidocaine, treatment
without additional anesthesia is possible. However, topical
anesthesia or an infraorbital local anesthetic block can be
applied prior to treatment.
Injectable PMMA is supplied in 0.8- and 0.4-mL syringes.
A 26-gauge 5/8-inch needle is recommended for use. A
25-gauge 1-inch needle may be substituted as the extra length
enables a smaller number of needle insertions. The syringe
must be brought to room temperature prior to injection. Prior
to injection, a small amount of material should be extruded
from the tip to ensure that there is no blockage. Postoperative
ice packs may be used.
PMMA is injected into the dermal–subcutaneous junction
utilizing the ‘tunneling’ or ‘linear threading’ technique.
Depending on the thickness of the skin and depth of the fold
receiving correction, the needle is inserted at a 20–40° angle
beneath the wrinkle. Proper needle placement will result in
the needle outline being visible. If the needle is placed too
superficially, the needle will be visible and blanching will be
observed upon injection. In this event, injection should then
immediately cease and proper placement re-established. If
any product was inadvertently injected, it should be massaged
out of the tract. If the needle is placed too deep, a pop will
be felt as the subcutaneous tissue is entered and the needle
outline is no longer visible. Injection into the subcutaneous
tissue results in loss of injectant and hence minimal correc-
tion. If in doubt, it is preferable to inject more deeply than
superficially as wasted PMMA is less problematic than that
of superficial injection, resulting in long-term skin surface
texture or color abnormalites.
Upon confirmation of correct needle placement, injection
of material should proceed in a retrograde fashion, with appli-
cation of constant even pressure on the plunger to ensure
uniform placement. The viscosity of PMMA is three times
higher than that of collagen, so a higher pressure is needed.
Also, resistance to injection will be felt with appropriate
placement in the dermis. In contrast, if the needle is too
deep (in the subcutaneous tissue) there will be less resist-
ance. Injection should proceed slowly and evenly and cease
before withdrawal of the needle from the skin. This tech-
nique is then repeated along the defect to be corrected to
produce a series of injection tracks which correct the
depressed nasolabial fold. After injection, the area should be
palpated to assure uniform deposition. Any palpable lumps
should be massaged gently until smooth. If there is any
blanching from superficial injection, this should be aggres-
sively massaged to distribute the material into the surround-
ing dermis.
Patient evaluation is recommended after 4–6 weeks to
assess the need for further additional treatments. The risk of
creating areas of excess fullness can be minimized by avoiding
overcorrection during each treatment session and by waiting
for 8–16 weeks between treatment sessions. Optimal correc-
tion usually requires two to three treatments. Recently sub-
mitted US data indicate that nasolabial fold correction after
injection of PMMA remains for at least 5 years. Reports from
Europe and Canada suggest longevity of correction of over 10
years.

389
Chapter 23  Soft Tissue Augmentation
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or Radiesse, or hyaluronic acid-based fillers, such as Restylane
or Juvéderm. Layering of soft tissue augmentation materials
of varying viscosity allows for slow, natural, smooth augmen-
tation, which minimizes risks of clumping and asymmetry.
Patients without prior experience with soft tissue filler should
consider a temporary filler, such as human collagen or
hyaluronic acid, before investing physically, emotionally, and
financially in more permanent fillers.
  SUMMARY
• Since the introduction of injectable bovine collagen in
1981, injectable fillers and soft tissue implants have
become an integral part of dermatologic surgery.
• Proven safety and efficacy of these products have
encouraged a large number of biotechnology companies
to invest in development of more ‘ideal’ filler materials.
• Patient demand and the number of dermatologists
performing injections to meet patient demand have
helped to stimulate the development of a diverse array
of fillers.
• Physicians need to be aware of the differences in
particle size, viscosity, placement depth, and duration of
correction of the diverse array of available dermal and
subcutaneous fillers.
• Physicians and patients must be aware of side effects
and advantages and limitations of each filler substance.
• Subcutaneous fillers, poly-L-lactic acid, and calcium
hydroxylapatite represent a considerable advance in
filler technology, allowing both correction of deeper
folds and rhytides as well as augmentation of volume
lost in lipoatrophy associated with HIV and photoaging.
• Continued development of novel filling substances and
novel indications for use of pre-existing fillers will occur
in the next decade, making this one of the most exciting
areas of growth in the field of aesthetics and
dermatologic surgery.
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2007;33(Suppl 2):S112–S121, discussion S121.
117. Sadick NS, Katz BE, Roy D. A multicenter, 47-month study of safety
and efficacy of calcium hydroxylapatite for soft tissue augmentation of
nasolabial folds and other areas of the face. Dermatol Surg 2007;33(Suppl
2):S122–S126.

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393
24
Chemical Peels
Sue Ellen Cox MD, John M Soderberg MD, and Kimberly J Butterwick MD
Summary box
 Understand the different depths achieved by the various
agents used in chemical peeling.
 Learn the indications for various chemical peels.
 Understand factors in patient selection.
 Learn the techniques involved for predictable outcomes with a
variety of chemical peels.
 Learn how to identify and treat potential complications.
 INTRODUCTION
Chemical peeling is the application of one or more exfoliating
agents to the skin, to produce controlled partial-thickness
ablation. The agent, usually an acid solution, removes varying
amounts of epidermis, and depending on the strength, affects
dermal collagen.1 Partial-thickness wounds heal by second
intention. Wound repair consists of epidermal regeneration
by migration from adenexal structures, or when the peeling
agent is applied, ‘punctual’ regeneration is from the adjacent
epithelium.2 Replacement of new connective tissue results in
skin rejuvenation including improvement in skin color and
texture and removal of actinically related growths.
 HISTORY
Aesthetic improvement of the skin dates back to ancient
Egypt. Papyruses contain descriptions of the use of acids,
balms, and oils for chemical peeling. Greek and later Roman
physicians used sour milk, grape juice, and lemon extracts for
rejuvenation. The active ingredients in these substances were
the α-hydroxy acids (AHAs): lactic acid, tartaric acid, and
citric acid.3 Light mechanical exfoliation similar to currently
popular microdermabrasion was performed in India with
pumice to exfoliate the stratum corneum.
Dermatologists pioneered the therapeutic use of chemical
peeling in the latter half of the 19th century. In 1882, the
German dermatologist Unna described using salicylic acid,
resorcin, phenol, and trichloroacetic acid (TCA) for chemical
peeling. In England, the British dermatologist Mackee used
phenol as a peeling agent to treat acne scarring as early as
1903 and published 50 years of experience with these peels
in 1952.4 During World War I, LaGassé used phenol to treat
facial gunpowder burns. His daughter Antoinette, a non-phy-
sician, brought phenol chemical peeling to the United States.
During this time chemical peels offered by salons often
resulted in slough and scarring.3
In the 1940s, physicians made great strides in advancing
the knowledge of chemical peeling. Highlights include Eller
& Wolff’s description of peeling agents including sulfur,
resorcinol, salicylic acid, phenol, and CO2 slush.3 Monash
described his use of TCA for treating scarring.5 Later, Ayres
combined the TCA experiments of Monash with his own
clinical experience and histology comparing TCA to phenol.5
In the early 1960s, otolaryngologists, dermatologists, and
plastic surgeons published their clinical experience with
phenol formulas. It is Baker & Gordon’s modified phenol peel
that is the standard deep chemical peel used.6 Today, in some
European countries like Germany, the use of phenol for deep
peeling is prohibited.
In the early 1980s, Stegman’s comparison of different
wounding agents based on histology set the stage for a more
academic approach to chemical peeling.7 Simultaneously, Van
Scott & Yu published extensively on the effects of AHAs on
the stratum corneum.8 This led to the widespread use of
superficial AHA peels by dermatologists in the 1990s.
Brody & Hailey introduced the concept of using two super-
ficial peeling agents to produce a medium-depth peel in
1986.9 They combined solid CO2 followed by TCA to produce
injury of the skin at the upper reticular dermis. In 1989,
Monheit described the use of Jessner solution followed by
the application of 35% TCA.10 This medium-depth peel is
extremely popular and reproducible. Coleman & Futrell pub-
lished on the combination of glycolic acid plus TCA to
produce medium-depth injury to the skin.11
 PREOPERATIVE PREPARATION
Preparing the skin for chemical peeling
The level of exfoliation and the depth of penetration into the
skin quantify superficial, medium-depth, and deep-depth
peels (Fig. 24.1 and Table 24.1) It is important to match the
skin pathology to the chemical agent. For instance, a patient
with extensive actinic keratoses would be better served by a
medium-depth peel, whereas a patient with acne would do
better with more superficial agents such as glycolic acid or
salicylic acid peels. Preparation of the skin prior to chemical
peeling is extremely important. The skin-care program con-
sists of patient education regarding sun avoidance, the use of
effective sunscreen on a daily basis, and pretreatment with
tretinoin and or AHAs (Box 24.1).

394
Part 3  Aesthetic Surgical Procedures
primarily affected by UVA and UVB in the wavelengths of
320–400 nm and 290–320 nm, respectively. The UVA radi-
ation penetrates deeper in the skin than UVB and causes
damage of the elastic tissues deeper in the dermis. In the
UVA range, light is absorbed by proteins and lipid. In the
UVB range, absorption affects DNA.13 In photoaging, the skin
surface is rough and dry. Clinically, photo-induced changes
of the skin account for its thickened, sallow, and coarsely
wrinkled appearance.
Pretreatment with tretinoin for chemical peels
Numerous benefits may be seen with the use of topical tretin-
oin on photodamaged skin. Tretinoin improves skin texture
and reduces fine wrinkling and mottled hyperpigmenta-
tion.14–17 Histologically, tretinoin increases epidermal and
granular layer thickness, decreases melanin content, and
causes stratum corneum compaction.16,18 Tretinoin also
increases re-epithelialization by increasing the mitotic rate of
keratinocytes and dermal collagen production and by stimu-
lating angiogenesis.19,20 These effects may account for the
improved wound healing in patients who are pretreated prior
to resurfacing procedures.
Topical tretinoin pretreatment accelerates wound healing
after medium-depth and deep-depth chemical peels. In a
double-blind, placebo-controlled, prospective, randomized
study, 16 males with actinically damaged skin were treated
daily with tretinoin 0.1% versus placebo cream to the left and
right sides of the face, forearms, and hands 14 days before a
35% TCA peel.21 Post-peel healing was evaluated on days 3,
Stratum corneum
Papillary dermis
Upper reticular
dermis
Mid-reticular
dermis
Lower reticular
dermis
Fat
Stratum granulosum
Stratum basal
(0.08 mm)
Superficial
wound
Medium-depth
wound
(0.45–0.6 mm)
Deep-depth
wound
(0.6–0.8 mm)
(2 mm)
Stratum spinosum
Hair
Sebaceous gland
Peel depth
Peel depths
Figure 24.1  Peel depths.
Table 24.1  Classification of chemical peels
TYPE
DEPTH OF PENETRATION
Superficial
Epidermis to papillary dermis
Medium
Papillary dermis to upper reticular dermis
Deep
Mid-reticular dermis
Box 24.1  Preoperative preparations for
chemical peeling
 Sun avoidance.
 Tretinoin/tazarotene.
 Alpha-hydroxy acids.
 Broad-spectrum-sunscreen.
 Hydroquinone (as indicated by skin type and depth of peel
injury).
 Antiviral medication (for superficial peels as indicated by
history of herpes simplex; however, some provide prophylaxis
or for all patients having mid to deep areas).
Role of sun damage
Long-term photo-induced exposure accounts for a significant
amount of the damage that we associate with aged skin. The
majority of this damage is from overexposure to ultraviolet
(UV) light. The sun and artificial tanning lights are both
sources of light that can be harmful to the skin.12 The skin is

395
Chapter 24  Chemical Peels
to melanocytes; and it decreases melanosome formation by
inhibiting tyrosinase. West & Alster provide us with a rand-
omized study of 100 patients that were pretreated with
topical skin lightening agents versus placebo 2 weeks prior
to laser resurfacing.30 There was no significant difference in
the incidence of hyperpigmentation after resurfacing in the
pretreated groups versus the placebo group. The use of
hydro­quinones postoperatively for postinflammatory hyper-
pigmentation is effective.31
Antiviral prophylaxis
All resurfacing procedures have the potential to induce reac-
tivation of herpes simplex virus (HSV). Active herpes infec-
tion is a contraindication to proceeding with a chemical peel.
Because many patients are unaware of their exposure to the
herpes virus, it is prudent to provide prophylaxis to all
patients prior to a medium-depth peel. Antiviral agents have
been shown to be effective in reducing reactivation. A recent
study looked at infection rates following laser resurfacing
after using prophylactic valaciclovir 500  mg twice daily,
beginning the day prior to the procedure and continuing for
10 or 14 days following the procedure. Among 120 patients,
no patients developed a HSV infection or recurrence.32
Photography
All patients should have preoperative photographs taken to
document the degree of actinic damage and facial dyschro-
mia. Additionally, patients tend to forget their preoperative
appearance; thus it is helpful for them to appreciate the
degree of improvement by looking at their photographs. In
our office (SEC), we use the Mirror Image Suite version 6.1.0
by Canfield Imaging Systems (USA).
Consent
Patients sign a surgical consent for superficial, medium-depth,
and deep-depth chemical peels. The consent specifies the
most common risks associated with peels. These stated risks
include stinging, burning sensation of the skin, visible peeling,
scaling, milia formation, pigmentary changes, persistant ery-
thema, infections, and rarely scarring.
Consultation
At the consultation, it is important to identify the patient’s
motivations for chemical peeling. It is also the physician’s
responsibility to direct the patient to the most effective treat-
ment based on the individual’s problems. The physician
needs to explain the limitations of each type of peel and
make sure that the patient has realistic expectations. It is
essential that the physician explain the postoperative course,
especially with medium-depth and deep-depth resurfacing.
The patient needs to review photographs of others immedi-
ately, 24, and 48 hours after peeling so that they can visual-
ize the healing process. Verbal descriptions are inadequate.
It is also important to stress the postoperative care needed
to ensure a good result. It is important to assess the patient’s
lifestyle with regard to recreational activities and sun expo-
sure. It is necessary for the physician to stress to the patient
that it is their responsibility to protect their skin from sun
exposure both during the healing phase and thereafter to
ensure that postinflammatory hyperpigmentation does not
occur.
5, 7, 9, 11, and 14. The appearance of intact, pink skin after
the brown desiccated skin sloughed off was an indication of
re-epithelialization. In 94% of patients, the sloughing occurred
earlier and was more uniform, regardless of body location, in
skin pretreated with tretinoin than with placebo-treated skin.
Maximal healing of the tretinoin-treated facial skin was
evident after 5 days (68% vs 52%; P < 0.005). The hands and
forearms took longer at 9 and 11 days respectively.21,22
The American Academy of Dermatology (AAD) Guide-
lines Outcomes Committee developed ‘Guidelines of Care
for Chemical Peeling’ in an effort to enhance quality of care
for patients having cosmetic procedures.23 This AAD com-
mittee recommended tretinoin pretreatment as preparation
for skin that is undergoing chemical peeling. The committee
also recommended postoperative tretinoin to enhance wound
healing and to maintain results.23
Tretinoin should be started in advance of the chemical peel.
Six weeks or more is preferable. Once re-epithelialization has
occurred, tretinoin should be restarted initially using a low-
concentration emollient or cream preparation such as 0.02%
Renova (Ortho Pharmaceutical Corporation, Raritan, NJ) or
0.025% tretinoin cream. Newer retinoic acid receptor creams
such as tazarotene can be used before and after peels and may
be more effective then tretinoin.
α-Hydroxy acids
AHAs have been used both prior to peels and as a superficial
chemical peeling agent. AHAs exert their epidermal effect at
the level of the stratum corneum and granulosum junction.
A thinner stratum corneum with a normal-appearing basket­
weave pattern is achieved by reducing the corneocyte cohe-
sion. This produces a smoother, more supple skin surface.24
The use of AHAs has been shown to reverse histologic signs
of photoaging. AHAs used regularly for 6 months showed a
25% increase in epidermal and papillary dermal thickness,
increase in mucopolysaccharides, improved quality of elastic
fibers, and increased collagen density. Additionally there was
a reversal in basal cell atypia, dispersal of melanin pigmenta-
tion, and normalization of the rete pattern of the dermoepi-
dermal junction.25
AHAs have also been used as an adjunct to tretinoin therapy
without increasing adverse sequelae.26–28
Sunscreens
Sunscreens work by absorbing, reflecting, and scattering UV
light. The effectiveness of the sunscreen is indicated by a sun
protection factor (SPF), which represents the ratio of the
amount of radiation needed to produce erythema with sun-
screen to the amount of radiation needed to produce ery-
thema without sunscreen.29 A sunscreen should be chosen
that blocks both UVA and UVB radiation. The mechanism
of action is to decrease pigmentation and lessen the potential
for development of hyperpigmentation. The decrease in UV
damage allows the skin to rest prior to the peel. This should
be started at least 3 months prior to the peel and continued
indefinitely after the peel.
Hydroquinone
Many surgeons advocate pretreatment with hydroquinones
to reduce the risk of postinflammatory hyperpigmentation
after the resurfacing procedure. Hydroquinone is cytotoxic

396
Part 3  Aesthetic Surgical Procedures
expectations. It is important to set appropriate patient expec-
tations at the outset.
Superficial peels are helpful in the treatment of acne and
may improve melasma. They provide smoothness and luster
to photodamaged skin but will not usually eliminate fine lines
or actinic keratoses.33 Solar lentigines lighten but may not
resolve. Pore size may or may not diminish with superficial
peels.
Patients need to be educated that one peel may have little
effect. Rather, the combination of a series of three to six peels
is likely to produce the best results in conjunction with a
topical regimen at home. A common misconception among
patients is that multiple superficial peels will produce the
same result as one deeper peel.13 Realistic benefits are par-
ticularly important to clarify when discussing the outcome of
superficial peeling on rhytides and deep acne scarring. If the
patient has Glogau grade II or III photoaging, multiple super-
ficial peels will not achieve the same results as a medium-
depth or deep-depth peel on medium to deep rhytides (Table
24.2). Similarly, patients with deep acne scarring will have
little benefit from superficial peeling and should be advised
accordingly. Patients with both superficial and deep melasma
can expect only partial improvement. A Wood’s lamp can be
utilized to detect epidermal melasma,34 but in one study, the
response to a superficial peel was difficult to predict on the
basis of this test.35
A questionnaire filled out by the patient prior to the con-
sultation is helpful so that the physician is aware of any
pertinent medical history (Box 24.2). Relevant history would
include knowledge of the patient’s history of HSV. Active
viral, bacterial, or fungal infection preclude chemical peeling
until there is complete resolution.
Medications and past medical and surgical history should
be carefully reviewed. Patients who have taken isotretinoin
within the past 6–12 months should not be peeled. Isotretin-
oin produces atrophy of the pilosebaceous unit. Re-epitheli-
alization originates from these adnexal structures so their
alteration can impair wound healing and increase the risk of
scarring. Similarly, patients who have had exposure to previ-
ous facial radiation therapy have diminished adenexal struc-
tures and are at a higher risk for scarring after dermal injury.
Recent facial surgery in which the blood supply to the skin
has been compromised by surgical undermining is a contrain-
dication to peels that affect the dermis. Facial rhytidectomy
or larger flap repairs for skin cancers should delay resurfacing
for 6 months or more.
Smokers have impaired microcirculation to the skin and
increased rates of infection. Additionally, smoking damages
the elastic fibers and collagen producing an increase in wrin-
kling and actinic damage. Smokers can benefit from chemical
peeling; however, they need to be educated about realistic
expectations and complications.
 SUPERFICIAL CHEMICAL PEELS
Superficial chemical peeling is the application of wounding
agents designed to exfoliate part or all of the epidermis which
may in turn lead to mild stimulation of collagen formation
in the superficial papillary dermis. Many agents of varying
strengths can accomplish this exfoliation (Box 24.3). The
indications for superficial peeling include melasma, postin-
flammatory hyperpigmentation, ephelides, acne vulgaris,
solar lentigines, photoaging, and fine rhytides.
Preoperative preparation
The popularity of superficial peels underscores the many
advantages of light peels (Box 24.4). The appeal of rapid
healing, relatively low cost, and minimal risk, even in darker
skin types, offsets the limitations of the procedure for most
patients (Box 24.5). Unfortunately, marketing hyperbole
regarding ‘lunchtime peels’ has created unrealistic patient
Box 24.2  Patient evaluation to
optimize outcomes
 Physician–patient relationship.
 Patient’s realistic expectations.
 Fitzpatrick skin type.
 Active infection.
 Tobacco use.
 Medications: minocycline, isotretinoin.
 History of herpes simplex virus infection.
 History of keloid formation.
 History of previous radiation exposure.
 History of immunosuppression.
 History of postinflammatory hyperpigmentation.
 Recent facial surgery.
Box 24.3  Superficial peeling agents
 Trichloroacetic acid 10–25% (35%; one coat).
 Jessner’s solution: resorcinol/salicylic acid/lactic acid.
 Modified Unna’s resorcinol paste.
 Solid CO2 slush.
 Salicylic acid.
 AHAs.
 Tretinoin solution.
Box 24.4  Advantages of superficial peels
 Excellent safety record.
 May be used on all Fitzpatrick skin types.
 Rapid healing, minimal downtime.
 Repeated peels provide cumulative effects.
 Amplifies effects of topical rejuvenating agents.
 Can be combined with laser modalities.
 May be performed by trained nurses, medical technicians,
and aestheticians.
 Affordable.
 No anesthesia needed.
Box 24.5  Limitations of superficial peels
 Little clinical effect with one peel.
 Multiple superficial peels do not provide the same results as
one mid-level or deep peel.
 Media has created unrealistic patient expectations.
 Minimal effect on medium to deep rhytides.
 Return to before-peel condition within 2 years without topical
agents.

397
Chapter 24  Chemical Peels
rubbing and pressure and also the number of coats applied
further determine the response to the peel. The practitioner
should become familiar with one technique and remain con-
sistent when using a particular agent so as to develop predict-
ability of a given peel.
The condition of the skin and the skin preparation tech-
nique similarly influence the depth of the peeling. If the
patient’s epidermal barrier is disrupted for any reason, such
as retinoid dermatitis, seborrheic dermatitis, or active acne
with erosions, the peeling solution may penetrate more
deeply and result in a medium-depth peel when a superficial
peel was intended.35 The depth of the peel is also altered by
the choice of the skin preparation technique. If the patient
has oily skin or advanced photoaging, vigorous degreasing with
septisol, alcohol, or acetone may be used for more uniform
penetrance of the peel. The skin may even appear lightly
frosted after thorough cleansing. Peikert et al.36 noted no
difference in evenness among four commonly used degreasing
agents; acetone, rubbing alcohol, Freon skin degreaser, or
Hibiclens (chlorhexidine). Because of the flammability of
acetone, the other agents were preferred. If the patient has
thin sensitive skin or a disrupted epidermis, light cleansing
with a cotton ball and gentle cleanser is recommended, espe-
cially when peeling with AHAs.
The area being treated is also a variable. On the face, the
forehead has a higher density of sebaceous glands and can
usually tolerate more vigorous cleansing and application of
the peeling agent than other facial areas, yet heal in the same
time interval as areas treated more conservatively. In general,
the thicker and more sebaceous the skin, the less susceptible
it is to the peeling agent. Non-facial areas such as the neck,
forearms, and dorsum of the hands have significantly fewer
sebaceous glands and adenexal structures from which to
regenerate new skin. Due to delayed healing and a tendency
to scar, these areas must be peeled conservatively and only
with superficial peeling agents repeated over time. With suc-
cessive peeling, the concentration of the agent applied should
be titrated up depending on the peeling agent used and the
reaction to the peel. When peeling with AHA agents, the
concentration of the solution is increased and the length of
time that the acid is left on the skin is reduced to 2 minutes.
Each practitioner usually develops a specific pattern of
peeling the face, which may differ with the peeling agent
The skin is ideally conditioned prior to superficial peeling.
Patients should be using sunscreen and avoid active tanning.
Tretinoin used topically before peeling accelerates healing but
should be stopped 2–4 days before superficial peeling to
assure an intact epidermis. It is best to start a bleaching agent
prior to peeling in patients with darker skin types or pigmen-
tary disorders. If an irritant or allergic contact dermatitis
develops to hydroquinone or other agents, it is helpful to
know this in advance. In general, antiviral agents are pre-
scribed preoperatively in patients with a history of facial
herpetic eruptions.
Technical aspects
Superficial peeling varies from producing a very superficial
slough of only a few layers of the stratum corneum to produc-
ing a slough of the entire epidermis and papillary dermis. The
depth of the peel is determined not only by the particular
agent and the concentration but also by the area treated, skin
preparation, methods of application, and the sebaceous
quality of the patient’s skin (Box 24.6). These variables may
change during the course of successive peeling in the same
patient and need to be evaluated prior to each peel.
The technique of application is a significant determinant of
the depth of the peel. The type of applicator and the degree
of saturation of the applicator determine the amount of peel
solution applied. Commonly used applicators include 4 × 4
gauze, 2 × 2 gauze, cotton-tipped applicators, and sable
brushes. Of these, the sable brush was found to deliver the
greatest quantity of solution in one study.2 The degree of
Table 24.2  Glogau’s classification of photoaging groups
GROUP
SEVERITY
AGE GROUP (YEARS)
FEATURES
I
Mild
Usually 28–35
No keratoses
Little wrinkling
Little or no make-up
II
Moderate
Usually 36–50
Early actinic keratoses – slight yellow skin discoloration
Early wrinkling – parallel smile lines
Small amount of make-up
III
Advanced
Usually 51–65
Actinic keratoses – obvious yellow skin discoloration with telangiectasia
Wrinkling – present at rest
Wears make-up always
IV
Severe
Usually 66–75
Actinic keratoses with skin cancers have occurred
Wrinkling – cutis laxa of actinic, gravitational, and dynamic origin
Wears make-up that does not cover, but cakes on
Box 24.6  Variables of peeling
 Agent selected.
 Concentration of agent.
 Technique of application.
 Skin preparation technique.
 Previous use of tretinoin.
 Sebaceous gland density.
 Integrity of epidermal barrier.
 Frequency of peeling.
 Area treated.

398
Part 3  Aesthetic Surgical Procedures
days 3–6. These are predictable peels that can be adjusted to
the patient’s pathology and available downtime by the con-
centration utilized. For pigmentary problems such as postin-
flammatory hyperpigmentation or melasma, the results may
be variable with TCA and the problem may even worsen.
Starting with lower concentrations and/or performing test
patches have been recommended.42
Jessner’s solution
Jessner’s solution (also known as Combes formula) consists
of 14  g each of resorcinol, salicylic acid, and lactic acid in
ethanol (Box 24.7). It was formulated by Jessner in the 1940s
with the goal of reducing the concentrations of salicylic acid
and resorcinol to minimize their respective side effects: tin-
nitus with salicylic acid and syncope and/or thyroid suppres-
sion with resorcinol.43 The result is keratolysis caused by
breakage of intracellular bridges with minimal side effects.
Jessner’s solution is applied to prepped skin and rubbed in or
painted on. It is not necessary to neutralize this peel. The first
peel usually consists of just one coat, with subsequent peels
of two to three coats as dictated by the patient’s pathology
and available downtime. There is usually no frosting, just
erythema and white speckling. A Jessner’s peel will usually
result in 2–3 days of light white desquamation, which often
serves as a pleasing demonstration to the patient that the peel
is effective. For the treatment of melasma, Jessner’s peels
were found in one study to be comparable to 70% glycolic
peels in efficacy and had fewer side effects.35 Jessner’s solu-
tion has been combined with topical 5-fluorouracil (5-FU)
weekly for 8 weeks for treatment of actinic keratoses and
photoaging with 88% clearing in one series.44 The ability of
the Jessner peel to disrupt the epidermal barrier has also been
utilized to enhance penetration of other agents; with TCA
35% for a medium-depth peel45 or with resorcinol paste 53%
for penetration to the deep papillary dermis.46
α-Hydroxy acids
AHAs are naturally occurring organic acids extracted from
fruit, sugar cane, and other foods.47 Of the AHAs, glycolic
acid is the smallest compound and the most commonly used
in superficial peeling. The choice of available formulations
ranges from 20 to 70%. AHAs are keratolytic at low concen-
trations and cause epidermolysis with increasing concentra-
tions and duration of contact time. In some studies, serial
glycolic acid peels have been found to have a long-term effect
on both the epidermis and dermis, with an increase in dermal
and epidermal glycosaminoglycans, an increase in dermal col-
lagen, and an increase in epidermal thickening.47 These ben-
eficial effects on the papillary dermis occur without tissue
necrosis.48 This may account for more clinical improvement
than one would predict with the level of injury sustained.
used. In one author’s practice (KJB), the superficial peeling
agent is applied to the forehead first. If the patient is unusu-
ally sensitive or has an unusually rapid response to the peeling
agent, it is helpful to know this in advance of treating other
less sturdy areas. Next, the outer aspects of the face are
treated in a clockwise rotation from one temporal region to
the other. The nose, cheeks, and perioral regions are next
treated and the infraorbital region is treated last. The patient
is instructed to keep the eyes closed. Moistened gauze may
be placed over the eyes for further protection.
One author’s (KJB) preferred applicator for superficial
peeling is a wrung-out 4 × 4 gauze for TCA or Jessner peels.
Saturated cotton balls are used for glycolic peeling because
they are less abrasive. The infraorbital region is always treated
with saturated cotton-tipped applicators regardless of the
agent, and care is taken to minimize drip or splash exposure
to the eyes. The level of discomfort is generally quite toler-
able. A hand-held fan is placed 6 inches from the face to
minimize discomfort. Occasionally, with 50–70% glycolic
acid, the patient experiences more than mild discomfort.
With this agent, significant burning sensation and itching are
important signs that the peel is penetrating more deeply and
the peel should be neutralized sooner than anticipated.
Superficial peeling agents
Trichloroacetic acid 10–25%
TCA is one of the most commonly used and time-honored
agents for superficial peeling. It has no known systemic toxic-
ity. The depth of cutaneous penetration varies with the con-
centration of this agent. TCA 10–25% will produce necrosis
of superficial layers by precipitation of proteins, clinically
causing a mild epidermal slough. Many classify a one-coat
application of 35% TCA in the superficial category.37
However, the depth of penetration of this concentration will
vary with patient factors and technique and an intermediate
to medium depth peel can be produced.23 Aqueous solutions
of distilled water mixed with TCA crystals are prepared by
the pharmacist and are stable for 6 months at room tem-
perature in amber glass bottles.38 A solution of TCA 25%
consists of 25 g (United States Pharmacopeia, USP, crystals)
in 100 mL of distilled water. It is important in mixing that
the weight/volume method is utilized, as tremendous varia-
tion in concentration has been noted with other methods.39,40
The application method of TCA may be single to multiple
coats to the skin prepped with acetone or other agents. A
wrung-out 4 × 4 gauze is generally rubbed in with pressure.
With lower concentrations, mild erythema or whitish speck-
ling may be evident. With concentrations of 25% or greater,
a distinct white frost is seen. If this does not appear uniform,
repeated applications can be made to areas that do not frost.
If the frost is unexpectedly rapid or intense, water neutraliza-
tion may dilute the effect if applied within 30 seconds.41
Otherwise, the frosted areas are sponged with cold water
after 1 minute. Cold wet compresses are applied immediately
after the peel. Patients are told that stinging will crescendo
for 2 minutes and then subside. Antibiotic ointment is then
applied. The white frosting resolves within 1–2 hours. Light
peels can be performed weekly or biweekly at concentrations
of 10–15% TCA for acne vulgaris with minimal downtime.
Applications of 25–35% TCA may take 5–7 days to heal with
darkening of the face for 2–3 days and fine desquamation on
Box 24.7  Jessner’s solution formula
Resorcinol 14 g
Salicylic acid 14 g
Lactic acid 14 g
Ethanol 95% qs ad 100 mL1

399
Chapter 24  Chemical Peels
epidermis will have minimal resistance to penetration and it
is often best to delay treatment another week until the barrier
is intact. For this reason, an abrasive skin-cleansing regimen
is avoided. In one author’s (KJB) practice, the patient cleans
his or her face with a gentle cleanser and fingertips. The solu-
tion is applied with cotton balls rather than gauze to avoid
abrasive effects of rubbing.
Time dependency is a unique aspect of glycolic acid peeling.
The agent is left on anywhere from 15 seconds to 3 minutes
maximum for the first peel. With subsequent peels, the solu-
tions may be left on 15–30 seconds longer, up to 7 minutes
maximum. The nurse assistant monitors the time and
announces each 15–30 second time interval. Its is mandatory
for the physician to stay in the room during an AHA peel and
observe the skin continuously. If ‘hot spot’ erythema occurs,
the solution should be neutralized. First, the AHA solution
or gel is washed off the face and a 5% sodium bicarbonate
solution with multiple rinses is used to neutralize the AHA
agent. After the AHA peel in a patient with acne, the exfolia-
tion of stratum corneum helps to ‘unroof’ comedones better.
Pinpoint frosting, edema, or microvesiculation are sometimes
seen selectively around acne lesions. Indicators to neutralize
the solution include an unusual degree of patient discomfort,
mild erythema, or adequate time interval. For patients with
pigmentary disorders and type IV or higher skin type, the
time interval is more conservative to minimize the risk of
postinflammatory hyperpigmentation. Patients are advised
that minimal peeling will occur. However, because cellular
stimulation occurs even without appreciable desquamation,
pigment will improve. To further minimize potential postin-
flammatory hyperpigmentation in these patients, a topical
hydrocortisone ointment is applied immediately after the
peel. Topical bleaching agents are applied between peels for
optimal lightening.
Salicylic acid
Salicyclic acid (ortho-hydroxybenzoic acid) is a β-hydroxy
acid employed by dermatologists as a topical agent for acne,
They are reported to be of particular benefit in treating
postinflammatory hyperpigmentation, solar lentigines, and
melasma, even in Fitzpatrick IV–VI skin types.49,50 Indeed,
monthly glycolic acid 70% peels are one author’s (KJB) treat-
ment of choice for melasma of any depth in combination with
topical bleaching agents (Fig. 24.2). In one of the few com-
parison studies, a series of six glycolic acid 20% peels were
preferred by patients over six microdermabrasion treatments,
although efficacy was similar and quite minimal as both treat-
ments were mild.51 In another comparison study, glycolic acid
70% peels were equivalent to Jessner’s solution for efficacy
in active acne, yet caused less exfoliation and downtime and
were preferred by patients.52 These peels have also proven
efficacious in photoaging.53
Many other properties of glycolic acid solutions also affect
penetration, rendering this agent somewhat less predictable
in any given patient (Box 24.8).54 Low pH solutions (pH < 2)
appear to create more necrosis without improving efficacy.55
Most physicians use 70% glycolic acid unbuffered and unneu-
tralized.56 It is important for the practitioner to gain experi-
ence with one formula and technique and to be consistent
with peeling methods in order to gain predictability with
these peels. In addition, the depth of penetration of glycolic
acid peels appears to be more dependent of the condition of
the epidermis at the time of the peel. An irritated or inflamed
A
B
Figure 24.2  (A) Before and (B) after glycolic
acid 70% peel.
Box 24.8  Factors affecting the penetration
of AHAs
 Acid concentration (pH).
 Bioavailability.
 Degree of buffering.
 Volume of agent applied.
 Duration of time acid remains on skin.
 Condition of the epidermal barrier.
 Extent of degreasing.

400
Part 3  Aesthetic Surgical Procedures
Solid carbon dioxide
Although popular for the treatment of acne for many years,
solid CO2 slush is now rarely used. A 5–10-inch block of dry
ice at −78.5°C can be purchased inexpensively from ice plants
and other manufacturers and stored in office ice chests. A
piece is then broken off, wrapped in a towel, and dipped in
a solution of acetone and alcohol 3:1 which serves to melt or
slush the tip. It is then brushed with light or firm pressure
against the skin for less than 10 seconds. The tip requires
ongoing softening and is frequently dipped in the solution
during the peel. More or less pressure can be applied to the
skin, which will vary the depth that the epidermis is injured.
Mild erythema or bullae formation can ensue, depending on
the time and pressure. However, unlike potential adverse
reactions with liquid nitrogen at −186°C, hypopigmentation
and scarring are generally not problematic. Solid CO2 applica-
tion has also been described by Brody & Hailey as an enhance-
ment step preceding application of TCA 35% for a uniform
medium-depth peel.9
Tretinoin
Topical tretinoin (all-trans retinoic acid) has been a mainstay
of acne therapy and photoaging for many years. It has also
been used to prepare the skin before peeling or to prolong
results after peeling. The use of tretinoin as a superficial
peeling agent has been more recent. Cucé et al.64 reported
improvement in melasma, ephelides, and acne after a series
of five superficial peels with tretinoin 1–5%. Histology
revealed an increase in epidermal thickness and a reduction
in stratum corneum thickness. Topical tretinoin imparts a
yellowish coloration after application, making it easier to
visualize the treatment. In 48–72 hours, the skin undergoes
noticeable fine white desquamation. In one author’s (KJB)
experience, tretinoin solution 1.0% can be layered over other
superficial peeling agents to enhance desquamation.65 It is a
very safe peel that does not require neutralization or timing.
Treatment of atypical keratinocytes
A number of studies reported in the literature have demon-
strated the benefit gained through facial resurfacing in the
treatment of atypical keratinocytes (AKs), and ultimately
prevention of non-melanoma skin cancer (NMSC). A variety
of resurfacing techniques have been employed to achieve
this, including dermabrasion,66 CO2 laser,67 erbium:YAG
laser,68 and TCA peels.69 Recently, Hantash et al.70 studied
the effectiveness of CO2 laser resurfacing versus 5% 5-FU
cream versus 30% TCA peel for the treatment of AKs and
prophylaxis against NMSC. They found that all three modal-
ities demonstrated significant clearing of AKs, even at 3-month
follow up, and no significant differences were observed
between the modalities. A much lower rate of development
of new NMSC was appreciated in the TCA treatment arm
compared to the 5-FU and CO2 resurfacing-treated groups.
However, the number of treated patients was small, so gen-
eralizations cannot be made.
5-FU is a topical chemotherapy agent that acts by inhibit-
ing DNA and RNA synthesis, and has long been used in the
treatment of AKs. Although very effective in clearing AKs,
5-FU is associated with significant morbidity in the form of
pronounced erythema, burning, or pain. And, while very
effective in the treatment of hyperproliferative AKs, 5-FU
and antiaging in low concentrations. Utilized for years as a
component of Jessner’s solution at 14%, it has been used
more recently as a solo agent in 20–30% solutions for super-
ficial peeling. There are few reports in the literature regarding
salicylic acid peels. Kligman & Kligman developed the 30%
salicylic acid peel and noted several advantages over glycolic
acid peels.57 Salicyclic acid offers the advantage of uniform
application because the peel causes an immediate white pre-
cipitation and skip areas are readily visible. The peel is self-
limited and there is no need for timing or neutralization. Due
to the anesthetic property of salicylic acid, there is very little
discomfort immediately following the procedure. Berger
noted less subjective irritation with salicylic acid peels com-
pared to AHA peels.58 However, both Kligman & Kligman
and Ashinoff described more stinging during the salicylic acid
peel compared to glycolic acid peeling despite its anesthetic
properties.57,59 Theoretically, this peel may benefit acne more
than other peels, because besides being keratolytic, it is
comedolytic. The peel has been used successfully in Fitz-
patrick V and VI skin types although it is advised to start with
the 20% peel and to resume hydroquinone topically 48 hours
after the peel.60 Swinehart has reported on a 50% salicylic
acid ointment under occlusion for photoaging of the dorsa of
the hands and forearms.61 Much maceration and desquama-
tion ensues and the process may take 4 weeks to heal. In one
author’s (KJB) experience, this peel causes excessive morbid-
ity, and in one patient caused a few fine reticulated scars.
A recent study by Kessler et al.62 compared the efficacy of
α-hydroxy to β-hydroxy acids in the treatment of mild to
moderately severe facial acne. In a split-face, double-blind,
randomized study, 20 patients with mild to moderate acne
received 30% glycolic acid on one half of their face and 30%
salicylic acid on the contralateral side. Chemical peels were
performed every 2 weeks for a total of six treatments. They
found that both the glycolic acid peel and the salicylic acid
peel demonstrated significant reduction in acne counts by the
second treatment. No significant difference was appreciated
between the two treatment modalities. By 2 months after
treatment, the salicylic acid peel-treated side had a better
sustained decrease in acne count, although the finding did not
meet statistical significance.62
Chemical peels utilizing salicylic acid are often prepared
using ethanol as a vehicle. These preparations may cause
stinging, burning, and redness when used in acne patients.
Dainichi et al.63 recently developed a new formulation of 30%
salicylic acid in polyethylene glycol in an attempt to reduce
the morbidity associated with traditional salicylic acid peels.
In an elaborate study, they evaluated clinical and aesthetic
effects on acne patients as well as histologic effects in mice
using this new peel. They were able to demonstrate that the
histologic studies done on mice produced no inflammatory
changes following the application of the peel. Chemical
peeling with salicylic acid in polyethylene glycol on one side
of the face produced improvement in skin texture and
achieved an overall rejuvenated appearance compared to the
untreated side, without complaints of burning, stinging,
redness, or edema. The comedones and papules were mark-
edly reduced within 1 month of treatment. They were able
to demonstrate that the erythema, burning, and stinging often
associated with chemical peeling is not required for an effec-
tive response.63 Given the clinical outcome and the low rate
of side effects, this may represent a promising new approach
to chemical peeling.

401
Chapter 24  Chemical Peels
could be a valuable adjuvant treatment for melasma. When
comparing the TCA alone-treated patients to patients treated
with the combination TCA and ascorbic acid peel, a signifi-
cant reduction in pigmentation was noted in the combination
peel patients.76 Thus, while chemical peels have been used
for years, these recent studies show that they continue to be
a valuable and evolving treatment option for both medical and
cosmetic dermatologic conditions.
Postoperative care
Immediate postoperative care is minimal with superficial
peeling. A thin coat of petrolatum or antibiotic ointment is
applied after most peels. A topical steroid ointment may be
used if the skin reaction has been brisk. If the patient’s skin
type is Fitzpatrick IV or greater, the topical steroid may
reduce the risk of postinflammatory hyperpigmentation. The
newly peeled skin appears mildly to moderately erythema-
tous from a few hours to a few days. Superficial desquamation
will then occur over the following few days to a variable
degree depending on the peel. The patient is instructed to
cleanse twice daily and to resume his or her regular skin-care
regimen as soon as the skin seems back to normal. This will
vary from 1–7 days depending on the depth of the peel.
Patients with a history of facial HSV are given prophylactic
antiviral therapy. For light peels, oral antibiotics are not rou-
tinely prescribed. Patients are instructed to avoid sun expo-
sure and to wear sun-blocking agents as soon as the skin will
tolerate them.
Optimizing outcomes
has not been shown to significantly improve rhytides or len-
tigines. To this end, Marrero & Katz developed a new com-
bination peel of 5-FU and glycolic acid (termed the
Fluor-Hydroxy Pulse Peel) given in weekly pulses to treat
AKs and provide improved cosmesis of fine lines and len-
tigines, without the significant morbidity associated with
traditional courses of 5-FU.71 They designed a prospective,
randomized, controlled study of 18 patients with clinically
diagnosed facial AKs. Using a split-face paradigm, 70% buff-
ered glycolic acid was applied to one half of the face and a
5% 5-FU solution with 70% glycolic acid was applied to the
other half. The glycolic acid was applied with gauze for 2
minutes, allowed to remain on the skin for 2 minutes, and
then neutralized with water for 2 minutes. A thin layer of the
5-FU solution was then applied to one side of the face. Sub-
jects were then instructed to refrain from cleansing their face
for 24 hours. This technique was repeated weekly for a total
of 8 weeks. They found that using this pulse technique (rather
than daily application of 5-FU) markedly decreased morbid-
ity; no participants experienced any significant erythema. In
addition, when comparing the 5-FU/glycolic acid-treated side
to the glycolic acid only-treated side, statistically significant
greater clearing of AKs occurred. The authors theorized that
the decreased corneocyte cohesion produced by the glycolic
acid may enhance the penetration of 5-FU.71 In addition,
there was a greater reduction in the number of lentigines, fine
rhytids, and telangiectasia on the halves of the faces treated
with the combination peel, thereby suggesting a more sig-
nificant improvement in cosmesis.72
More recently, this pulse peel concept has been applied to
other disorders of hyperproliferative keratinocytes. Porokera-
toses are clonal hyperproliferation of keratinocytes. Reports
of malignant transformation of these lesions are abundant in
the literature. Treatment options have been limited and with
varying success, ranging from tretinoin, 5-FU, imiquimod,
cryosurgery, and photodynamic therapy among others. A
recent case report by Teixeira et al.73 treated disseminated
superficial actinic porokeratosis (DSAP) with the Fluor-
Hydroxy Pulse Peel. The patient underwent 8 weekly peels
with combination 70% glycolic acid and 5% 5-FU. Clinical
improvement in appearance and texture of the affected areas
was noted, and decrease in erythema was also noted lasting
up to 12 months.73 Despite these promising studies with this
combination peel, there have been no larger studies to date.
Recent novel approaches in chemical peels
for melasma
Several studies have been published recently on the treat-
ment of melasma with chemical peels. One such study com-
pared the efficacy of a 92% lactic acid chemical peel to
Jessner’s solution chemical peel in darkly pigmented skin.74
The study revealed both the lactic acid peel and Jessner’s
solution to be effective treatments, and no significant differ-
ence existed between the two modalities. Another study
treated patients with photodamage, superficial scarring, and
melasma with a series of peels using a new 50% pyruvic acid
peel, and achieved reasonable clinical results while being well
tolerated.75 Soliman et al.76 compared the treatment of
melasma using a 20% TCA peel alone versus a combination
20% TCA peel with topical 5% ascorbic acid. They hypoth-
esized that since ascorbic acid reduces the activity of tyrosi-
nase and thereby reduces melanin synthesis, ascorbic acid
Optimizing outcomes of superficial peels
 Target superficial pathology.
 Perform a series of light peels.
 Perform maintenance peels as needed.
 Recommend a topical regimen before and after the peel.
 Choose the most superficial peel for sensitive skin or dark
skin types.
 Combine with other modalities.
It is important that the goal of the peel does not exceed the
capability of a series of superficial peels. As stated previously,
multiple superficial peels, rather than one or two, need to be
performed to achieve optimal improvement. Some disorders,
such as melasma or acne vulgaris, may be recurrent or chronic
during a patient’s lifetime. It is best to advise these patients
that the problem may require periodic maintenance peeling
after the initial series for long-term control. Indeed, mainte-
nance peeling should be discussed with all patients since the
effects of superficial peels are not permanent. Studies have
shown a return to the pre-peel state within 60 days to 6
months.77,78
Topical regimens are essential to successful long-term
results. In one study, superficial peels that were not followed
with topical regimens had only temporary results.79 The skin
returned to pre-peel condition within 2 years. Sunscreens,
retinoids, bleaching agents, low-concentration AHAs, antioxi-
dants, and other appropriate agents should be prescribed and
recommended by the physician.14

402
Part 3  Aesthetic Surgical Procedures
TCA, and 70% glycolic acid with 35% TCA. Whichever tech-
nique is chosen, it is important to be consistent so that one
can be confident of obtaining good results.
The benefits of medium-depth peeling are seen in patients
with moderate actinic damage and sallow discoloration of the
skin without significant wrinkling (Box 24.10). Lawrence
et al.82 showed a 75% reduction in the number of AKs after
a medium-depth peel with Jessner’s solution and 35%
TCA. This was equal to the results one could achieve with
For patients with deeper pathology, combination therapies
may yield the best results. These may include layering a
therapeutic agent over a superficial peel. For actinic kera-
toses, the literature describes 5-FU solution applied either
over Jessner’s44 or glycolic acid peels.71 Efficacy is similar with
both peels: 88% clearing of actinic keratoses with Jessner’s
solution and 91.9% clearing with glycolic acid 70% and 5-FU.
Cosmetic improvement in photoaging was noted in both
series. Topical tretinoin is another topical enhancing agent for
acne vulgaris or melasma layered over various superficial
peeling agents.65
Another combination technique to optimize outcome and
minimize risk is to use different concentrations of the same
solution, different prep techniques, or even different peeling
solutions concurrently in the same patient depending on the
cutaneous pathology to be treated. One could more vigor-
ously treat acne scars on the cheeks or periorbital lines with
an abrasive prep and TCA 25% and treat other areas with a
conservative prep and weaker solution. Matarraso & Glougau
recommend that the final peel is individualized for each
patient.1
Combinations of laser therapy and superficial peels may
offer the most targeted therapy and the least downtime for
patients with more than superficial pathology. Lee et al.72
have suggested the combination of Q-switched alexandrite
laser with concomitant superficial TCA peeling for treatment
of recalcitrant pigmentary disorders. Although the peeling
agent was applied after laser treatment, it seems prudent to
apply the peel before the laser procedure to avoid deeper
penetration in the laser-treated areas. For patients with mul-
tiple solar lentigines and diffuse dyschromia, one author
(KJB) often treats the lentigines first with a Q-switched
yttrium-aluminum-garnet (YAG) or alexandrite laser, fol-
lowed a few weeks later by three successive monthly glycolic
peels for overall global improvement. Weiss described the
combination of microdermabrasion and non-ablative 1320-nm
resurfacing for acne scars.80 The combination was found to
be synergistic with superior results than either modality
alone. Rather than microdermabrasion, a superficial peeling
agent could be utilized prior to non-invasive laser thera-
pies. These and other novel combinations await further
investigation.
 MEDIUM-DEPTH CHEMICAL PEELS
Medium-depth peeling is defined as the application of one or
more wounding agents to the skin to produce a wound at or
through the level of the papillary dermis. The injury is associ-
ated with coagulation necrosis of the epidermis and part of
the papillary dermis with inflammation to the reticular
dermis. Indications for this type of peel include epidermal
growths such as AKs (Fig. 24.3), superficial seborrheic kera-
toses, lentigines, and other pigmentary dyschromia.81
TCA has been the gold standard wounding agent to achieve
a medium-depth peel to the skin. Medium-depth peeling
concentrations range from 35% to 50%. However, 45–50%
TCA may produce an unpredictable response. In an attempt
to reduce morbidity of higher concentrations of TCA, com-
binations of chemical peeling agents should be used. These
combination peels produce a more even and deeper penetra-
tion than higher concentrations of TCA (Box 24.9).
The most common combination peels include: solid CO2
ice freezing with 35% TCA, Jessner’s solution with 35%
A
B
C
Figure 24.3  (A) Before, (B) 8 days after, and (C) 6 months after
TCA medium-depth peel for actinic keratosis.

403
Chapter 24  Chemical Peels
5-FU topical therapy (Fig. 24.4). Other indications include
atrophic acne scars,69 pigmentary dyschromia such as lenti-
genes, and melasma. Blending of facial areas in conjunction
with other deeper resurfacing methods can optimize the
outcome of a medium-depth peel. Today, dermatologists and
cosmetic surgeons are blending these areas using the frac-
tional resurfacing laser. Other acids such as bichloroacetic
acid can be carefully used as spot treatments for conditions
such as trichodiscomas, sebaceous hyperplasia, syringomas,
and trichoepitheliomas (Fig. 24.5). TCA in higher concentra-
tions such as 50% or greater can be used to spot treat thick
actinic keratoses.
Technical aspects
The technique that one author (SEC) finds most predictable
is the Jessner plus 35% TCA peel. The technique of medium-
depth peeling with Jessner’s solution and 35% TCA includes
pretreatment conditioning of the skin as described previously
in this chapter.
The patient is asked to come in without make-up and
cleanses the skin with a gentle cleanser. With the patient in
Box 24.9  Medium-depth chemical
peeling agents
 50% TCA.
 Solid CO2 + 35% TCA.
 Jessner’s solution + 35% TCA.
 70% glycolic acid + 35% TCA.
 88% phenol.
 Pyruvic acid.
Box 24.10  Indications for medium-depth peel
 Actinic damage.
 Epidermal growths.
 Pigmentary dyschromias.
 Superficial scarring.
 Superficial rhytides.
 Blending sun-damaged skin with deeply resurfaced skin.
A
B
C
D
Figure 24.4  (A,C) Before and (B,D) 19 days after TCA medium-depth peel for actinic keratosis.

404
Part 3  Aesthetic Surgical Procedures
A
B
Figure 24.5  Treatment of trichodiscomas on the nose and cheeks. (A) Before and (B) after bichloroacetic acid spot treatment.
the upright-seated position, the inferior edge of the mandible
is marked so that when the patient is supine, one can feather
the 35%TCA below this point. The neck can be treated with
Jessner’s solution at the same time as a medium-depth facial
peel. The author uses 4 × 4 gauze with acetone and a moder-
ate pressure scrub to degrease the skin. This is repeated until
no residual oils are apparent on the skin.
After cleansing is complete, Jessner’s solution is applied
with large cotton-tipped applicators or 2 × 2 gauze. The
cotton-tipped applicators are not as easily saturated and
deliver less acid to the skin. One to two coats of Jessner’s
solution is applied in order to achieve a light, white even frost.
Patients usually experience a mild stinging and burning sensa-
tion. The skin appears slightly erythematous with speckled
areas of whitening. One can identify the uniformity of the
peel solution by using a Wood’s lamp. The salicylic acid in
the Jessner’s solution fluoresces under the Wood’s light,
giving the physician another method for ensuring even cover-
age of the solution.83
The use of Jessner’s solution disrupts the barrier function
of the skin, allowing for a uniform penetration of TCA. TCA
35% is applied starting from the mid-face, where there is the
highest concentration of sebaceous glands. The author uses
several large cotton-tipped applicators to apply the acid. The
applicator is more saturated initially; this is the rationale for
starting in the central face where there is less risk of scarring.
The entire face should be treated and feathering into the
hairline and below the jawline should be done to ensure that
no lines of demarcation occur between treated and untreated
areas. The reaction of precipitated protein coagulation of the
skin is manifested as a ‘frost’ or whitening and it takes 1–2
minutes to complete. The time it takes for the skin to frost
is directly related to how well the skin has been pretreated
and degreased. An additional factor is the amount and con-
centration of the TCA used and the degree of actinic damage.
The coarser, more sun-damaged skin will react more slowly
and require more heavily applied acid. Areas where frosting
is patchy may be retreated with a minimally saturated cotton-
tipped applicator. The more heavily saturated the applicator,
the deeper the penetration of the acid. For this reason, when
treating the lower eyelid skin it is important to use a mini-
mally damp cotton-tipped applicator. Additionally, an assist-
ant should hold two small dry cotton-tipped applicators at
the medial and lateral canthus of the eye to catch any tears
that may develop and prevent ‘wicking’ of the acid into the
eye. Artificial tear solution, for rapid flushing of the eyes,
should be available if necessary. The author (SEC) likes to
hold a dry 4 × 4 gauze so that acid does not drip onto any
untreated areas. If the patient has deep vertical upper lip lines
and one is not using a deeper peeling agent or laser resurfac-
ing, an assistant should stretch out the lip lines while the peel
solution is applied with a small cotton-tipped applicator. This
allows for even coating and prevents pooling of acid into
rhytides.
Hyperkeratotic growths such as thick seborrheic keratoses
and AKs can be curetted or frozen with liquid nitrogen prior
to the peel. Thinner lesions can be treated simply by applying
extra peel solution and rubbing it directly into the lesions.84
Within seconds of applying the TCA there is a burning sensa-
tion on the skin. Whitening appears and the intensity of the
burning decreases quickly. There is no neutrilization of TCA
peels. Once the solution has been applied, there are about 30
seconds in which it can be diluted prior to keratocoagulation
and the frosted appearance. Ice-soaked gauze is applied
directly on the skin to relieve the burning sensation and cool
packs are placed over this gauze to decrease the hot sensation.
Once the patient feels comfortable, petrolatum-based oint-
ment or Aquaphor ointment (Beiersdorf, Inc, Wilton, CT),
or Cold-Cream (La Roche-Posay, France) may be applied as
a thin layer multiple times per day.85 The patient may be
given an injection of steroid or an oral steroid taper to help
decrease post-procedure edema.
Postoperative care
Within approximately 30 minutes after the peel, the skin
appears erythematous and there is a ‘sun-burn’-like sensation.
Edema occurs within the first 24 hours. The patient is
instructed to keep the skin greasy with the above emollients
until desquamation is complete, generally within 5–7 days.
Acetic acid 0.25% and cool water soaks can be applied three
to five times daily for the first few days. Alternatively, patients
can splash cool water on their face or shower several times
during the day. By 24 hours after the peel, the skin has a light
brown appearance (Fig. 24.6). Areas of pigmentary dyschro-
mia and freckling appear darker. Desquamation begins around

405
Chapter 24  Chemical Peels
facilitate the peeling process by scrubbing or picking at the
skin. It is also important to warn them against coming in
contact with harsh chemicals or cleaners that may be aero-
solized and irritate the newly epithelialized skin (Fig. 24.7).
Patients can wear make-up within 7–10 days post peel and
the erythema fades between 2 and 4 weeks post peel (Figs
24.8 and 24.9). Sun avoidance and the use of sunscreen are
required once re-epithelialization is complete. Post-peel visits
may vary among physicians. This author (SEC) sees the
patients on day 3 and day 7, to reassure them and review
post-peel care. AHAs may be restarted on week 3 after the
peel, and tretinoin 4–6 weeks after the peel if the skin is not
too sensitive.
Opimizing outcomes
The use of botulinum toxin injections (Botox, Allergan, Inc,
Irvine, CA) 7–10 days before the peel will enhance the
results. Botox denervates the underlying muscles of facial
expression that produce dynamic wrinkling. The onset of
action occurs within 24–72 hours after injection and lasts 3–6
months.86 New collagen formation can then be laid down over
a stationary area allowing the fabric of the skin to heal without
reinforcing the creation of the wrinkles.
Other ancillary procedures such as injectable fillers will
enhance the results. Laser resurfacing to the deeper perioral
rhytides complements medium-depth peeling and should
always be performed after the peeling, at the end of the
procedure. It allows the practitioner to individualize the peel
and optimize the results (Fig. 24.10).
 DEEP CHEMICAL PEELS
(PHENOL PEELS)
Phenol is a keratocoagulant originally used in carbolic acid as
a disinfectant. In the 1940s and 1950s, a ‘secret’ formula that
contained phenol was brought by lay peelers to the USA from
Eastern Europe. Baker & Gordon and Litton provided the
scientific clinical works demonstrating the dramatic effects
following phenol facial peels.87–90
the mouth and in the central portion of the face. The last
areas to peel are usually along the hairline. Peeling often starts
on day 3 and is complete within 1 week. Once peeling has
occurred, the skin will have a subtle erythema. If peeling has
occurred too quickly, the skin will appear blotchy and redder
than expected. It is important to counsel patients not to
A
B
C
Figure 24.6  TCA medium-depth chemical peel and glabellar
botulinum toxin. (A) Before, (B) 2 days after, and (C) 12 days
after.
Figure 24.7  Seven days after TCA medium-depth chemical
peel. Contact dermatitis as a result of Tilex cleaning solution
exposure. Note the patchy erythema on the chin and the area
superior to the nasolabial folds.

406
Part 3  Aesthetic Surgical Procedures
A
B
Figure 24.8  (A) Before and (B) 28 days after TCA medium-depth chemical peel for actinically damaged skin actinic keratoses and
lentigines.
A
B
C
D
E
F
Figure 24.9  (A–C) Before and (D–F) 12 weeks after TCA medium-depth peel for actinic keratosis.

407
Chapter 24  Chemical Peels
before applying the solution, followed by an additional
1000 mL of fluid during the operative and immediate post-
operative period.92
Phenol is known to be cardiotoxic. To avoid cardiac arrhyth-
mias, a full-face peel should extend over a 60–90 minute
period. No more than 50% of the face should be treated
during a 30-minute period.92 Cardiac monitoring is necessary
during and after the procedure.
‘Baker’s formula,’ developed by Baker and Gordon, is the
most widely used deep-peel agent (see Box 24.11 for the
formulation). The solution should be freshly prepared
and stirred constantly both before and during the applica-
tion to ensure a more even peel. In Israel and Europe, the
Phenol Peel Exoderm, developed by Fintsi & Landau,93 is
mainly used. The solution is manufactured in Israel and ready
for use; it is a stable solution which does not need to be
stirred.
Proper patient selection is the most important aspect of
obtaining satisfactory results and avoiding complications. The
ideal patient is a thin-skinned woman with fair complexion
and generalized wrinkling. These individuals are less likely to
have lines of demarcation between peeled and unpeeled skin.
Because of the cardiotoxicity of phenol, if the deep phenol
peel is being considered for the entire face, the patient must
have a normal hepatorenal and cardiovascular (electrocardio-
gram) status. The following conditions are most successfully
treated:
• Facial wrinkles, periocular and periorbital regions.
• Pigmentary dyschromia.
• Actinic keratoses.
• Superficial, shallow acne scars.91
Preoperative preparation
Adequate cleansing of the face and removal of deep facial oils
are imperative, especially if an open technique is used instead
of taping the skin after phenol peeling. The use of Septisol is
advocated as the astringent of choice as it has keratolytic
properties. Following facial cleansing, acetone is used to
further remove facial oils.
Intravenous sedation is standard when full-face phenol
chemexfoliation is being performed. Adequate hydration is
necessary to avoid renal and cardiac toxicity. The recom-
mended hydration consists of 500  mL of Ringer’s lactate
A
B
C
D
E
F
Figure 24.10  TCA medium-depth peel with adjunctive treatments: Vbeam, botulinum toxin, and injectable fillers. (A–C) Seven days
after Vbeam to cheeks and botulinum toxin to glabella, and before TCA medium-depth peel and injectable fillers. (D–F) Seventeen
days after TCA medium-depth peel and injectable fillers to lips and oral commissures.
Box 24.11  Baker/Gordon phenol formulation
Phenol USP 88% 3 mL
Distilled water 2 mL
Septisol liquid soap (8 drops)
Croton oil (3 drops)

408
Part 3  Aesthetic Surgical Procedures
 NON-FACIAL PEELS
Peeling techniques have traditionally been limited to the face,
because standard techniques have resulted in inconsistent
results. Non-facial skin has a decreased number of hair fol-
licles, sebaceous glands, and dermal vessels. This decrease in
adenexal structures impairs wound healing. Non-facial areas
have a narrower margin for error than the face. Traditionally,
peeling of these areas requires a lower concentration of acids
and serial treatments.
A controlled chemical peel technique for non-facial skin
using 70% glycolic acid gel combined with 35% or 40% TCA
has given consistently good results on the arms, hands, chest,
neck, back, and legs. This peel is easy to implement and
produces a peel in which the depth can be controlled more
precisely, ranging from light to medium. The technique has
been called the ‘Cook total body peel.’96 The skin is degreased
with acetone and 70% glycolic acid gel is applied to the skin
using 4 × 4 gauze. This is followed immediately by 40% TCA
on 4 × 4 gauze. The skin is carefully monitored so the physi-
cian can neutralize the peel at the desired depth with copious
amounts of 10% sodium bicarbonate solution. The typical end
point desired is characterized by erythema with scattered
white speckles (Fig. 24.11). Certain areas may require more
time or more TCA to achieve the desired end point control-
led by the physician. Blending can easily be achieved with this
technique. It is important to use glycolic acid gel rather than
liquid, because the gel acts as a partial barrier to the TCA
penetration. Liquid glycolic acid could result in increased
penetration of the TCA and resultant scarring.
After this body peel, the skin will flake for 2–4 weeks
depending on the area (Fig. 24.12). Hydrating the skin with
an emollient helps during the healing phase. Clinical results
produce smoother skin texture, decreased wrinkling, and
fading of lentigines (Fig. 24.13). The author (SEC) has also
used this peel to achieve reduction of actinic keratosis and
disseminated superficial actinic porokeratosis (Fig. 24.14).
Other peeling options for non-facial skin include low con-
centrations of TCA, varying from 20% to 25%, and perform-
ing serial treatments over time. Brody has advocated the use
of 35% TCA for acne scarring of the back with the placement
of 50% TCA to the elevated peripheral scar edges.97 Serial
Technical aspects
After proper degreasing with Septisol, cleansing with water,
and wiping the skin with acetone, the peel may begin. Fresh
Baker’s solution is mixed to provide a turbid emulsion. It is
then applied using cotton-tipped applicators that have been
pressed against the rim to remove excess solution. The solu-
tion is applied slowly over aesthetic units, allowing 10–15
minutes to elapse between regions to prevent cardiotoxicity.
The skin immediately turns white (frosted) as the phenol
solution causes keratolysis and keratocoagulation. The initial
pain that is felt subsides within minutes but then returns later
in the day as the effect of the initial sedation and the anes-
thetic effect of the phenol subside. The solution is feathered
beyond the margins of the peeled areas to reduce lines of
demarcation.
Periorbital and perioral areas must be treated cautiously.
When applying the solution in the periocular area, there
should be no excess solution on the applicator. Upper eyelid
peeling should not be carried down below the superior tarsal
fold. Lower eyelid peeling should be done with the patient
gazing upward. Cotton-tipped applicators should be placed in
the medial and lateral canthi to blot tears. Perioral peeling
should be carried out by stretching out the vertical rhytides
so that the peel solution can be applied evenly. A broken
wooden applicator can be used to apply more solution to the
deepest crevices.
Postoperative care
Postoperatively, the patient should be monitored for cardiac
arrhythmias for at least 1 hour.94 Several authors have
switched from using a closed technique of taping to an open
technique.92,94,95 The advantages of an open technique include
less pain, less penetration of phenol, lower risk of scarring,
quicker re-epithelialization, and less risk of infection.
However, if deep wrinkles are treated, the result may be
better if a waterproof zinc oxide non-porous tape is applied
in short overlapping strips and then optionally covered with
several long horizontal strips for better adherence.85 The
mask is removed 24 hours after application of the phenol
solution.
Fintsi & Landau developed a powder with bismuth subni-
trate used as a second ‘mask’ for 1 week, forming a dry crust
until full re-epithelialization of the skin is achieved.93 The
mask is then removed using repeated applications of Cold-
Cream (La Roche-Posay). The next day, that is the 8th day
after the peel, the skin is completely healed. When using the
open technique, petrolatum ointment should be applied to
the peeled areas and liberally reapplied during the subsequent
week. The patient gently washes or soaks the skin and reap-
plies the ointment to prevent dehydration and crust forma-
tion that could retard healing. This process is repeated six
times a day until re-epithelialization is complete, usually
within 7 days. The skin appears erythematous for up to 12
weeks. Sun avoidance for 3–6 months is important to prevent
hyperpigmentation from developing.
Histologic and clinical changes in the epidermis and dermis
persist for as long as 15–20 years.88 Histologically, there is
improvement in the dermal architecture, and a grenz zone
measuring 2–3 mm develops between the epidermis and the
underlying elastotic tissue.
Figure 24.11  Frosting from Cook body peel.

409
Chapter 24  Chemical Peels
Figure 24.12  In the process of peeling 5 days after Cook body
peel.
A
B
Figure 24.13  (A) Before and (B) 21 days after Cook body peel.
Pitfalls and their management
 Careful patient selection is essential, as well as screening for risk
factors, especially those that increase the risk of scarring (such
as recent isotretinoin, previous radiation therapy, and recent
surgery that has compromised vascular supply to the skin).
 Advise patients about sun protection after the peel to avoid
dyschromia and postinflammatory hyperpigmentation.
 For deep peels, advise patients to expect hypopigmentation.
 Institute meticulous wound hygiene to reduce the risk of
infection.
 For mid to deep peels, use antiviral prophylaxis in all patients
who are immunocompromised or have a history of HSV infection.
Jessner peels and 50% salicylic acid ointment under occlusion
described by Swinehart may also be used.61
 PITFALLS AND THEIR MANAGMENT
A
B
Figure 24.14  (A) Before and (B) after two treatments of Cook body peel for disseminated superficial actinic porokeratosis.

410
Part 3  Aesthetic Surgical Procedures
are applied to the skin during the early healing process. They
are easily treated with an 18-gauge needle and comedone
extractor.
Prolonged erythema
Persistent erythema is more closely associated with deeper
resurfacing procedures but it may be seen after medium-
depth peels and rarely after superficial peels. When erythema
is localized and persistent, one needs to consider both contact
dermatitis and early impending scarring (Fig. 24.16). Maloney
et al.98 evaluated the etiology of persistent erythema after
chemical peeling and devised a successful treatment plan in
all 196 cases reviewed. Suggested treatment included avoid-
ance of possible irritants, emollients, bland topical steroids,
0.25% acetic acid soaks, and if needed, systemic steroids. In
one author’s (SEC) practice, long pulsed-dye laser treatment
is also initiated if the erythema persists beyond 6–8 weeks or
if textural changes occur. Rarely does one need to administer
intralesional steroids.
Infection
Infection is rare following chemical peels. Both TCA and
phenol are bactericidal,99 although this is generally not a
factor since infection occurs often days after the peel. Poor
The risks of complications from peels (Box 24.12) increase
proportionately with the depth of the wound. Superficial
peels carry the lowest risk of adverse reactions, and if they
occur they are usually pigmentary in nature. Medium-depth
peels can cause pigmentary changes and rarely scarring. Deep
peels are associated with these risks and systemic reactions
can occur.
Pigmentation (hypo-/hyperpigmentation)
The most common complication of chemical peeling is
abnormal pigmentation. Lighter peels are more likely to be
associated with hyperpigmentation and deeper peels with
hypopigmentation. Hyperpigmentation is usually transient
and is best treated with hydroquinone bleaching agents, retin-
oic acid, or tazarotene cream and a physical barrier sunscreen
such as titanium dioxide. Exogenous estrogens, photosensitiz-
ing medications, and direct sun exposure during the first 6
weeks after peels increase the risk of hyperpigmentation (Fig.
24.15). Hypopigmentation is a normal sequela of phenol
peels and deeper resurfacing procedures. It is essential to
educate the patients pursuing deeper peels that hypopigmen-
tation or a line of demarcation between peeled and non-
peeled areas is a tradeoff for smoother, more youthful skin.
Accentuation of nevi may also occur after chemical peeling.
Milia
Milia result from occlusion of the pilosebaceous unit. They
usually occur within the first 1–3 months after peels. They
may be due to the use of petrolatum-based ointments that
Figure 24.15  Postinflammatory hyperpigmentation.
A
B
Figure 24.16  (A) Persistent erythema 1 month after 70% glycolic acid peel. (B) After two treatments with pulsed-dye laser.
Box 24.12  Complications of chemical peeling
 Pigmentary alteration.
 Scarring.
 Infection.
 Milia.
 Persistent erythema.
 Atrophy.
 Textural changes.
 Cardio-, nephro-, and hepatotoxicity; laryngeal shock; toxic
shock syndrome (limited to phenol peels).

411
Chapter 24  Chemical Peels
wound care is what most frequently contributes to post-peel
bacterial infection (Fig. 24.17). Occlusive ointments may
promote folliculitis that may be secondarily infected with
Staphylococcus or Streptococcus. Pseudomonas is another path-
ogen that can be identified with poor wound hygiene. When
infection is suspected, cultures should be taken and immedi-
ately broad-spectrum antibiotics and frequent acetic acid
soaks should be instituted. Toxic shock syndrome has been
reported in association with phenol-based peels.100
Chemical peeling may activate HSV (Fig. 24.18). It is
important to note that the development of postoperative
HSV infection cannot be predicted based on a prior history
of a ‘cold sore.’ This supports the policy of prescribing anti-
viral prophylaxis for all patients regardless of HSV history.101
The onset of HSV infection is often heralded by severe facial
or perioral burning pain. Within 24 hours, vesicles develop
and these give way to punched out ulcers. Untreated infec-
tion will spread to the de-epithelialized areas. Despite oral
HSV prophylaxis, occasionally patients will develop ‘break-
through’ infection. The prophylaxis that one author (SEC)
adheres to is valaciclovir 500 mg twice per day beginning the
day prior to the procedure and until completely re-epitheli-
alized – usually 7–10 days after the peel. If a herpetic infec-
Figure 24.17  Bacterial infection after peel.
Figure 24.18  Perioral herpes simplex virus infection after
resurfacing.
Figure 24.19  Cutaneous candida infection after peel.
tion does develop. the dose is increased to 1000 mg every
8 hours.
Cutaneous candida infection may also be seen after chem-
ical peeling or resurfacing (Fig. 24.19). Perioral pustules
develop and rapidly spread to adjacent areas. Patients com-
plain of an itching or burning sensation. Topical or oral anti-
fungal agents can be used to treat this superficial infection.
Perlèche, concomitant vaginal candidiasis, and recent oral
antibiotics may be predisposing risk factors.
Scarring
Scarring is one of the most dreaded complications of chemi-
cal peeling. The risk of scarring increases with the depth of
the peel (Fig. 24.20). TCA at concentrations greater than
50% is unpredictable and can lead to scarring. Factors that
may increase the risk of scarring include a history of isotretin-
oin within a 6-month period. Surgery that involves large areas
of undermining may increase the risk of sloughing if done at
the same time as a peel. Previous medium or deep peels,
dermabrasion, or laser resurfacing without waiting 6–12
months also can increase the risk for scarring. Hereditary
predisposition or connective tissue disease such as the mitis
form of Ehlers–Danlos syndrome can affect the rate of
healing.98
Early scarring manifested as indurated, patchy erythema
should be treated aggressively as discussed above with pulsed-
dye laser, topical, intralesional, or oral steroids.
Systemic complications
Systemic complications may be seen with phenol peeling.
Phenol applied quickly can produce cardiotoxicity, hepato-
toxicity, and nephrotoxicity. It is suggested that peeling the
skin in segments and intervals allows the metabolism of the
absorbed phenol and thus decreases the chance of arrhyth-
mias.92 For that reason, cardiac monitoring is extremely
important. Intravenous hydration assists in clearing the phenol
from the circulation and decreases the likelihood of toxicity.
 SUMMARY
Chemical peeling is an effective technique to combat the
effects of photoaging, a variety of pigmentary disorders and
epidermal growths. Given the media hyperbole, it is particu-
larly important that patients are fully aware of the efficacy

412
Part 3  Aesthetic Surgical Procedures
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A
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100. Resnik SS. Complications of chemical peeling. Cosmet Dermatol
1995;13:309.
101. Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing.
Dermatol Surg 1998;24:315–320.
43. Pascher F. Systemic reactions to topically applied drugs. Bull NY Acad
Med 1973;49:613–627.
44. Katz B. The new fluor-hydroxy pulse peel: a pilot evaluation of a new
superficial chemical peel. Cosmet Dermatol 1995;8:24–30.
45. Monheit G. The Jessner’s + TCA peel: a medium-depth chemical peel.
J Dermatol Surg Oncol 1989;15:945–950.
46. Hernandez-Perez E, Jaurez-Arce V. Gross and microscopic findings with
a combination of Jessner solution plus 53% resorcinol paste in chemical
peels. J Cosmet Surg 2000;17:85–89.
47. Bernstein E, Lee J, Brown D, et al. Glycolic acid treatment increases
type I collagen mRNA and hyaluronic acid content of human skin.
Dermatol Surg 2001;27:429–433.
48. Moy L, Peasce S, Moy R. Comparison of the effect of various chemical
peeling agents in a mini-pig model. Dermatol Surg 1996;22:429–432.
49. Lim JT, Tham SN. Glycolic acid peels in the treatment of melasma
among Asian women. Dermatol Surg 1997;23:177–179.
50. Sarkar R, Kaur C, Bhalla M, et al. The combination of glycolic acid peels
with a topical regimen in the treatment of melasma in dark-skinned
patients: a comparative study. Dermatol Surg 2002;28:828–832.
51. Alam M, Omura N, Dover J, et al. Glycolic acid peels compared to
microdermabrasion: a right–left controlled trial of efficacy and patient
satisfaction. Dermatol Surg 2002;28:475–479.
52. Kim S, Moon S, Kim J, et al. Glycolic acid versus Jessner’s solution:
which is better for facial acne patients? Dermatol Surg 1999;25:269–
273.
53. Moy LS, Murad H, Moy R. Glycolic acid peels for the treatment of
wrinkles and photoaging. J Dermatol Surg Oncol 1993;19:243–246.
54. DiNardo J, Grove G, Moy L. Clinical and histological effects of glycolic
acid at different concentrations and pH levels. Dermatol Surg
1996;22:421–424.
55. Becker FF, Langford FPJ, Rubin MG, et al. A histological comparison
of 50% and 70% glycolic acid peels using solutions with various pHs.
Dermatol Surg 1996;22:463–465.
56. Brody H, Coleman W, Piacquadio D, et al. Round table discussion of
alpha hydroxy acids. Dermatol Surg 1996;22:475–477.
57. Kligman D, Kligman A. Salicylic acid peels for the treatment of photo-
aging. Dermatol Surg 1998;24:325–328.
58. Berger R. Initial studies show salicylic acid promising as antiaging prep-
aration. Cosmet Dermatol 1997;10:31–32.
59. Ashinoff R. Beware too high expectations with peels. Skin and Allergy
News 1999:February.
60. Grimes PE. The safety and efficacy of salicyclic acid chemical peels in
darker racial-ethnic groups. Dermatol Surg 1999;25:18–22.
61. Swinehart J. Salicylic acid ointment peeling of the hands and forearms.
J Dermatol Surg Oncol 1992;18:495–498.
62. Kessler E, Flanagan K, Chia C, et al. Comparison of α- and β-hydroxy
acid chemical peels in the treatment of mild to moderately severe facial
acne vulgaris. Dermatol Surg 2008;34:45–51.
63. Dainichi T, Ueda S, Imayama S, et al. Excellent clinical results with a
new preparation for chemical peeling in acne: 30% salicylic acid in
polyethylene glycol vehicle. Dermatol Surg 2008;34:891–899.
64. Cucé L, Bertino M, Scattone L, et al. Tretinoin peeling. Dermatol Surg
2001;27:11–14.
65. Fitzpatrick RE, Goldman MP, Butterwick KJ. Reversal of photoaging in
ten weeks: a novel skin peeling system with a uniquely formulated post-
peel regimen. Int J Cosmet Surg Aesthet Dermatol 2001;3:199–203.
66. Coleman WP III, Yarborough JM, Mandy SH. Dermabrasion for prophy­
laxis and treatment of actinic keratoses. Dermatol Surg 1996;22:
17–21.
67. Trimas SJ, Ellis DA, Metz RD. The carbon dioxde laser: an alternative
for the treatment of actinically damaged skin. Dermatol Surg 1997;
23:885–889.
68. Iyer S, Friedli A, Bowes L, et al. Full face laser resurfacing: therapy and
prophylaxis for actinic keratoses and non-melanoma skin cancer. Lasers
Surg Med 2004;34:114–119.
69. Waiz M, Ali Al-Sharye. Medium-depth chemical peels in the treatment
of acne scars in dark skinned individuals. Dermatol Surg 2002;28:383–
387.
70. Hantash BM, Stewart DB, Cooper ZA, et al. Facial resurfacing for
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71. Marrero G, Katz B. The new fluor-hydroxy pulse peel. Dermatol Surg
1998;24:973–978.

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415
25
Implants
J Michael Carney MD
Summary box
 The chin plays a key role in contributing to facial balance and
harmony, from ancient history through contemporary culture.
 Proper head positioning in the Frankfort horizontal plane is
essential for preoperative assessment.
 Proper implant material selection and design achieve pleasing
results with minimal complications.
 Techniques are described for the submental and
subperiosteal approaches to placing an extended Silastic
implant.
 Suggestions are presented for improving implantation
technique; bone has many advantages for a dissection plane.
 A review of complications, including mental and marginal
mandibular nerve injury, emphasizes their prevention and
management.
 INTRODUCTION
For centuries a strong chin has been a desirable attribute,
from ancient times to contemporary high fashion and enter-
tainment. A look through any popular celebrity ‘image’ mag-
azine reveals predominantly strong chins, on both women and
men. Visualize some of the major stars of movies, past and
present, male and female, or national leaders. Try to imagine
an Oscar winner or president with a weak chin – it is quite
difficult to do so. A strong chin implies power, beauty, con-
fidence, intelligence, success, and ‘strength’ (Fig. 25.1). A
weak chin connotes submissiveness, indecisiveness, or ‘weak-
ness.’ Our perception of character based on particular facial
characteristics dates back to Aristotle. In one study regarding
facial features and military rank at West Point, men whose
features were prominent – including a strong chin – were
compared with submissive-looking men, who had, among
other things, receding chins. Photographs alone were predic-
tive of rank and achievement, with prominent-featured men
outranking their submissive-appearing classmates in their
junior and senior years, as well as in their profession later.1
A study of idealized profiles compared with those in the
general population showed that ‘ideal’ chins are actually
larger than those that occur naturally;2 these ideal chins, seen
on beautiful people and on sculptures, are truly ‘larger than
life.’
What is it that defines a profile as ideal?
Gonzalez-Ulloa, in the 1960s, published a series of articles in
which he studied profiles of ‘ideal’ faces and applied the
principles described by artists to surgical ‘profileplasty.’4–6
Profile analysis is based on the interrelationship of several soft
tissue landmarks (Table 25.1). Based on these, Gonzalez-
Ulloa used two reference lines to evaluate the profile. The
first was the Frankfort horizontal plane, introduced in Frank-
furt, Germany, in 1884 as a reliable reference plane for
standardizing the position of the face in relation to the surface
of the earth.7 (Frankfort is often, though not always, spelled
with an ‘o’ in North American literature.) It is defined as a
horizontal line from the superior border of the external audi-
tory canal (porion) to the inferior aspect of the orbital rim
(orbitale) with the patient’s gaze parallel to the floor (Fig.
25.2). This is considered a neutral position and should be
consistent and reproducible in evaluation and photographs.
The reliability of the Frankfort horizontal plane was outlined
by Ricketts8 who emphasized its importance in standardizing
clinical communication. Professional journals require that
photographs submitted for publication should be in the
Frankfort plane.9
Historical vignette
 Classical sculptors believed than an ideally proportioned face
required, among other characteristics, the chin to be
projected anteriorly enough to meet their aesthetic guidelines.
 Michelangelo used the Apollo Belvedere (Fig. 25.1A) as a
model for his Christ in the Last Judgment at the Sistine
Chapel, and Goethe and other leaders of the Greek Revival
saw it as the perfect example of classical beauty; this Apollo
was also used by Edward Angle, the father of orthodontics, in
defining the ideal face.3
 Artists and sculptors as far back as the classical era, and
possibly earlier, depicted beauty by following mathematical
concepts.
 The Greeks strove to envision the human body as perfectly
and harmoniously proportioned; thus, for example, Plato
believed that beauty required proper measure and proper
size of parts fitting harmoniously into one whole.
 Guidelines based on mathematics and geometry developed
during classical and Renaissance periods have persisted, and
have been adopted by aesthetic surgeons.

416
Part 3  Aesthetic Surgical Procedures
The second reference line was a vertical line (facial plane)
drawn from the depression at the root of the nose (nasion),
intersecting the Frankfort horizontal line at an angle of 90°.
Using these two reference planes in an analysis of classically
beautiful faces in art and contemporary culture, Gonzalez-
Ulloa concluded that in ideal profiles the most anterior
portion of the chin meets this vertical line. He adapted this
concept to surgical planning. When the chin falls behind
this vertical line (dashed line in Fig. 25.2), a chin defi-
ciency becomes apparent and indicates that surgically
A
B
Figure 25.1  Strong chins have traditionally implied strength, beauty, and harmony. (A) Apollo Belvedere, a Roman copy of a Greek
work, in the Belvedere courtyard above the Vatican Palace. (Courtesy of Takashi Okamura.) (B) Idealized athletes on a gold medal
from the eighth Winter Olympics. (Courtesy of Tom Kimmell.) (C) The actress Grace Kelly. (From Taraborrelli JR. Once upon a time:
behind the fairy tale of Princess Grace and Prince Rainier. New York: Rose Books Inc; 2003. Copyright © Yousef Karsh.)
Table 25.1  Key soft tissue points and planes in
profile analysis
ANTERIOR
CERVICAL LINE
TANGENTIAL TO THE VERTICAL
PORTION OF THE NECK
Cervical point
Intersection of submentum (submental or
horizontal line) and neck (anterior cervical
line)
Facial plane
Vertical line from nasion, intersecting
Frankfort plane at 90°; the ideal chin
(Gonzalez-Ulloa), should approach this line
Frankfort plane
Horizontal line extending from porion to
orbitale
Menton
Lowest contour point on soft tissue chin
Nasion
Deepest depression at the root of the nose
Pogonion
Most anterior point of soft tissue chin
Porion
The highest point on the external auditory
meatus
Orbitale
The lowest point on the inferior orbital rim
Riedel’s line
Connects most prominent portion of upper
lip to the lower lip; the ideal chin (Riedel)
should be along this line
Submental line
Tangential to submental area, from cervical
point to menton
Frankfort
horizontal plane
Facial
plane
Riedel's
Figure 25.2  Augustus Caesar. Demonstrates ideal facial
proportions for chin projection (Gonzalez-Ulloa), upper and
lower lip to chin relationship (Riedel), and chin to lower lip
relationship (vertical line from vermilion of lower lip) (increased
width of vertical white line).

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Chapter 25  Implants
The mental protuberance is the thick bone at the medial
and inferior aspect of the mandibular body, with mental
tubercles raised on each side. The upper border of the man-
dible is the alveolar part, containing alveoli for the roots of
the teeth. The oblique line runs posteriorly from each tuber-
cle along the inferior mandibular border (Fig. 25.3A).17
The mental foramen is a bilateral structure through which
exits the mental nerve and vessels. The horizontal position of
the mental foramen is variably described as inferior and
slightly anterior to the second premolar tooth,17 or just pos-
terior to a line drawn down from the oral commissure,18 or
below the apex of the second premolar tooth in the midpupil-
lary line, approximately 2.5 cm from the midline,19 though it
may range from 1.5 to 4.5 cm from the midline.20 A study of
100 adult mandibles revealed the foramen to be at the level
of the root of the second premolar (bicuspid) in 50%, between
the first and second premolar (bicuspid) in 20–25%, and
posterior to the second premolar (bicuspid) in 24%.21
The mental nerve provides sensation to the skin of the chin
and lower lip, as well as to the mucosa of the lip and adjacent
gum (Fig. 25.3B). It is a branch of the mandibular nerve of
the third division of the trigeminal nerve (see Chapter 1),
running superiorly as it exists the mental foramen, surrounded
by a fibrous sheath. The bony angle of the mental foramen
allows the lower labial branch to run upward toward the lip,
while the mental branch travels anteriorly and medially to the
skin of the chin.22
The muscles of the chin are the mentalis, the depressor anguli
oris, and depressor labii inferioris (Fig. 25.3C). The paired
mentalis muscle originates from the anterior mandible at the
level of and below the roots of the incisors, running downward
and inserting into the skin of the chin. It elevates the lower lip
indirectly (its fibers do not enter the lip), draws the lower lip
against the gums and teeth, and protrudes the lower lip (as in a
pout).23 The depressor muscles originate from bone at the
oblique line and insert into skin and mucosa of the lower lip and
orbicularis oris muscle. They pull the lower lip downward and
laterally; the depressor labii inferioris also everts the lip.
The marginal mandibular nerve, a branch of the facial
nerve, provides motor innervation to the muscles of the chin
and lower lip. It enters these muscles deeply on their lateral
undersurface, after coursing medially under the superficial
musculoaponeurotic system (SMAS) and platysma until it
crosses superficial to the facial artery and vein at the medial
border of the masseter muscle. Approximately 2 cm lateral
to the oral commissure it lies in the soft tissue overlying the
dissection plane.
If the marginal mandibular nerve is injured during surgery,
the patient is unable to perform chin muscle functions on
that side. With smiling, that side of the lower lip remains up,
unable to be drawn downward and laterally, and the vermil-
ion border cannot be everted on that side.24 This is not appar-
ent with the mouth at rest.
Age-related changes affect the vertical position of the
mental foramen (Fig. 25.3D). In adults, it is midway between
the upper and lower borders of the mandible. In older, eden-
tulous patients, because of atrophy of the alveolar ridge, its
relative position is nearer the superior border.25 Its distance
from the inferior mandibular margin remains constant, at
least 8–10  mm.11 Also with aging, bony resorption of the
mandible at its inferior aspect below the mental foramen
results in a depression, named the anterior mandibular groove
by Mittelman.26
augmenting the chin anteriorly would bring the profile closer
to the ideal.
Other authors have suggested different guidelines for
ideal chin position. Some drop a vertical line from the lower
lip,10–12 or the most anterior white roll of the lower lip.13
Other surgeons choose a position just behind this vertical
line.14 Riedel suggests that the most prominent portion of the
chin should be tangential to a line connecting the upper and
lower lips, with the most prominent aspect of the chin on
the same plane as the upper and lower lip.3,15 Because of the
variability of facial structures, gender, family, and ethnic
characteristics, as well as the patient’s desires and surgeon’s
aesthetic judgment, no formula or measurement system can
be followed to the letter for each and every person; it is,
however, generally agreed upon that the correction for
women should be less than that for men.
Harmony and beauty depend on proportional relationships
between facial structures, with emphasis here on the chin’s
position in relation to the nose, lips, and neck. The balance
of the face is influenced by alteration of any of its compo-
nents. A weak chin makes the nose appear larger; augmenting
the anterior projection of that chin will cause the same nose
to appear smaller.
Bone and soft tissue structures of the neck also contribute
to aesthetic appreciation of the profile. The hyomandibular
angle16 is formed by the submental line (horizontal line),
tangential to the submental area, intersecting with the ante-
rior cervical line, tangential to the vertical portion of the neck.
Their intersection is the cervical point.
An ideal ‘sculpted’ neck has a sharp angulation, approaching
a hyomandibular angle of 85–90°.16 However, if the hyoid
bone is low and anteriorly located, the hyomandibular angle
is made obtuse. This blunting of the hyomandibular angle
created by a low anterior hyoid bone contributes to the per-
ception of a small chin.
Redundant skin, muscle, and adipose tissue also contribute
to making the hyomandibular angle blunted and not attrac-
tive. These soft tissues that define the anterior cervical line
and submental line can be retracted and elevated, improving
the neck angulation, with submental liposuction, face lift,
and/or platysmaplasty.
A low anterior hyoid and weak chin can limit this improve-
ment. The hyoid position cannot be changed, but chin posi-
tion can be with chin augmentation. The most anterior soft
tissue part of the chin is the pogonion, and the menton is
the most inferior soft tissue point of the chin. By surgically
augmenting the chin, shifting both these landmarks anteri-
orly, the submentum is lengthened and the submental line
or horizontal line is made more horizontal, improving
the hyomandibular angle. By creating a greater distance
between the hyoid bone and pogonion, the illusion that
the hyoid bone is not as anterior nor as blunting to the
hyomandibular angle is achieved,16 and a more pleasant neck
can be achieved. In analyzing results of neck sculpting proce-
dures, it can be seen that in aesthetically pleasing necks,
virtually all patients have ‘good’ chins either from nature or
surgery.
Anatomy
Anatomic considerations of importance to augmenting the
mandible include bone, bony foramina, muscle, motor and
sensory nerves, blood vessels, and skin.

418
Part 3  Aesthetic Surgical Procedures
B
Facial branch
Mental branch
Buccal–labial
branch
Mental nerve
A
Mental tubercle
Alveolar bone
Oblique line
Second premolar
Mental foramen
Mental protuberance
Incisive fossa
Skeletal anatomy of the chin
C
Orbicularis oris
Mentalis
Depressor labii inferioris
Depressor anguli oris
Muscular anatomy of the chin
D
Adult
Child
Aged
Mental foramen
Age-related changes of the mandible
Figure 25.3  (A) Skeletal anatomy of the chin. (B) Mental nerve. (C) Muscular anatomy of the chin. (D) Age-related changes of the
mandible.
Soft tissue changes also occur with age. A soft tissue depres-
sion, the pre-jowl sulcus,26 develops between the jowl and
chin. This overlies the anterior mandibular groove, accentuat-
ing the pre-jowl sulcus. Atrophy of chin musculature and the
alveolar ridge also contributes to less anterior projection of
the chin.
 PREOPERATIVE PREPARATION
Evaluation and exam
The surgeon must be able to recognize a chin deficiency to
be able to improve it and to know when chin augmentation

419
Chapter 25  Implants
common for the patient with a chin deficiency, excess sub-
mental fat, or low, anterior hyoid to hold his or her head
in a position which is more flattering, projecting the chin
anteriorly by tilting the head slightly upward (Fig. 25.4).27
Slouching also encourages anterior positioning of the mandi-
ble.28 These things must be recognized, and the patient
asked to sit erect without leaning back in a chair during the
examination.
If this naturally assumed, subconscious compensatory
posture is unrecognized and not addressed by the evaluating
surgeon, the opportunity to improve the profile with chin
augmentation may be missed.
The position of the hyoid bone and hyomandibular angle
should be noted and considered, because a low, anteriorly
positioned hyoid, which is not surgically correctable, may
limit improvements attainable by face lift, by platysmaplasty,
or submental liposuction. A chin implant improves aestheti-
cally pleasing angles by lengthening and subsequently making
more horizontal the submental line from cervical point to
menton.16
is the appropriate procedure. This requires aesthetic judg-
ment and a systematic approach, because few patients present
with ‘weak chin’ as their primary area of concern. They may
think that their neck is not well defined and needs liposuc-
tion, or that their nose is too large.
Patients are often unaware of the imbalance of their own
profile because they typically view themselves from the
frontal view, not the profile view. Occasionally, a person will
recognize their chin weakness in candid, unposed family pho-
tographs, or recognize it in others, especially if it is a heredi-
tary feature. To appreciate a chin deficiency, the physician
must consistently examine the profile, using mirrors, instant
photography, digital photos, or computer imaging, and present
it to the patient in such a way that the chin deficiency and
its role in facial balance is understood.
The profile view is only helpful and accurate if the head
is positioned consistently for evaluation and photos. The
Frankfort horizontal plane described above is that consistent
head position. The inclusion of the tragus is thus required
in photos or the plane is uncertain. Unfortunately, it is
A
B
C
D
Figure 25.4  (A) Head position naturally
assumed by this patient with a full neck,
or obtuse hyomandibular angle. The chin
is projected anteriorly, falling in a plane
drawn vertically from the lower lip. (B)
However, the Frankfort plane is not
horizontal when the patient holds her
head in this compensatory position. (C)
The patient’s head is then positioned in
the Frankfort horizontal plane revealing
the chin deficiency; (D) by using the
vertical line of Gonzalez-Ulloa, at an angle
of 90° to the Frankfort plane, or a line
drawn from the lower lip with the head in
the Frankfort plane. This patient was not
initially offered chin augmentation,
previously undergoing only submental
liposuction. This suboptimal outcome
was a missed opportunity to enhance the
facial balance with a chin implant.

420
Part 3  Aesthetic Surgical Procedures
Muscle function should be evaluated and photographically
documented with the patient smiling, as asymmetry is not
uncommon.
Lip posture is assessed at rest and in animation. In patients
with more severe retruded chins, dimpling of the skin of the
chin often accompanies labial incompetence as the mentalis
muscles ‘overwork,’ attempting to create lip closure at rest.29
This is a relative contraindication to chin augmentation with
implants because of a higher rate of complications (see Pit-
falls and their management).
Other notable features of the physical exam are the presence
of submental scars, skin thickness, a dimple or cleft, vertical
height, pre-jowl sulcus, ptosis (witch’s chin), and symmetry.
Intraorally, hygiene, occlusion, and the presence or absence
of teeth or dentures are documented.
Chin/mandibular implants are appropriate for patients with
mild microgenia (small chin) and normal or near-normal
dental occlusion, and/or a pre-jowl sulcus. Microgenia is the
result of underdevelopment of the mandibular symphysis
with an adequate mandible.17 Micrognathia is hypoplasia of
various parts of the jaw with malocclusion. Patients with
micrognathia, or microgenia with greater degrees of maloc-
clusion, should be offered orthodontic or surgical correction
– not chin augmentation with implants. Patients requiring
more than 0.5 cm augmentation (approximately 0.8 cm ante-
rior dimension implant) may develop complications from too
large an implant; consideration should be given to horizontal
osteotomy with mandibular advancement.22 Increased or
decreased vertical height, and bony asymmetries, are also
better addressed by orthognathic procedures.
A surgeon who performs cervical liposuction or other neck
and face contouring procedures will enhance satisfaction by
educating patients on the role of their chin in facial balance
and harmony.
Implant selection
Implant materials used historically include paraffin, gold,
silver, ivory, bone, cartilage, dermis, and fat. Unpredictable
absorption, reaction, and rejection have been some of the
problems that have prompted surgeons to search for predict-
able and safe implants.
Alloplastic materials used with documented experience
include silicone,28,30,31 polymethacrylate (hard acrylic),32
porous materials such as Mersiline mesh (Ethicon, Sommer-
ville, NJ),33 Proplast (polytetrafluoroethylene, withdrawn
from the market by the US Food and Drug Administration
in 1992), Medpor18 (polyethylene; Porex Industries, Fair-
burn, GA), and more recently Gore-Tex (expanded poly-
tetrafluoroethylene; e-PTFE, WL Gore, Flagstaff, AZ).18,34,35
(For general reading on implant materials see Choe & Stucki-
McCormick,18 Romo et al.,34 Binder et al.36)
The ideal implant material (Box 25.1) should be well toler-
ated with a non-palpable, natural feel, be stable and resist
resorption and infection, be non-immunogenic and non-car-
cinogenic, and be easily removed, as well as straightforward
to insert and modify, flexible enough to conform to the
underlying bony surface, and capable of being folded for
placement through a relatively small incision.
Silicone
Silastic is solid silicone rubber, which satisfies criteria for an
ideal chin implant.28,30,31,37,38 Silastic is flexible enough to be
Box 25.1  Ideal chin implant
 Well tolerated.
 Non-palpable.
 Natural feel.
 Stable, resistant to resorption and infection.
 Non-immunogenic.
 Non-carcinogenic.
 Easily removed.
 Straightforward to insert and to modify.
 Flexible enough to conform to the underlying bony surface,
and to be folded for placement through a relatively small
incision.
able to bend, allowing it to be inserted through a 2–3-cm
incision. It is soft enough to suture through, to place holes,
and to modify with a blade or scissors. At the same time, it
is firm enough to approximate a natural feel to the chin, as
its consistency is between that of hard bone and soft tissue.
It maintains its shape, resisting resorption indefinitely.
A thin fibrous capsule forms around the non-porous implant;
there is no tissue ingrowth as in porous implants, making
Silastic easy to remove if necessary and unlikely to harbor
bacteria. It is heat stable, allowing removal and resterilization
if necessary. Holes are manufactured in some implants, and
can be made on others, to allow fibrous tissue ingrowth for
stabilization. This capsule does not distort the implant as a
fibrous capsule may do to a silicone gel breast implant because
the implant is solid, not gel, and is spread over bone. The
capsule is even thought to help stabilize the implant to the
surrounding tissues.39
Design of Silastic implants has evolved and improved over
the past two decades with the development of the extended
mandibular implant. Formerly, implants were designed to
augment the mandible in its anterior dimensions only, con-
fined to a region between the mental foramina (thus, they
are called ‘central’ implants). This anterior-only augmen-
tation led to the term ‘button’ chin and, by augmenting
only centrally, these implants often further deepened and
accentuated the pre-jowl sulcus (Fig. 25.5 (top) and see
Fig. 25.11).
Mittelman26 recognized that the anatomy of the aging man-
dible required augmentation in the pre-jowl sulcus, the
depression formed by the bony anterior mandibular groove
and soft tissue atrophy in the pre-jowl region. Central
implants did not extend far enough laterally to augment this
area. By designing a thicker extended lateral limb in the
region of the pre-jowl sulcus, his Prejowl Chin Implant
(Implantech, Ventura, CA) was able to address this anatomic
deficiency in addition to anterior augmentation (Fig. 25.5
(bottom)).
For the patient with adequate anterior chin projection but
needing pre-jowl augmentation alone to create a smoother,
stronger jawline, Mittelman designed the Prejowl Implant
with a thin central portion, providing minimal anterior projec-
tion, with thickness confined to the pre-jowl sulcus (Fig. 25.5
(middle)). In his experience, 75% of face-lift patients have a
treatable pre-jowl sulcus and 40% have microgenia improva-
ble with anterior augmentation as well.11 Because the pre-jowl
sulcus has a bony as well as a soft tissue component, face-lift
tightening of soft tissues alone is often insufficient to signifi-

421
Chapter 25  Implants
extrusion. Another method of shortening an implant is to
remove a central portion and to suture the two remaining
halves together. This can give an implant the same length as
if trimmed bilaterally, while preserving the thin tapers of the
lateral edges. A pre-jowl implant can be sewn to a pre-jowl
chin implant to provide additional pre-jowl augmentation
without additional anterior projection.
To add augmentation to an already manufactured implant
centrally only, a Glasgold Wafer (Implantech), a 2-mm disc
without lateral extensions, can be positioned underneath the
implant and sutured to the implant with non-absorbable
sutures.12 If any uncertainty exists regarding size, the smaller
implant is inserted, and if necessary, a wafer added. This
avoids the time and additional surgical manipulation when
using sizers.
 TECHNICAL ASPECTS
Surgical technique
Two surgical approaches have been utilized for placing a chin/
mandibular implant – the intraoral (transoral) and submental
(extraoral). Because a submental incision is used in neck
contouring procedures such as liposuction, platysmaplasty,
and often in face lift, it will be discussed here. The intraoral
technique is described elsewhere.20 Its primary advantage is
that there is no external incision; disadvantages include more
difficult placement of extended implants laterally under the
mental nerve, and more difficult suture fixation to the inferior
border of the mandible. A review of over 100 cases of adverse
events after chin implant augmentation stated ‘almost all chin
implant problems that the senior author has seen were caused
by implants placed transorally.’13 Training and experience
of the surgeon certainly contribute to choice of approach as
well.
Submental approach
The scar from the submental approach usually heals well and
is inconspicuous since it is on the underside of the chin and
not visible from the front or side.
Anesthesia may be accomplished in a variety of manners.
If the surgeon and patient choose intravenous sedation or
general anesthesia, 1–2% lidocaine with 1 : 100 000 or
Figure 25.5  Silastic implants. From top to bottom: central
implant; Mittelman Prejowl Implant; Mittelman Prejowl Chin
Implant.
Figure 25.6  Proper position of an extended implant (blue sizer)
over thick cortical bone of the mental symphysis, along the
inferior mandibular border under the mental foramen, tapering
laterally.
cantly smooth the entire sulcus; the thickening in pre-jowl
sulcus of these implants helps to augment this defect.
Flowers28 hand sculpted implants from silicone blocks and
later designed preformed extended implants with slightly
softer consistency, greater flexibility, and different dimen-
sions. He addressed the variety of angles of incline of the
anterior face of the mandible, noting that an implant with a
straight vertical back (as many central implants have) can
cause problems in positioning. His implant, the Flowers Man-
dibular Glove (Implantech), has a caudal lip allowing vertical
tilt, helping to create a smooth transition from implant to the
non-augmented adjacent mandibular body.
Extended implants address the anatomy which results in
chin and pre-jowl deficiencies; at the same time, they intro-
duce additional considerations and features.
Dissection of a pocket to place these laterally extended
implants requires care to avoid the mental and marginal man-
dibular nerves (Fig. 25.6). The limited lateral extent of
central implants does not require dissection in these danger
zones. Chin Implant Style 3 (Allied Biomedical Corporation,
Goose Creek, SC) has preformed cut outs on its superior
aspect below the mental foramina, allowing more space
(safety zone) between implant and mental nerve. Other
design characteristics include fenestrations medially or later-
ally. These holes allow tissue ingrowth to help stabilize the
implant, and the medial holes may be used as well for suture
fixation. Fenestrations for tissue ingrowth and stabilization
can be created by using a small (1.5-mm) trephine or punch
biopsy instrument.
Because implants are commercially manufactured in a
limited number of sizes, some modification may be per-
formed on the implants if necessary. The implants may be
trimmed superiorly to allow more clearance for the mental
nerve, or to prevent pressure on dentures. Trimming laterally
may facilitate insertion and prevents augmenting the jowl
itself if a significant portion of the implant extends beyond
the pre-jowl sulcus. Care must be taken to smoothly taper
the lateral wings when trimming as sharp edges may result in

422
Part 3  Aesthetic Surgical Procedures
1 : 200 000 epinephrine is infiltrated by injecting through
the skin with a 30-gauge 1-inch needle in a perpendicular
manner to bone and periosteum, along the soft tissue adjacent
to the periosteum, and skin and subcutaneous tissue at the
incision line.
If the patient will be sedated orally, or not sedated at all,
a bilateral mental nerve block may be administered prior to
local infiltration.
Prior to surgical prep, the midline is marked on the chin
and submental area across the proposed incision. The position
of the mental foramen may be marked after locating it by
intraoral palpation at the base of, or anterior or posterior to,
the second premolar, approximately halfway down the man-
dible.22
The incision is made in the submental crease, or slightly
posterior to it. Because the incision and resulting scar is so
well hidden, it is not necessary to minimize the incision.
A longer incision will provide better exposure, facilitate
implant insertion, and allow the periosteal elevator to remain
on bone when it advances laterally as the mandible curves
posteriorly. A 2–3-cm incision is carried through skin and
subcutaneous tissue to the mandible. The periosteum is
exposed, then incised horizontally with the blade, and a sub-
periosteal plane developed superiorly with a Freer periosteal
elevator. The bony surface should be clearly seen (Fig. 25.7).
The feel and sound of the elevator on bone should be present
during the entire dissection of the pocket. When superior
pocket elevation has reached 1.5  cm or the labiomental
sulcus, a Joseph periosteal elevator is used to develop the
lateral pocket along the inferior border of the mandible (Fig.
25.8A). The non-dominant hand is essential to externally
palpate the elevator, guiding it and providing feedback that
it is indeed hugging the inferior mandibular border, avoiding
the mental nerve and not levering upward into the overlying
soft tissues.
The mental foramen and nerve lie 1.5 cm superior to the
inferior mandibular border in younger patients.12,34 In the
aging mandible, 8–10 mm of distance remains.11 Therefore
Figure 25.7  Bone exposed after subperiosteal dissection.
the width of the elevator should be 8 mm in an older patient
to avoid injury to the nerve (up to 1 cm in younger patients).
The implant should have a height of 6–8 mm in this area.11
The superior border of the implant may be trimmed with
scissors if necessary.
Opinion is divided regarding the necessity to visualize the
mental nerve and foramen. Terino20 recommends an Aufricht
fiberoptic light retractor for direct visualization to prevent
injury. On the other hand, if the dissection is carefully guided
using knowledge of anatomic landmarks (palpation and
marking of the mental foramen), staying on bone, and on the
inferior mandibular border (and not below it) at all times, it
may not be necessary to visualize the mental nerve and
foramen.22,28 Using these principles, and the non-dominant
hand, the lateral dissection may proceed without direct visu-
alization of the developing pocket.
The lateral extent of the pocket is judged by knowing the
dimensions of the implant. Most extended lateral implants
have a posterior surface 9–12 cm long, so the lateral dissec-
tion must at least be 4.5–6.0 cm on either side of the midline.
The pocket should be made slightly larger, around 5  mm,
than the dimensions of the implant to accommodate it
comfortably.
A sizer implant can be placed on the skin to give a close
idea of the size and extent of the pocket (Fig. 25.9A),
keeping in mind that the thickness of the skin and anterior
dimensions of the implant will require a more laterally
extended pocket on bone than is apparent from marking
around an implant placed on skin. Before placing an implant,
the pocket is examined using an Aufricht retractor for any
bleeding or irregularities. A gentamicin solution in which the
sizers and implant are placed is then used to generously
irrigate the pocket. Sizer implants may be used to assess the
adequacy of the pocket, and the appropriate size of implant
for the patient. Sizers are manufactured in identical sizes to
the permanent implants, and are intended for insertion,
inspection, and then removal once the ideal size has been
chosen. It must be kept in mind that in the supine position,
the mandible retracts. A jaw thrust can advance the mandi-
ble for better size assessment. Local anesthesia may also
distort the volume of the soft tissue of the chin; minor adjust-
ments must also be made for this.
The procedure for inserting a sizer (Fig. 25.9) is identical
to that of inserting the permanent implant (with suture fixa-
tion following insertion for the permanent implant).
One limb of the sizer/implant is grasped with an Adson
dressing forceps and directed through the incision into the
far-side pocket, exposing and opening the pocket with the
Aufricht retractor (Figs 25.8B and 25.9B). When it has been
advanced as far as it can go, the middle of the implant is
grasped with a hemostat or Adson forceps near the midline
and stabilized. This maneuver helps keep the first side from
slipping out of the incision while the second side is inserted.
When both ends are in their respective lateral pockets, the
center of the flexible implant may still be buckled outside
the incision. The center can be pressed down toward the
bone, pushing each tip outward toward the full lateral extent
of the pocket (Figs 25.8C and 25.9C).
After an implant has been placed, it should lie flat without
lifting away from bone, which would indicate too small a
pocket, or ends misplaced in soft tissue irregularities, pre-
venting full lateral extension along the bony surface. To
assure that the ends are not folded, curled, or in a ‘false

423
Chapter 25  Implants
covered in a sling or hammock-like dressing with Steri-Strips
or Elastoplast (Johnson & Johnson, New Brunswick, NJ) tape,
left on for 3–5 days.
 OPTIMIZING OUTCOMES
The subperiosteal dissection plane has been chosen for
description here because of its several advantages. Bone is the
surgeon’s guide to safety. It is a well-defined plane, easily
identifiable with exposed bone at the entire floor of the space.
Bone also adds stability to the implant,11,18 as does the overly-
ing periosteum.40 The dissection plane is relatively avascular.
Another safety feature is created by confining the dissecting
instrument to contact with bone, using audible, palpable, and
visual feedback, thereby dissecting deeper and further away
from the marginal mandibular nerve, which lies in the overly-
ing soft tissues between periosteum and muscle.
tunnel,’20 a flat elevator can be advanced laterally above and
below the implant to unfold it.
Next, the midline marker of the implant is aligned with the
midline previously marked on the skin. If no midline marker
is on the implant, the midline must be marked on the implant
with a notch prior to insertion. Once its midline position is
established, the implant should be stabilized in at least two
places. One 5-0 Vicryl (polyglactin 910) suture is placed on
each side of the midline (Fig. 25.8D), either through prefab-
ricated holes, or by placing the curved needle directly through
the implant. This is sutured to the inferior cuff of periosteum
and soft tissue. For all implants, the inferior aspect of the
overlying soft tissues is incorporated in the closure with infe-
rior periosteum to cover the implant. The remainder of the
deep tissue and muscle is closed with 6-0 Vicryl in two layers
and the skin closed with a suture of choice. Steri-Strips (3M,
St Paul, MN) are applied over the closure and the chin is
A
B
C
D
Figure 25.8  (A) Dissection of lateral pocket at inferior mandibular border with Joseph periosteal elevator. (B) Insertion of implant
into pocket. (C) Buckled center of implant pressed toward bone. (D) Midline marker of implant aligned with midline skin markings,
with sutures on either side prior to placement.

424
Part 3  Aesthetic Surgical Procedures
The subperiosteal dissection becomes somewhat techni-
cally difficult 1.5–2  cm lateral to the midline because of
dense connective tissue,28 and the anterior mandibular
ligament.20
A theoretical disadvantage to the subperiosteal plane is
bone resorption (see Complications under Pitfalls and their
management). Some surgeons, concerned with bone resorp-
tion under implants placed directly on bone (subperiosteal),
prefer a supraperiosteal pocket (especially for the medial
portion of the implant), to prevent bone resorption. The
supraperiosteal plane, however, has the disadvantages of
being more vascular and closer to the marginal mandibular
nerve, and the implant is visible in thin skin. Because a supra-
periosteal plane allows increased mobility of the implant, it
has been suggested to convert from a supraperiosteal to a
subperiosteal dissection laterally, 1–1.5 cm40 or 2–3 cm11,28,34
lateral to the midline. This provides stability laterally while
theoretically avoiding bone resorption centrally.
 POSTOPERATIVE CARE
Minimal care is required postoperatively. The dressing, in
place for 3–5 days, minimizes swelling and bruising and is a
reminder to the patient that surgery did take place because
postoperative pain is often not significant. Pain may be greater
for a larger implant due to distention of the periosteum.
Trauma, such as that which may be encountered with an
active child, could result in displacement. A soft diet should
be followed to minimize muscle motion.
 PITFALLS AND THEIR MANAGEMENT
Complications
Marginal mandibular nerve injury
If the elevator levers upward off bone into overlying soft
tissue, the marginal mandibular nerve is at risk of injury.
This may occur if its angle of entry is restricted by too
small an incision. A larger incision will assist in keeping the
elevator on bone as it follows the curvature of the mandible
posteriorly.
A ‘false tunnel’20 created in this way may allow placement
of an implant tail into it, resulting in nerve compression.
Figure 25.10A illustrates a case in which marginal mandibular
nerve injury was clinically demonstrated by weakness of the
left lip depressors and inability to pull the ipsilateral lip
downward and laterally. Nerve stimulation testing revealed
the nerve to be functional (thus intact), rather than having
been severed and non-functional. A computed tomography
(CT) scan documented the position of the left limb of the
implant to be inferior to the mandible laterally, and not in
contact with bone but rather in the soft tissue in proximity
to the marginal mandibular nerve (Fig. 25.10B).
The implant was subsequently removed, the lateral limbs
shortened by trimming the implant with curved scissors, and
repositioned entirely on bone. A larger incision was used to
allow the elevator to better follow the curvature of this
patient’s narrow mandible, improve visualization of the
pocket, and allow easier insertion of the implant. Following
this revision, the patient exercised the lip depressors and
nerve stimulation was performed. Complete recovery of the
injured nerve occurred in 2 months.
A
B
C
Figure 25.9  Insertion of a blue sizer. (A) Size of pocket
estimated by marking with sizer on skin. (B) Adson dressing
forceps directing sizer into lateral pocket. (C) The opposite limb
of the sizer has been inserted into its pocket. The center of the
flexible sizer is grasped in its center, and pushed down toward
bone.

425
Chapter 25  Implants
implant may meet the vertical plane established by Gonzalez-
Ulloa, but it may still appear overcorrected in the formula of
Riedel. Consideration of ethnicity and relationships with the
nose, lips, and neck may influence the decision.
Another factor that makes precise measures difficult is that
the soft tissue response is not 1 : 1. For a chin implant, the
ratio is reported to be from 0.66 : 1,22 to 0.8 : 1.15 For example,
at a soft tissue ratio of 0.66 : 1, an implant with a 0.8-cm
anterior projection will provide approximately 0.52  cm of
projection22 because of redistribution and circumferential dis-
placement of soft tissues, as well as posterior settling into
bone.41 Most properly selected patients with microgenia only
require a slight increase in volume.14 The augmentation
should not need to exceed 0.5 cm.22 If a larger implant than
size small or medium is required, orthognathic surgery should
be offered because of complications arising from too large an
implant.22
Undercorrection
Undercorrection may be addressed by adding a Glasgold
Wafer (Implantech) without having to replace the original
implant,12 or replacement with a larger implant.
Removal of implants
If an implant is removed because it is too large, it should be
replaced with a smaller implant because of unpredictable
distortion of the soft tissue chin pad after removal without
replacement.13,17 Others suggest osseous genioplasty on all
patients who require removal of chin implants.42
Visible or palpable projections
The borders of implants may be visible or palpable; a firm,
non-flexible (acrylic or hard rubber) central-type implant
may be too stiff to conform to the curvature of the mandible,
Mental nerve injury
Short-term dysesthesias may be experienced by 20–30% of
patients.11 This may occur from operative trauma to the
mental nerve by direct contact or cautery, or indirectly by
traction on the nerve or by swelling around the nerve within
the non-expandable subperiosteal pocket, or by hematoma.
If complete anesthesia exists, or if dysesthesia (unilaterally
or bilaterally) is present 2 weeks20 to 3 weeks13 postopera-
tively, and is not resolving or improving, removal should be
considered. Prior to removal, if any questions about the posi-
tion of the implant remains, a three-dimensional model can
be made from a CT scan to show the position of the implant
relative to the mental foramen. This may document impinge-
ment on the mental nerve, and if so, should be followed by
surgical removal of the implant. Prior to immediate replace-
ment, the surgeon should develop the pocket inferiorly to
allow the implant to descend and settle. If the CT scan shows
a properly positioned implant at the inferior mandibular
border still with impingement on a low foramen, as in a ver-
tically short mandible,17 the implant should be modified by
trimming its superior border laterally under the position of
the nerve. This should be performed by 4 weeks. Permanent
loss of sensation may occur if impingement is allowed to
persist for 8 weeks or more.13 If impingement is not present
on CT scan or if the above revisions do not restore sensation,
the nerve may have been severed, although this is rare.
Extended implants increase the risk to the mental nerve, as
central implants are not as long. Central implants reside
medial to the foramina, not inferior and lateral to the nerve
as extended implants do (see Fig. 25.6).
Overcorrection
As noted above, no mathematical formulas exist to correctly
choose implant size in every patient. For example, a chin
A
B
Figure 25.10  (A) Left-sided injury to marginal mandibular nerve results in inability of lip depressors to pull lip downward and
laterally when smiling. (B) A CT scan showing left limb of implant displaced inferiorly and laterally in the soft tissues away from
bone, impinging upon the marginal mandibular nerve.

426
Part 3  Aesthetic Surgical Procedures
causing projection laterally. Larger central implants are more
likely to do so (Fig. 25.11). Serial cuts made on the back of
a stiff, non-conforming implant have been described to allow
the implant to conform to the bony arch.30 An articulated
chin implant is also manufactured to accomplish the same
thing (Allied Biomedical Corporation).
An implant may be visible in a patient with very thin skin.
This would be more likely with supraperiosteal dissection
(Fig. 25.11); subperiosteal placement entirely, or at least
laterally, should minimize this possibility, by holding the
implant in a more compact space over bone.
Softer flexible, extended implants with thin tapered tails
help implants conform to the shape of the mandible and
almost imperceptibly blend with bone inferiorly and laterally,
where the skin is thinner and the implant potentially more
visible.
Bone resorption
First reported in 1969,43 bone resorption was radiographically
documented in 12 of 14 patients. A subsequent study of 85
asymptomatic patients revealed 47 to have bone resorption.44
Common to these groups of patients reported in the 1960s
and 1970s was subperiosteal placement.
There is evidence that the placement above or below the
periosteum does not make a difference in bone resorption,45
and that when implants are properly placed over the thick
cortical bone of the inferior mandible, bone resorption is
asymptomatic and of minor concern. Loss of correction has
not been noted with bone resorption,44,46 which is self-limit-
ing, occurring during the first 6–12 months22,47 and stabilizing
Figure 25.11  Visible borders in a patient with thin skin who
was augmented with a large, non-conforming, non-tapered,
central implant placed above the periosteum. Also note
accentuation of pre-jowl sulcus.
after 2 years. Bone resorption is a problem if the implant is
resting over the thin alveolar bone overlying dental roots.29
Erosion through the alveolar bone can damage the roots of
the teeth and cause premature loss. Local symptoms, such as
toothache, require radiographic evaluation.48 This positioning
can result from cephalad migration of the implant, more
likely with the intraoral approach because of difficulty stabi-
lizing the implant to the inferior mandible.
Increased pressure of an implant on bone resulting in bone
resorption can occur with too large and/or hard an implant
as a result of mentalis muscle action. Extended implants
spread the pressure on the bone over a much wider area,
9–12  cm versus 3–4  cm for a central implant, presumably
reducing the incidence of bone resorption.28 This pressure
effect is increased in patients with more mandibular retrusion
or severe microgenia, secondary to more tensing of the men-
talis muscle to create good lip seal. A clinical sign of this
potential problem is labial incompetence (Fig. 25.12A).29 In
these patients, lip seal is accomplished by mentalis muscle
strain, leading to skin dimpling (fasciculation) in the chin.
This also occurs during speech and swallowing. These patients
should be followed clinically and radiographically for signs of
dental root impingement49 which, if discovered, suggests
bone resorption resulting from cephalad migration and/or
original cephalad positioning and requires implant removal.
Silastic implants should be avoided in these patients. Rather,
they should be offered correction using orthognathic surgical
techniques.
In properly selected patients with mild microgenia, no chin
dimpling, or labial incompetence, with implants properly
positioned over the lower, central, thick, hard mentum, bone
resorption is asymptomatic, self-limiting, may help stabilize
the implant as it settles into bone,29 and does not require
removal.
Migration/malposition
Improper position of an implant may be secondary to incor-
rect surgical positioning of the implant, or to subsequent
migration. Displacement of silicone implants occurs in less
than 0.5%.31 The implant should rest over the thick bone at
the inferior mandibular border, laterally extending beneath
the mental foramina. The lateral extensions and mental
nerves help stabilize the lateral limbs.20 Stabilization can be
achieved by subperiosteal placement of the implant20 either
entirely or laterally.11,34,40 Suture may be used to secure the
implant, preventing migration and cephalad slippage,13,34 one
on each side of the midline11,12,14 or three sutures 1 cm apart.20
Screw fixation may also be used to accomplish stabilization.18,35
Mentalis hyperactivity in patients with labial incompetence
may also contribute to migration.
Some surgeons choose porous implants such as Mersiline
mesh (Ethicon) for tissue ingrowth and stability.33 Gore-Tex
(WL Gore) has pore sizes up to 30  mm, allowing limited
fibrous tissue ingrowth,34,35,40 and early stabilization,18 though
still requiring suture stabilization.34
Infection
Infection with silicone implants has been reported to be rare,
at 0.7%31 (Fig. 25.12B). The intraoral procedure had a higher
infection rate in one report.50 The implant material has been
suggested to play a role because with porous materials, such

427
Chapter 25  Implants
Infection,53 trauma,38 hematoma,48 or the sharp edges of a
hand-carved silicone implant are additional etiologies.
Hematoma
Hematoma is also uncommon.22 The subperiosteal plane is
relatively avascular and should be less likely than the supra-
periosteal dissection to develop this complication. Most
bleeding is encountered at the incision site. The mental
artery exits the mental foramen with the nerve; this neuro­
vascular bundle is to be carefully avoided. Intraoperative
hemostasis is achieved with the use of epinephrine 1:100 000
to 1:200 000 in the local infiltrate, electrocautery, including
directly on bleeding from bone,46 and blood pressure control.
Preoperatively, avoidance of the numerous agents that pre-
dispose to bleeding (aspirin, anticoagulants, herbal products,
and foods) and attention to hypertension are required.
To prevent hematoma postoperatively, a compression
dressing for at least 3–5 days, pain control, rest, avoidance of
trauma, gentle mastication with soft diet, maintenance of
normal blood pressure, and control of nausea and vomiting51
are essential.
Necrosis
The compression dressing must not be placed too tightly
as this has been reported to cause ischemia and necrosis of
overlying skin;48 tape should be applied with little tension.
Pressure necrosis may result from a large implant placed
intraorally, exerting tension on the closure and resulting in
extrusion.17
Asymmetry
Asymmetry may result from early postoperative edema,38,48
hematoma, malpositioning during placement, migration post-
operatively, or unappreciated preoperative asymmetry. It can
be avoided by adequately preparing the pocket, stabilizing the
implant, visualizing the midline marker on the implant aligned
as Gore-Tex and Medpor, tissue, blood, and bacteria can
enter the implant through the pores, whereas this is not the
case with Silastic.38,51,52 Mobility may predispose to infec-
tion.46 ‘Micromotion’ may lead to chronic inflammation,
which in turn can result in secondary bacterial seeding.35
Infection may manifest as cellulitis, abscess, or fistula. A
3–4-week trial of oral antibiotics or a brief course of intrave-
nous antibiotics may be tried.46 Porous implants are less likely
than Silastic to be salvaged in this way.15,38 If infection per-
sists, the implant should be removed. In a retrospective study
of 480 implants, 0.62% of patients required removal because
of infection.30 If an implant must be removed because of
infection, a reinsertion delay of 3 months,37 6 months, or 12
months38,46,48 should be observed.
Infection may be avoided with the use of perioperative anti-
biotics, removal of glove powder, or by soaking the implants
and sizers in an antibiotic solution of gentamicin11 or cephazo-
lin20 and using this solution to irrigate the pocket. Irrigation
also assists in removing any blood or tissue debris. Avoidance
of hematoma38 and use of sterile technique are important.
Late infections are usually from seeding from another
source, such as a dental infection31,46,53 or dental procedure.46
Because many patients will not think to tell their surgeon
about their dental appointments, it has been suggested that
patients reveal the presence of an implant to their dentist
prior to dental procedures,20,46 and patients with chin implants
should be given prophylactic antibiotics 12–24 hours before
a dental procedure, even cleaning.51
Extrusion
Extrusion of silicone implants is uncommon, affecting fewer
than 0.5% of cases,31 but does occur. It is not secondary to
allergic or foreign body reactions.37 A pocket that is too
small may cause a pressure point on skin or oral mucosa; an
implant that is too large for the pocket, especially if placed
intraorally, may increase tension on the incision and result in
extrusion.17,38
A
B
Figure 25.12  (A) Labial incompetence.
(B) Fistula. Infection, possibly from poor
dental hygiene, or mobility secondary to
labial incompetence, resulted 1 year
postoperatively in a draining fistula. This
patient had an extended silicone implant
placed subperiosteally, through the
submental route.

428
Part 3  Aesthetic Surgical Procedures
 SUMMARY
Chin augmentation with silicone implants produces pleasing
aesthetic results by contributing to facial balance and harmony,
while not appearing ‘surgical’ or artificial. It can be performed
independently or with complementary procedures, enhancing
the outcome of these procedures in a subtle manner (Figs
25.13–25.17).
Properly performed on appropriate patients, chin implants
have minimal morbidity and provide great patient satisfaction.
with the patient’s midline, and recognizing and addressing
with the patient preoperative asymmetry.
If unrecognized, pre-existing asymmetry can be exagger-
ated by the addition of an implant, which may be a cause of
patient dissatisfaction if not discussed preoperatively. The
patient should be told that asymmetries will often persist and
are difficult to correct with implants.
If asymmetry is noted postoperatively, preoperative photo-
graphs should be reviewed, and edema, infection, hematoma,
folding of a lateral limb, and migration must be considered
and addressed. To correct minor asymmetries, an implant
may be carved or a Glasgold Wafer12 (Implantech) modified
and added. Significant bony asymmetry should be referred
for orthognathic surgery.
Changes in pre-existing characteristics
Changes in pre-existing characteristics may also occur. A
central cleft or dimple may be changed by alloplastic augmen-
tation.28 If a new dimple is desired, this may not be achiev-
able by placing clefts in the implant because the overlying
soft tissue may be too thick and stretched to conform to a
depression in the implant.
Dentures
Dentures may create excess pressure by resting on the
implant in the labial sulcus. Edentulous patients have a
shorter vertical mandibular height, and implants placed
intraorally may be positioned higher on the mandible. If this
occurs, the implant should be trimmed superiorly or reposi-
tioned inferiorly. The edge of dentures may also place pres-
sure on an intraoral incision and lead to possible pressure
necrosis.
Speech and smile alterations
Swelling and disruption of the muscles of the chin may cause
temporary changes in smiling and speech. The central
portion of the lower lip may not function properly due to
disruption of the mentalis muscle, more common with the
intraoral approach.42 The lip depressors originate along the
oblique line at the inferior mandibular border; dissection
A
B
Figure 25.13  Patient (A) before and
(B) after submental liposuction and chin
augmentation.
Pitfalls and their management
 Failure to offer or perform chin augmentation resulting from
lack of proper preoperative analysis.
 Nerve injury (marginal mandibular or mental nerve) due to lack
of knowledge of anatomy or poor technique.
 Permanent nerve damage if impingement upon nerve not
recognized early and corrected.
 Overcorrection due to inadequate preoperative analysis.
 Bone resorption resulting in dental root injury if implant placed
too high.
 Migration if implant not stabilized by sutures or subperiosteal
placement, or if displaced by unrecognized mentalis muscle
hyperactivity in patients with labial incompetence.
 Infection from unrecognized dental source or later infection
from dental procedure.
 Asymmetry secondary to improper placement or unrecognized
preoperative asymmetry.
at this point, distention by the implant, or edema may
cause temporary dysfunction. This, along with alteration
in sensation, may cause slight speech impediment. These
problems usually resolve in 2–4 weeks as muscles reattach
to the capsule that forms around the implant.37 Other prob-
lems may be caused by disinsertion of muscles, including
disfigurement.42

429
Chapter 25  Implants
A
B
Figure 25.14  Patient (A) before and
(B) after submental liposuction and
chin augmentation, and fat grafting
to mid-face and cheeks.
A
B
Figure 25.15  Patient (A) before and
(B) after medium-depth chemical peel,
upper blepharoplasty, submental
liposuction, and chin augmentation.
The surgeon who offers and performs a chin implant has
provided the patient with a long-term predictable procedure.
This can only be accomplished after a thorough profile analy-
sis with the patient’s head posed in the Frankfort plane. Chin
augmentation with Silastic implants significantly improves
the results of neck sculpting and face lifts, as well as liposuc-
tion of the neck.
With diligent attention to surgical technique, including cre-
ating a subperiosteal pocket and stabilizing the implant with
sutures, complications can be minimized and corrected when
they do occur, typically in less than 1% of patients.
Profile enhancements with chin implants accomplish a
natural look and feel while providing permanent improve-
ment in facial balance.

430
Part 3  Aesthetic Surgical Procedures
A
B
Figure 25.17  Patient (A) before and
(B) following upper blepharoplasty, face
lift, and chin augmentation.
A
B
Figure 25.16  Patient (A) before and (B)
after upper blepharoplasty, medium-
depth full-face peel with deep periorbital
peel, face lift, and chin augmentation.
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