Phẫu Thuật Tạo Hình Thẩm Mỹ Khuôn Mặt Người Á Đông

V Facial Skin and Hair Rejuvenation
334
holes are created at 45 degrees, made ~ 4 mm apart. They
can be oriented horizontally or vertically to the brows.
Alternatively, a bone tunnel guidance device (Browlift Bone
Bridge System, Medtronic Xomed, Jacksonville, Florida) can
be used to create the bone tunnel. Once the tunnel is cre-
ated, a device designed to pull a suture through the bone
tunnel is used to engage the suture. Either 2–0 polypropyl-
ene or polydioxanone can be used for anchoring in a similar
fashion as for the resorbable screws. Fig. 25.16 shows the
results for a patient who underwent EFBL using the cortical
bone tunnel xation method.
The advantages of this method are its low cost and there
is no risk of implant palpability. Cortical tunnel suture xa-
tion has been shown to be simple, stable, and reproducible
in maintaining brow position in EFBL with low morbidity.18
Jones et al19 compared two xation methods, brin glue
versus polydioxanone sutures tied through bone tunnels,
in his review of 538 patients. He found that xation with
polydioxanone sutures tied through bone tunnels produces
a signi cantly more stable result than brin glue alone,
w ithout greater risk.
Fixation with Endotine Forehead Device
Fixation of the elevated brows can also be done with the
use of the Endotine Forehead device (Coapt Systems, Palo
Alto, California) (Fig. 25.17). Chowdhury et al20 reported
that this device is e ective, safe, and easy to use with high
patient satisfaction. This is a resorbable triangular device
w ith spikes or tines on one side that are oriented at an
angle. These spikes are able to skewer or grab tissues so
that they can be held in the desired position after lifting.
This device is composed of a bioabsorbable copolymer of
lactic and glycolic acids and completely dissolves within 6
to 12 months.
Alternatively, longer titanium screws can be used.
However, they protrude from the skull and require removal
in 2 weeks. In this method, the amount of lift required is
measured from the cephalic border of the lateral incision
cephalically. As the scalp is rotated superoposteriorly to
achieve the desired elevation, the screw is inserted and
skin staples are placed caudal to the screw to maintain the
elevation (Fig. 25.14).16
Fixation with Cortical Bone Tunnels
Another xation method, described by McKinney et al,17 is
by creating cortical bone tunnels in the calvarium to allow
anchoring (Fig. 25.15). The bone bridge is created with a
1.1-mm bur with a safety guard of 4 mm. Two opposing bur
Fig. 25.13 Fixation with monocortical screws and sutures. (a) Monocortical screw. (b) Monocortical hole drilled in the skull bone. The
amount of brow lift is determined by the distance of the hole drilled from the caudal border of the incision. (c) Placement of monocortical
screw into the hole. (d) Sutures secured between the screw and the caudal margin of the incision, resulting in desired brow lift.
Fig. 25.14 Fixation with monocortical screws and staples.
(a) Monocortical screw inserted and brow lifted in the superior
direction. (b) Skin staples are placed caudal to the screw to main-
tain the desired brow elevation.
a
b
c
d
a
b

25 Endoscopic Forehead and Brow Lift
335
Fig. 25.15 Fixation with cortical bone tunnels. (a) Bone tunnel guid-
ance device (Browlift Bone Bridge System, Medtronic Xomed, Jackson-
ville, Florida) and drill. (b) Demonstrating the engagement of drill in
the guidance device. (c) Using the guidance device to create cortical
bone tunnel. (d) A device designed to pull suture through the bone
tunnel is used to engage the suture. (e) Successful engagement of
suture in the bone tunnel. (f) Needle introduced to engage the caudal
margin of the lateral incision. (g) Sutures are then tied to achieve the
desired brow lift.
Fig. 25.16 A 45-year-old female who had endoscopic forehead lift, lower blepharoplasty, rhinoplasty, rhytidectomy, and fat injection of
upper and lower face. (a) Before the surgery. (b) Two months after the surgery. (Courtesy of Dr. In-Sang Kim.)
a
b
a
b
c
d
e
f
g

V Facial Skin and Hair Rejuvenation
336
can be more accurately determined. This w ill allow a more
conservative blepharoplasty, reducing the risk of lagoph-
thalmos postoperatively. If the upper eyelid skin is removed
rst, the correct brow lift may result in lagophthalmos.

■Postoperative Care
The patient is advised to sleep with head elevated 30
degrees to minimize swelling and bruising. Furthermore,
ice packs to the exposed areas and eyes can help minimize
edema. The patient should not engage in any vigorous exer-
cise or activity for 1 week.

■Botulinum Toxin
Botulinum toxin can serve as an adjunct to EFBL. Injection
into the procerus and corrugators serves to elevate the
medial brow, and some substitute this technique for sec-
tioning of the muscles. Botulinum toxin injected into the
brow depressors preoperatively can also facilitate the reat-
tachment of the brows in the elevated position during the
healing process.

■Key Technical Points
The principles behind endoscopic forehead and brow lift are
1. Use of a minimal number of incisions, which are
small, short, and well camou aged
2. Dissection in a safe and bloodless plane
3. Release of all brous, ligamentous, and muscular
attachments of the brows to allow maximal
mobilization
Two monocortical wells are created with a drill
equipped with the Endotine drill bit and sleeve at the cau-
dal margins of the lateral incisions. The Endotine Forehead
device is then inserted with the aid of an insertion device
into the well. Once the device is rmly xated, the forehead
and scalp can be lifted and redraped over the tines and be
held at the desired position. Digital pressure over the tines
is necessary to ensure adequate penetration of the perios-
teum by the tines. The symmetry and height of the brows
are checked. If the height is inadequate or if there is any
asymmetry, the ap can be released from the device and
redraped again to achieve the desired outcome.
The advantage of using this device is that the implant
resorbs. In addition, the Endotine Forehead device provides
multiple points of contact with the elevated tissue and can
theoretically create a w ider distribution of holding strength
that does not rely on a single suture.5 It also eliminates the
concern of undue tension on the scalp incision.
There is still a risk of implant extrusion and infection.
The device may be palpable or tender, and it increases the
cost of the surgery.
Closure and Dressing
The incisions can be closed with skin staples, which are
removed in 10 days. The hair and scalp are washed with
hydrogen peroxide and normal saline. A pressure dressing
is then applied to the forehead and removed after 24 hours.
Sequence of the Combined Approach
If an upper blepharoplasty is planned for the same setting,
it is usually done after the EFBL. In this sequence, an accu-
rate brow lift can rst be achieved and the residual hooding
Fig. 25.17 Fixation with Endotine Forehead device. (a) Endotine Forehead device with multiple tines shown. (b) Placement of the device
in a monocortical hole created in the skull bone. (c) Lifting of the forehead superiorly to achieve the desired brow lift and redraping the
ap over the device. (d) Finger pressure applied over the device to ensure adequate penetration of the periosteum by the tines so that the
brow can be held at the desired position.
a
b
c
d

25 Endoscopic Forehead and Brow Lift
337
Intracranial Injury
Intracranial injury such as cerebrospinal uid leak and
hemorrhage can happen during the monocortical drilling
process for the screws, cortical tunnels, or Endotine devices.
Wound Problems
The incisions may heal with hypertrophic scars or keloids,
especially if closed under tension. Intralesional steroids or
scar revision may be required.
Implant Problems
The screws and Endotine devices may cause discomfort and
irritation to the patient. Rarely are they palpable or visible.
Alopecia
The scalp incision sites can have alopecia. This occurs most
often if closed under tension, if cautery was used on hair
follicles, or if gross mismatch of skin edges exists.
Raising Hairline
This is not a complication as much as a consequence of
EFBL. For this reason, patients with a pre-existing high
hairline are not ideal candidates for this type of brow lift.
Over- and Under-Correction
Over- and under-correction are possible outcomes.
Under-correction can be improved with a revision or bot-
ulinum toxin injection in the brow depressors. Over-cor-
rection, with the undesirable resultant facial expression, is
extremely di cult to reverse.
Relapse
As the patient continues to age, the brows will again
descend. Longevity varies according to many variables,
including skin elasticity, sun exposure, smoking, and pos-
sibly the xation method used.

■Conclusion
In conclusion, EFBL represents the use of advanced tech-
nology in facial cosm etic surgery. The desire to have
sm aller and well-cam ou aged incisions, less postopera-
4. Separation of the depressors and frontalis to
overcome the rhytidosis
5. Cephalic rotation of the entire scalp to achieve
desired brow position and tightness of the forehead
6. Fixation of the brows, forehead, and scalp complex
7. Postoperative care

■Complications and
Their Management
Seroma or Hematoma
Seroma and hematoma can occur in the potential space of
the forehead and scalp. This risk is minimized by careful
dissection in the correct plane, hemostasis at the incisions,
and use of a rm pressure dressing over the forehead. Fibrin
sealant can further reduce the risk of bleeding.
Edema and Ecchymosis
There will inevitably be some edema and ecchymosis
within the rst 48 hours. EFBL may involve less edema than
the open coronal and trichophytic approaches.
Infection
Wound site infection is very uncommon due to the robust
blood supply of the scalp. Postoperative antibiotics are usu-
ally not necessary.
Nerve Injury
The frontal branch of the facial nerve can be injured dur-
ing the temporal dissection. It can also be injured by ther-
mal injury when attempts at arresting bleeding from the
sentinel vein are done with electrocautery. The nerve can
also be stretched during the dissection, resulting in tempo-
rary neuropraxia. If this occurs, the nerve may take several
months to recover.
The sensory nerves, supraorbital, and supratrochlear
nerves, can be injured during the subperiosteal dissection
near the supraorbital rim, and this will result in paraesthe-
sia in the forehead and scalp areas.
Suture Extrusion and Granulomas
If permanent sutures are used for anchoring, suture granu-
lomas or extrusion can occur. On occasion, this will require
surgical removal to alleviate symptoms.

V Facial Skin and Hair Rejuvenation
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9. Sclafani AP, Fozo MS, Rom o T III, McCorm ick SA. Strength
and histological characteristics of periosteal xation to
bone after elevation. Arch Facial Plast Surg 2003;5(1):
63–66
10. Kim JC, Crawford Downs J, Azuola ME, Devon Graham H III.
Time scale for periosteal readhesion after brow lift. Laryn-
goscope 2004;114(1):50–55
11. Kriet JD, Yang CY, Wang TD, Cook TA. Evaluation of peri-
cranial skull adherence during healing in the rabbit m odel.
Arch Facial Plast Surg 2003;5(1):67–69
12. Holzapfel AM, Mangat DS. Endoscopic forehead-lift us-
ing a bioabsorbable xation device. Arch Facial Plast Surg
2004;6(6):389–393
13. Troilius C. Subperiosteal brow lifts without xation.
Plast Reconstr Surg 2004;114(6):1595–1603, discussion
1604–1605
14. Sidle DM, Loos BM, Ramirez AL, Kabaker SS, Maas CS. Use of
BioGlue surgical adhesive for brow xation in endoscopic
browplasty. Arch Facial Plast Surg 2005;7(6):393–397
15. Harirchian S, Kuperan AB, Shah AR. Safety of cranial xa-
tion in endoscopic brow lifts. Am J Otolaryngol 2013;
34(6):690–694
16. Putterman AM. Intraoperatively controlled sm all-inci-
sion forehead and brow lift. Plast Reconstr Surg 1997;
100(1):262–266
17. McKinney P, Celetti S, Sweis I. An accurate technique
for xation in endoscopic brow lift. Plast Reconstr Surg
1996;97(4):824–827
18. Malata CM, Abood A. Experience with cortical tunnel xa-
tion in endoscopic brow lift: the “bevel and slide” m odi -
cation. Int J Surg 2009;7(6):510–515
19. Jones BM, Grover R. Endoscopic brow lift: a personal review
of 538 patients and comparison of xation techniques.
Plast Reconstr Surg 2004;113(4):1242–1250, discussion
1251–1252
20. Chowdhury S, Malhotra R, Sm ith R, Arnstein P. Patient and
surgeon experience with the Endotine Forehead device
for brow and forehead lift. Ophthal Plast Reconstr Surg
2007;23(5):358–362
tive edem a, shorter recovery tim es, and, m ost important,
less vertex num bness has led to its w ide acceptance and
popularity. The key factors in EFBL are w ide underm in-
ing in the correct plane, complete periosteal release, and
e ective xation. Careful sculpting of the brow shape is
imperative to create an aesthetic and natural-appearing
expression.
References
1. Vasconez LO, Core GB, Gamboa-Bobadilla M, Guzman G,
Askren C, Yamamoto Y. Endoscopic techniques in coronal
brow lifting. Plast Reconstr Surg 1994;94(6):788–793
2. Puig CM, LaFerriere KA. A retrospective comparison of
open and endoscopic brow-lifts. Arch Facial Plast Surg
2002;4(4):221–225
3. Graham DW, Heller J, Kurkjian TJ, Schaub TS, Rohrich RJ.
Brow lift in facial rejuvenation: a system atic literature re-
view of open versus endoscopic techniques. Plast Reconstr
Surg 2011;128(4):335e–341e
4. Pitanguy I, Ram os AS. The frontal branch of the facial
nerve: the importance of its variations in face lifting. Plast
Reconstr Surg 1966;38(4):352–356
5. Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an
important reference point for surgery in the temporal re-
gion. Plast Reconstr Surg 1998;101(1):27–32
6. Sabini P, Wayne I, Quatela VC. Anatom ical guides to pre-
cisely localize the frontal branch of the facial nerve. Arch
Facial Plast Surg 2003;5(2):150–152
7. Winslow CP, Burke A, Bartels S, Cook TA, Wax MK. Bipo-
lar scissors in facial plastic surgery. Arch Facial Plast Surg
2000;2(3):209–212
8. Romo T III, Sclafani AP, Yung RT, McCormick SA, Cocker
R, McCorm ick SU. Endoscopic foreheadplasty: a histo-
logic comparison of periosteal re xation after endoscopic
versus bicoronal lift. Plast Reconstr Surg 2000;105(3):
1111–1117, discussion 1118–1119

339
26 Facial Rejuvenation Using Energy Devices
Un-Cheol Yeo

■General Principles
Principles of Nonablative Rejuvenation
The aim s of nonablative rejuvenation (NAR) are to reduce
w rinkles and to increase elasticity. NAR includes not only
type II rejuvenation w ithout ablation of the skin, but
also type I rejuvenation, w hich can be achieved by IPL,
Q-sw itched laser, or dye laser. NAR delivers heat to the
epiderm is, derm is, and subcutis using lasers or radiofre-
quency. Since NAR treatm ent does not cause epiderm al
dam age, it is safe and allows a rapid recovery, w ith less
chance of the hyperpigm entation and prolonged ery-
them a that is associated w ith laser peeling. NAR includes
various lasers and radiofrequencies. Based on the chro-
m ophores that interact w ith each laser, the NAR lasers
can be classi ed into three categories: (1) dye lasers,
w hich use hem oglobin as a chrom ophore; (2) Nd:YAG
lasers, w hich use hem oglobin, m elanin, and water as
chrom ophores; and (3) m idinfrared lasers, w hich use
water as a chrom ophore.

■Introduction
Skin rejuvenation is an aesthetic procedure to counteract
or reverse signs of the aging process such as pigmentation,
vascular ectasia, wrinkle, and loss of elasticity. Skin reju-
venation can be divided into two types. Type I rejuvena-
tion reverses skin problems such as dyspigmentation and
vascular changes, while type II rejuvenation aims to reduce
wrinkles and restore skin elasticity. Ablative versus non-
ablative rejuvenation is a concept di erent from type I and
type II rejuvenation. Ablative rejuvenation is used to tar-
get photo-damaged skin that progressively worsens with
age. Through the ablation of the epidermis and portions
of the super cial dermis, as well as the induction of col-
lagen remodeling in the deeper dermis, ablative resurfacing
can reduce wrinkles, dyschromia, skin laxity, and vascu-
lar changes. On the other hand, nonablative rejuvenation
delivers heat to the epidermis, dermis, and subcutis with-
out epidermal damage, thereby inducing collagen denatur-
ation. Either an ablative or a nonablative method could be
either type I or type II rejuvenation.
Pearls
• Collagen denaturation is one of the mechanisms for
nonablative rejuvenation laser treatment.
• Cooling during nonablative facial rejuvenation is
very important for the skin of East Asians.
• Energy devices that do not use light may be safer
in Asian skin. Pigmentation in the epidermis of
Asian skin hinders e ective delivery of light into
the dermis and causes complications such as
hyperpigmentation. Energy devices that do not use
light have no interaction with epidermal melanin.
• Energy device emissions other than light can bypass
epidermal melanin tissue, but Asian skin reacts
immediately to in ammation caused by skin damage
and may develop hyperpigmentation even when a
light source is not used for rejuvenation.
• Depending on the nature of the energy device,
surgeons can target di erent depths for
rejuvenation. Sometimes multilayer therapy is
possible with the combined use of these devices.
• In ltrative radiofrequency (RF) can target di erent
depths by changing the lengths of the needles, thus
facilitating multilayer therapy.
• Intense pulsed light (IPL) is very useful for type I
rejuvenation. But it should be used with caution
as it has a large spot size and complications can be
catastrophic.
• Among the types of fractional laser treatment,
super cial treatment lasers such as the thulium
fractional laser give immediate e ective results.
Because it targets the surface, the changes are
readily visible. This phenomenon doesn’t imply that
shallow treatment is better than deep treatment.
• To reverse aging beyond the depth of the skin, high-
intensity focused ultrasound (HIFU), in ltrative
RF with long needles, or interstitial lasers can be
applied.
• HIFU was originally introduced to tighten the
super cial musculo-aponeurotic system (SMAS) and
may destroy fat when delivered to the fat layer. This
can be used very e ectively for chubby cheeks.

V Facial Skin and Hair Rejuvenation
340
Concept of Type I and Type II
Rejuvenation
For type I rejuvenation of Asian skin, IPL, Q-switched lasers,
chemical peeling, and medical skin care, including vitamin
C iontophoresis, can be used. Although medical skin care
requires long-term treatment, it is safest and very useful
when combined with other treatment. Vitamin C iontopho-
resis is often used before and after laser treatment. Patients
with sensitive skin can get type I rejuvenation safely with
IPL as opposed to chemical peeling. Normal skin treated
with chemical peeling may respond positively, showing
improvement in both pigmentation and wrinkling. The
Q-switched laser is the standard laser for pigmentation
problems. It targets speci c lesions and has a small treat-
ment beam size, whereas IPL has a very big spot size.
For type II rejuvenation aimed at improving the appear-
ance of wrinkles, various kinds of lasers and energy devices
can be applied. To reverse epidermal aging, ablative or nonab-
lative fractional lasers and in ltrative fractional RF can be used.
In Asian skin, the ablative lasers are subject to complications
such as hyperpigmentation, and so the nonablative fractional
laser is safer. For dermal reform, LED, pulsed dye laser, NAR and
fractional lasers, and in ltrative fractional RF can be used. In l-
trative fractional RF bypasses the epidermis with cold penetra-
tion needling, so it could be a good option for Asian skin, which
easily develops hyperpigmentation. The same factor renders RF
useful for patients who have sensitive skin. Reduction of fat vol-
ume in the subcutaneous fat and tightening of SMAS are pos-
sible with monopolar RF, HIFU, and interstitial lasers.
Commonly Used Devices in
Facial Rejuvenation
Devices used in facial rejuvenation can be divided into four
groups based on energy source: light, radiofrequency, ultra-
sound, and pneumatic. Light-based devices include the dye
laser, IPL, Nd:YAG laser, midinfrared laser, fractional laser,
and interstitial laser. Radiofrequency devices are divided
into monopolar, bipolar, and in ltrative types using the
electrical current through a treatment tip. Recently, ultra-
sound and microjet injection by pneumatic compression
are being used as noninvasive methods.

■Rejuvenation by Light Devices
Dye Laser
The pulsed dye laser uses the wavelength of 585 to 595
nm. It targets hemoglobin in the capillaries of the dermis,
indirectly stimulating the dermis. The conventional pulse
duration of 0.45 ms produced purpura, but low-energy
treatment with an NLite laser (Clemson Eye) with pulse
duration of 0.35 ms showed e ectiveness with no purpura.11
Most lasers for NAR use water as a chromophore to
generate heat in the skin. Wavelengths between 1,300 and
1,600 nm are used for this purpose. Within this range, the
wavelength that has high absorption to water can penetrate
the skin more shallowly than the wavelength that has low
absorption to water. Using these characteristics, appropri-
ate wavelengths can be chosen to heat the exact depth of
the skin. Fractional treatment, a nonablative type, also uses
a wavelength between 1300 and 1600 nm, and determines
its depth of penetration according to the wavelength. The
key mechanism of NAR is collagen denaturation, which
results in regeneration of new collagen. Generally, collagen
exposed for more than 1 second to 60°C showed denatur-
ation. But when it was exposed to a temperature less than
50°C, activated heat shock protein (HSP) increases the col-
lagen synthesis rather than denaturation.1,2 In the case of
dye laser treatment, collagen bers showed changes after
2 weeks and increased collagen bers appeared after 4
weeks. After 5 weeks, an increased number of broblasts
was conspicuous.3 A light-emitting diode (LED) was also
able to demonstrate increased activity of broblast with-
out collagen denaturation.4 CO2 lasers, dye lasers, and NAR
treatments are also known to increase matrix metallopro-
teinases (MMPs), which remove photo-damaged collagens
and result in the activation of broblasts, thus contributing
to the reversal of the aging process.5,6 Collagen synthesis
was apparent in 1 to 2 months and the result persisted up
to 1 year.7 On the other hand, the e ect of treatment with
ablative fractional CO2 laser was maintained from 3 months
to up to 2 years.8,9 This implies that ablative laser is more
e ective and the e ect is longer-lasting compared with the
nonablative laser in terms of collagen synthesis.
Principles of Ablative Rejuvenation
Beyond tissue ablation, short-pulsed, high-energy, rapidly
scanned CO2 lasers are able to tighten the skin by means
of two mechanisms: controlled instantaneous heating and
wound healing.10 Precise heating of collagen leads to imme-
diate contraction and visible skin tightening from destruc-
tion of the hydrogen bonds within the collagen triple helix
without destroying the collagen molecule. The ideal tem -
perature has been shown to be 63°C. As temperature rises,
more and more cross-link bonds are broken until dena-
turation and loss of structure occur. Denatured collagen
sloughs in the rst few days after the procedure with full
re-epithelialization within 1 week. Over the ensuing 3 to
6 months, this process stimulates new collagen deposition
and broblast proliferation. The wound healing response
induces contraction through broplasia. This ablative frac-
tional treatment has a higher risk of complications, but the
e ect of treatment is superior. Modern fractional ablative
technology allows for ablation of a portion of the epidermis
while leaving adjacent, untreated skin to act as a reservoir
for healing, resulting in a shorter downtime and lower risk
for complications.

26 Facial Rejuvenation Using Energy Devices
341
masked by other pigmentation problems. Since IPL treat-
ment uses a very large spot size compared with lasers, it
is suitable for obscuring the dyspigmentation in the whole
face and achieving general improvement (Fig. 26.1).
Depending on the site of the face, however, the optimal
setting can vary dramatically. Areas such as the forehead,
mandibular line, and zygoma should be treated cautiously.
These areas overlying the facial bones are prone to ery-
thema and pain. The forehead should be treated w ith a u-
ence at least 2 J/cm 2 lower than the settings used to treat
the cheek. During IPL treatment, cooling gel is useful to
prevent formation of air space between the treatment tip
and skin surface. Filling the space with gel can help propa-
gate light evenly into the skin. The gel can also help to cool
down the treatment tip, which becomes hot with continu-
ous ring of IPL. Depending on the thickness of the gel, the
attenuation of light can be changed. More than 10% attenu-
ation is expected with the use of gel. Hence, it’s essential
to know the thickness of the gel applied. It is more likely
to nd curved areas such as the nose and forehead better
covered by the gel. When the assumption is that the gel is
too thick and the parameter is adjusted to compensate for
the attenuation by the gel, overly high uence may be deliv-
ered. If the attenuation is not as expected, this may become
dangerous to the patient. It is therefore safer to set the
parameter with the assumption that the layer of gel is thin.
Some operators may attempt to push the crystal closer to
the skin surface. This would not increase the uence deliv-
ered to the skin, though any possible complication would
be negligible. In any case, the thickness of the gel should be
kept constant at all times.
Immediately after irradiation, the pigmented lesion
may become darker, which indicates adequate treatment.
The treatment end point should be controlled carefully.
Immediately after IPL irradiation, the skin shows mild
erythema. That is generally regarded as a treatment end
point. When the redness is di used, it is ne; but the situ-
ation is dangerous if the redness is intense and shows the
mark of the treatment tip. This ill-de ned erythema usu-
Intense Pulsed Light
Intense pulsed light, or IPL, is broadband light, as opposed
to a a laser, that emits light with a single wavelength. The
spectral distribution is between 550 and 1200 nm. Various
wavelengths interact w ith various chromophores in the
skin, and generally longer wavelengths penetrate deeper.
Because broadband light has diverse e ects on the skin,
selectivity toward a certain target is low compared with
laser. There are various kinds of IPL with di erent spectral
distributions, spot sizes, etc. The parameter shown on the
computer screen, however, may not be the real IPL beam
parameter. Therefore, using the same parameter between
di erent IPL devices is unreliable and should be avoided.
Type I Rejuvenation with IPL
Treating a vascular lesion with IPL risks heating melanin
pigments at the same time due to the broad spectrum of
the light. When using IPL to treat vascular lesions, blisters
and crusts are seen before the development of purpura.
Blisters and crusts are manifestations of epidermal heat
damage. Multiple pulses of IPL can generate heat around
the vessels. Therefore, epidermis must be given time to cool
down. This can be achieved by allowing a longer thermal
relaxation time than the interval between subpulses of IPL.
As for treatment of pigmentation, IPL has a long pulse
duration, which leads to mild changes after treatment.
It heats up and produces mild changes in a melanocytic
lesion without melanosomal destruction. By selecting the
appropriate lter, the optimal setting for each skin photo-
type can be achieved. When IPL is used for the treatment
of melasma, special adjustment of the parameters is neces-
sary. The parameter used for the treatment of melasma is
lower compared with other pigmentation problems. Inad-
vertent high uence irradiation on melasma can lead to
aggravation of this condition. This phenomenon typically
manifests in the case of invisible melasma or mild melasma
Fig. 26.1 IPL treatment for freckles. (a) Before treatment. (b) Immediately after treatment with IPL. The freckles became darker and the
treated area shows di use erythema, which indicates a treatment end point. (c) Ten days after treatment freckles are e ectively removed,
and the skin appears bright.
a
b
c

V Facial Skin and Hair Rejuvenation
342
and 1,540 nm (Aramis, Quantel) are frequently used for
NAR. These wavelengths are called “midinfrared.”
Water absorption of light ranges from 1,200 to 1,450
nm. At around 1,450 nm it reaches the peak and thereafter
it decreases. To modify middermis requires selection of the
optimal wavelength—neither too high nor too low—within
the water absorption range. So the optimal wavelength for
skin rejuvenation is 1,200 to 1,600 nm.
The low absorption coe cient w ith regard to mela-
nin means less reaction with epidermis, safer use, and less
chance to develop hyperpigmentation. The wavelength of
1,540 nm has a lower absorption rate by melanin compared
with 1,450 nm. This works favorably for type II skin. The
depth of treatment and absorption by water molecules
di er among products. The absorption by water is high-
ally subsides in several minutes. The erythema is not the
only signal for completed treatment. To predict the optimal
treatment end point, various factors should be taken into
account such as pain, color change in pigment after treat-
ment, skin type of patient, outdoor activity, patient’s gen-
eral condition, and gender.
One of the common complications of IPL treatment are
rectangular crusts. The mild cases spontaneously subside.
A crust is a problem when it becomes big and visible. After
the crust falls o , redness persists for several months. Gen-
erally, the most serious complications of IPL treatment are
blisters, crusts, long-lasting erythema, and hyperpigmen-
tation (Fig. 26.2).
Type II Rejuvenation with IPL
The e cacy of IPL for type I rejuvenation is well accepted.
IPL is inferior to NAR in type II rejuvenation for wrinkles
and elasticity. In the beginning IPL was known to have dual
e ects through vascular heating by short-wavelength light
and water heating by long-wavelength light. It is known
that shorter wavelengths that work through the vascular
pathway contribute to tissue rejuvenation.
Nd:YAG Laser
The Q-switched Nd:YAG laser has been used as a basic treat-
ment method for pigmentation problems. The Q-switched
Nd:YAG laser12 and long-pulsed Nd:YAG laser have also
been used in NAR to reduce wrinkling. When Q-switching
stops, the lasers are in what is called “free running” mode
with a 0.3-ms pulse duration. Using this pulse duration and
a 5-mm handpiece, continuous irradiation of 14 J/cm 2 and 7
Hz is called the “genesis technique.” It delivers 1,000 shots
to each cheek, making the surface gradually go from warm
to hot. This temperature elevation is believed to result in
dermal remodeling. The genesis technique is performed
w ith brushing and no contact.13 For skin rejuvenation, pulse
durations from nanoseconds to milliseconds are used. The
Q-switched Nd:YAG laser with the nanosecond setting
could be ablative or nonablative depending on the intensity
of treatment. The genesis technique using the millisecond
pulse duration is a kind of nonablative rejuvenation.
Midinfrared Laser
Wavelengths between 1,300 nm and 1,800 nm are well
absorbed by water and used for heating the dermis dif-
fusely. These wavelengths have water absorption coe -
cients of 20/cm to 80/cm (Fig. 26.3). When a wavelength
in this range is applied to skin, the depth of 0.2 to 0.4 mm
below the skin surface is targeted and heated. Among these,
1,320 nm (CoolTouch), 1,450 nm (Smoothbeam, Candela),
Fig. 26.2 Complications of IPL treatment. Rectangular mark with
crusts and swelling and redness after IPL treatment. These prob-
lems resolve with time although redness and hyperpigmentation
may persist in the area for many months after the crust peels o .
A
b
s
o
r
p
t
i
o
n

C
o
e
f
f
i
c
i
e
n
t
W
a
t
e
r

(
c
m
–
¹
)
;

H
b
O
2
,

M
e
l
a
n
i
n

(
c
m
–
1
m
o
l
–
1
l
)
0.0001
0.001
0.01
0.1
1
10
100
1,000
10,000
Water
HbO2 Melanin
1.0
0.1

10
Wavelength (µm)
Fig. 26.3 Absorption coe cients of various chromophores
(water, hemoglobin, melanin) in skin. Midinfrared wavelengths of
1,300 to 1,800 nm are absorbed by water and useful in di usely
heating up the dermis. It is used for NAR. The same wavelengths
are used for nonablative fractional lasers. The thulium fractional
laser uses 1,927 nm, the Er:YAG laser uses 2,940 nm, and the CO2
laser uses 10,600 nm.

26 Facial Rejuvenation Using Energy Devices
343
and avoids the appearance of scar. The Mosaic fractional
laser,14,15 which uses the same technology as the Fraxel, has
been introduced in South Korea and is w idely used. This
treatment method delivers NAR in a fractional way without
cooling.
Ablative Fractional Laser
After the advent of nonablative fractional lasers such as
the Fraxel, curiosity regarding the usage of the CO2 laser
or Er:YAG laser in a fractional way surged. In ablative frac-
tional laser treatment, the temperature of the core of the
coagulation column is over 100°C. This means vaporization
of water and evaporation of skin. As the water vaporizes, it
removes the tissue that harbors water into the air, produc-
ing a real hole in the skin. This ablative fractional treatment
causes more down time and heightens the risk of complica-
tions, but the e ect of treatment is superior (Fig. 26.5).
Thulium Fractional Laser
The thulium fractional laser, with a 1,927-nm wavelength,
has a water absorption coe cient between those of the CO2
laser and the nonablative fractional laser, such as the Fraxel
or the Mosaic (Lutronic). In other words, its characteristics
position it between ablative fractional and nonablative
fractional laser treament. Because of this, the thulium frac-
tional laser can provide either type of treatment depending
on the parameter.
Fractional laser treatment using thulium has high
absorption by water compared with nonablative fractional
lasers, so its penetration into the skin is very shallow but
est at 1,450 nm for Smoothbeam) and the treatment depth
for Smoothbeam is 0.2 mm, by far the shallowest. Aramis
(1,540 nm) has a treatment depth of 0.3 to 0.7 mm with
a moderate rate of absorption by water and it targets the
upper dermis. This depth of treatment is useful for wrinkle
reduction and acne treatment (Fig. 26.4). CoolTouch (1,320
nm) has the lowest absorption by water but penetrates the
deepest, at 1.4 mm. Deep penetration does not necessar-
ily mean a better treatment. Thermage (Solta Medical) is a
product that penetrates deep like CoolTouch.
Deep treatment is good for reversing laxity or increas-
ing elasticity, while shallow treatment is good for ne
w rinkle reduction. The surgeon needs to select treatment
depth according to the patient’s needs. The absorption by
water is not the only factor that regulates the penetra-
tion depth of treatment with the midinfrared laser. Longer
wavelengths are associated with lower scattering charac-
teristics and penetrate deeper. Large spot size is helpful in
increasing penetration depth as well.
Fractional Lasers
CO2 lasers have been used for a long time for resurfacing
but are compromised by long down time. To overcome this
demerit, the Er:YAG laser was introduced. It has less down
time, but is also less e ective than the CO2 laser. One tech-
nique to circumvent this problem was to deliver the energy
in a fractional way. Fractional treatment targets a portion of
the entire skin. Fractional treatment spares normal, unin-
jured tissue in between irradiated columns of coagulation,
to serve as a regeneration source during the regeneration
period. Advantages of fractional treatment are less down
time and relatively high e cacy. The depth of treatment
depends on the laser being used.
Nonablative Fractional Laser
The Fraxel fractional laser irradiates with 1,550-nm -wave-
length light and scans the skin with tiny dots (80 to 180
µm). These dots form numerous (375 to 4,000 per square
centimeter) microthermal zones (MTZs). A MTZ is a col-
umn-shaped coagulation zone from the skin surface to the
dermis. Sixty minutes after application of the topical anes-
thetics, the Fraxel laser scans the skin multiple times and
covers ~ 10 to 20% of the skin surface. The nonirradiated,
healthy skin participates in regeneration and the recovery
is very easy. The procedure causes swelling for 1 to 3 days.
The erythema after treatment subsides within 3 to 7 days
in 85% of the patients. It may last up to 3 weeks in some
patients. This treatment is repeated biweekly to monthly,
usually for three to ve sessions. Unlike other forms of
NAR, this fractional treatment can modify the epidermis
and super cial dermis safely. This treatment to the super-
cial portion of the skin improves wrinkles and elasticity
Fig. 26.4 Non ablative rejuvenation for periorbital wrinkles using
the midinfrared laser Aramis. (a) Before treatment. (b) After four
treatments with Aramis the periorbital wrinkles decreased.
a
b

V Facial Skin and Hair Rejuvenation
344
withdrawn. It is aimed at damaging the undersurface of the
dermis for remodeling and regeneration. Interstitial laser
treatment not only can safely be used for lipolysis but also
can be used in combination with liposuction. After inter-
stitial laser treatment, it is easier to do liposuction as the
fat tissue has already been destroyed partially by the laser.
A wavelength of 1,927 nm is the latest treatment option
available as an alternative for lipolysis and dermal remod-
eling (Fig. 26.6). After interstitial treatment with a 1,927-
nm laser for subdermal remodeling, an increased amount
of collagen in the targeted dermis can be noted (Fig. 26.7).
Interstitial treatment bypasses the epidermis and is associ-
ated with less risk for hyperpigmentation, which makes it
useful for Asian skin.

■Rejuvenation by
Radiofrequency Devices
Radiofrequency (RF) devices utilize electricity in the fre-
quency range 3 kHz to 300 MHz to achieve skin rejuvena-
tion. When the electrical current goes through the skin, it
creates friction within the tissue. This friction causes heat-
ing. The heated tissue is a good media for electric current
because tissues with higher temperature have lower imped-
ance. The RF current follows the less resistant pathway.
RF devices have monopolar and bipolar treatment tips.
Recently, insulated needles have been used for RF. After
multiple insulated needles are inserted into the skin,
the reaction is intense. As a result, it is used for wrinkle
reduction. The changes caused by thulium fractional treat-
ment are mostly super cial and thus are easily recog-
nized by observers. Because of the intense damage that
occurs in the epidermis, the thulium fractional laser can
also be a good modality for pigmentation problems. Thus,
thulium fractional lasers can be used in type I and type II
rejuvenation.
Interstitial Lasers
The laser treatments for skin rejuvenation discussed so far
use only external irradiation with laser beams. Now a new
method is available that involves inserting optical ber into
the skin and having the irradiation done under the skin
surface. It is called interstitial laser. Some examples are
Smartlipo (Cynosure), a 1,064-nm laser, and Accusculpt
(Lutronic), with a 1,444-nm wavelength; both wavelengths
are absorbed by fat tissue. Optical ber is inserted into the
fat layer and used for lipolysis. After insertion the optic
ber is oriented upward while it irradiates and is gradually
Fig. 26.5 Facial rejuvenation using the Edge ablative fractional
laser (Jeisys Co., South Korea). (a) Before treatment. Periorbital
wrinkles and infraorbital fat bulging are observed. (b) After four
treatments with the Edge (30 mJ, 30 W, 300 dots/cm 2 used for
each treatment), improvement of periorbital wrinkles and removal
of infraorbital fat bulging can be seen.
µa, cm –1
12
6
0
500

1500

2500 nm
425
555
1210
1424
1724
1759
1927
2300–2400
2129
Fig. 26.6 Optical properties of the subcutaneous adipose tis-
sue in the spectral range 400 to 2,500 nm. Spectral dependence
of the absorption coe cient of the subcutaneous adipose tissue
calculated from the experimental data by the inverse adding-dou-
bling method. The vertical lines indicate the standard deviation.
The arrows and numerals indicate the absorption band maxima.
(Adapted with permission from Bashkatov AN, Genina A, Kochubey
VI, et al. Optical properties of the subcutaneous adipose tissue
spectral range 400–2500 nm. Opt Spectrosc 2005;99:836–842.)
a
b

26 Facial Rejuvenation Using Energy Devices
345
change in the energy delivery method. Unlike previous gen-
erations, CPT divides the energy into 5 pulses and during
the intermission, cryogen is sprayed, which contributes to
the decreased pain. Third, the CPT Thermage uses a framed
tip. The membrane of the tip is covered with a frame so that
RF can pass through the membrane evenly, and not through
the edge. In addition, the e ciency of energy delivery is
increased 25% and deeper heat generation is possible.
The selection of the proper patient is important. Patients
with mild to medium laxity who are between 35 and 60
years old might be the best candidates for Thermage. Since RF
doesn’t interact with the melanin and preserves epidermis
when properly used, it can be used safely in people of color.
Bipolar RF with Light
In bipolar RF treatment, an electric circuit is formed
between two closely situated electrodes. RF is an alternat-
ing current; the current moves forward and back between
the two electrodes, exerting friction and heat.
From the beginning, bipolar RF was developed in com -
bination with the use of light. In bipolar RF with light, the
skin area that is in contact with the RF is di erent from the
skin area that comes into contact with the light. As the light
goes through the skin perpendicularly, an electric current is
created between two electrodes. The two forms of energy
cross in the dermis at a point where strong heat is exerted
on a focal area of the dermis with minimal surface heating.
This technology was introduced as electro-optical synergy
(ELOS). The commercial products for this technology are
Polaris and Aurora (Syneron), and they have progressed
to E-laser and E-light. In Korea, the same principle is used
with the Antilax (bipolar RF + infrared (IR):1,100–1,800
nm) and Arneb (bipolar RF + diode: 635, 915 nm).
In ltrative Fractional RF
In ltrative fractional RF uses insulated slender needles.
Multiple needles are inserted into the skin. The noninsu-
lated distal tip of each needle emits RF after insertion. The
proximal part of the needle is insulated; the epidermis and
super cial dermis are not thermally injured, which means
it is a kind of micro needling or cold penetration technique.
By circumventing the super cial part, in ltrative fractional
RF can safely deliver intense energy into the deep dermis.
Generally, in ltrative fractional RF has a lower density of
needles than the micro needling technique and fractional
laser treatment, so it causes less epidermal damage. The
damage in the super cial part heals within a few days and
the dermal coagulation recovers within several months.
Moreover, di erent depths can be targeted with the correct
selection of needles.
In ltrative fractional RF is used to treat various condi-
tions in Korean and Asian patients. It is used for rejuvenation
(Fig. 26.8), scar treatment, and pore size reduction.16,17,18,19
the noninsulated distal tip delivers RF current. Usually
it employs bipolar needles and the electric current runs
between the needles. This is called in ltrative RF treatment
in a fractional way.
Monopolar RF
In monopolar RF treatment the return pad is usually
attached to the back or abdomen of the patient and the
treatment electrode is used on the face or body. The rst
monopolar device used for aging skin was the Thermage
ThermaCool TC system. It was introduced for facial rejuve-
nation in 2001. Thermage uses RF for heat production in
the dermis for remodeling and rejuvenation. While electric
current is emitted from the square, at membrane, cryo-
gen is sprayed onto the surface of the membrane. Initially
Thermage was used to treat the forehead and temple, and
to lift the upper eyelid and eyebrow. Thermage is also used
for lifting and tightening the cheek and the perioral and
mandibular line. To deliver multiple passes in a short time,
bigger tips and faster tips are developed, including the big
tip (1.5 cm 2) and the superbig tip (3.0 cm 2). As experience
has grown, Thermage has come to be used to treat other
parts of the body, including the abdomen, arm, and dorsum
of the hands. Using it in combination with other treatments
can have a synergistic e ect.
Comfort Pulse Technology (CPT) is a new version of
Thermage. The upgraded version gives patients a more
comfortable treatment with minimal pain. CPT technology
features three upgrades. First, it has a vibrating handpiece
that allows the patient to feel less pain. Second, there is a
Fig. 26.7 Subdermal remodeling after 1927-nm thulium intersti-
tial laser (Xlender-Y, Wontech Co., South Korea) treatment. After
subdermal irradiation using the Xlender-Y, localized subdermal
coagulation is observed. It can be used e ciently for subsurface
resurfacing because it does not involve super cial dermis and epi-
dermis (a total 3,850 J was delivered over 100 cm 2, 4.8 W/40 Hz /
Duty 40%/120 mJ of pulse energy).

V Facial Skin and Hair Rejuvenation
346
The m ethod relies on the delivery of concentrated ultra-
sound energy from the ultrasound transducer. The HIFU
m ethod is not only used for lysing fat in the body but also
for targeting the SMAS in the face. Ulthera was the rst
device claim ing to target the SMAS under the skin. HIFU
delivers ultrasound energy to the SMAS and denatures
collagen and stim ulates regeneration. Ulthera uses 4-, 7-,
and 10-Mhz transducers and targets a spot 4.5 m m , 3.0
m m , or 1.5 m m from the skin surface w ith the respective
transducers. The focused coagulation area is called the
therm al coagulation zone (TCZ). After 12 weeks the TCZ
is replaced by new collagen synthesis.20,21,22 The shape of
the TCZ is an “inverted cone” or cylinder, and the size is
~ 1 m m . TCZs are m ade fractionally in line by the scanner
of the transducer. This is called the “treatm ent line.” Each
treatm ent line is 2.5 cm and is composed of 17 to 23 TCZs;
the interval between TCZs in the line is 1.1 to 1.5 m m .
Even though it is reported that a 4-MHz, 4.5-m m trans-
ducer has a TCZ at the 4.5 m m depth, the depth of the TCZ
w ill di er depending on w hether it is phantom , fat tis-
sue, skin, de-epithelialized skin, etc. When HIFU traverses
low-impedance tissue such as fat, it results in a deep TCZ.
When HIFU traverses high-impedance tissue such as skin,
it form s TCZ at a shallow depth. The depth of TCZ is not
xed according to the transducer. Thus, it should be taken
into account w hen clinically applied. When we treat the
thin-skinned patient w ith HIFU, the TCZ may be deeper
than expected, because thin skin w ill not absorb HIFU
m uch. On the other hand, when we treat thick-skinned
patients w ith HIFU, too m uch energy m ay be absorbed in
its early propagation, form ing the TCZ at a shallow depth.
These factors should be considered in the treatm ent pro-
tocol (Table 26.1).
Good candidates for this procedure are those who have
a fatty cheek. They may be satis ed with the shrunken cheek
after HIFU treatment. Conversely, those with a thin cheek
would complain about a sunken cheek appearance after
HIFU treatment. Sometimes focal depression is observed
after HIFU treatment, which is regarded as fat atrophy.
The in ltrating needles can also target and destroy seba-
ceous glands and improve acne problems. Reports suggest
that it is e ective for active acne.19 In ltrative fractional RF
can be used with a combination of di erent needle lengths
in one session. This results in multilayer treatment.

■Rejuvenation by High-Intensity
Focused Ultrasound
The high-intensity focused ultrasound (HIFU) device
em its ultrasound, w hich penetrates through skin and
focuses the signal on a sm all point below the skin surface.
Fig. 26.8 Periorbital rejuvenation by in ltrative fractional RF
(Intracel, Jeisys Co., South Korea). (a) Before rejuvenation. (b) The
full face was treated with one pass (bipolar, level 2, needle 1.5 mm),
and additional treatments in the periorbital area used two or three
passes (bipolar, level 2, needle 0.8 mm or 1.5 mm). Sixty days after
treatment the patient shows improved periorbital wrinkles. (Cour-
tesy of Dr. Takashi Takahashi, Tokyo, Japan.)
Table 26.1 Types of cartridges that should be used for targeting di erent HIFU penetration depths in various
conditions
Thin skin and fat
Thin skin, normal fat
Normal skin and fat
Thick skin and fat
Dermis
A type
A, B types
Fat layer
A type
A, B types
B type
B, C types
SMAS
B type
B, C types
C type
D type
A type cartridge: 2 mm penetration in normal-type skin and subcutis.
B type cartridge: 3 mm penetration in normal-type skin and subcutis.
C type cartridge: 4.5 mm penetration in normal-type skin and subcutis.
D type cartridge: 6 mm penetration in normal-type skin and subcutis.
a
b

26 Facial Rejuvenation Using Energy Devices
347
pro lometric, histologic, ultrastructural, and biochemical
evaluations and comparison of three di erent treatment set-
tings. J Photochem Photobiol B 2007;88(1):51–67
5. Orringer JS, Kang S, Johnson TM, et al. Connective tis-
sue rem odeling induced by carbon dioxide laser resur-
facing of photodamaged hum an skin. Arch Derm atol
2004;140(11):1326–1332
6. Orringer JS, Voorhees JJ, Ham ilton T, et al. Derm al matrix
rem odeling after nonablative laser therapy. J Am Acad Der-
matol 2005;53(5):775–782
7. Dainichi T, Ueda S, Fumimori T, Kiryu H, Hashim oto T.
Skin tightening e ect using fractional laser treatment II:
a pilot anim al study on skin rem odeling. Dermatol Surg
2010;36(1):71–75

■Rejuvenation by
Pneumatic Devices
Skin rejuvenation technology using pneumatic energy is a
noninvasive procedure delivering micro-jet uid into the
dermal or subdermal layer without the use of a needle.14,15
Micro-jet uid is broken down into micro-bubbles in skin
tissue and spreads through the dermis evenly, forming a
vortex and accelerating collagen boosting in collagen-rich
dermal tissue by high pressure. This can be used for facial
lifting, scar treatment (acne scars, surgical scars, and keloid
scars), wrinkles, etc. Various uids can be used, such as
saline solution, diluted non-cross-linking hyaluronic acid
(HA) solution, 20% glucose solution, and poly-deoxy ribo-
nucleotide (PDRN) according to the speci c requirements.
When using a pneumatic energy–based device, su cient
pressure and speed are needed. However, the pressure and
volume of uid should be adjusted to various skin condi-
tions such as thickness, elasticity, exibility, and strength.
An immediate skin rejuvenation e ect is achieved by ll-
ing the empty space between skin tissue cavities with micro-
bubbles and performing skin tightening by physical injection.
Facial wrinkles caused by collapse of skin tissue can be
improved by injection of diluted non-cross-linking HA solu-
tion into the appropriate skin structure. Right after injection,
the injection site will appear like a balloon with bleaching
seen. This will remain from minutes to hours depending on
the type and viscosity of uid injected. As the injected uid is
absorbed, the bleaching balloon formed at the injection site
subsides slowly and occasionally remains erythematous.
A prolonged skin rejuvenation e ect is now possible
due to damaged skin tissue regeneration with new colla-
gen synthesis. Due to the new collagen synthesis, patients
can feel continuous skin changes such as improvement
of skin texture and the facial contours. These changes are
manifested three months after the treatment. Three to ve
treatments biweekly can result in aesthetic improvement
(Fig. 26.9).
References
1. Desmettre T, Maurage CA, Mordon S. Heat shock protein
hyperexpression on chorioretinal layers after transpu-
pillary therm otherapy. Invest Ophthalmol Vis Sci 2001;
42(12):2976–2980
2. Souil E, Capon A, Mordon S, Dinh-Xuan AT, Polla BS, Bach-
elet M. Treatment with 815-nm diode laser induces long-
lasting expression of 72-kDa heat shock protein in norm al
rat skin. Br J Dermatol 2001;144(2):260–266
3. Om i T, Kawana S, Sato S, Honda M. Ultrastructural changes
elicited by a non-ablative wrinkle reduction laser. Lasers
Surg Med 2003;32(1):46–49
4. Lee SY, Park KH, Choi JW, et al. A prospective, randomized,
placebo-controlled, double-blinded, and split-face clinical
study on LED phototherapy for skin rejuvenation: clinical,
Fig. 26.9 Neck wrinkle treatment with Innojector (Amorepaci c
Co., South Korea). (a) Before treatment of neck transverse line. (b)
Single treatment using needle-less tip (150 µL saline per shot, pres-
sure level 3, distance between injection sites ~ 1.0 cm). Swelling is
observed immediately after injection. (c) One month after treat-
ment. (Courtesy of Dr. Beom-Joon Kim, Seoul, South Korea.)
a
b
c

V Facial Skin and Hair Rejuvenation
348
16. Lee HS, Lee DH, Won CH, et al. Fractional rejuvenation us-
ing a novel bipolar radiofrequency system in Asian skin.
Dermatol Surg 2011;37(11):1611–1619
17. Seo KY, Yoon MS, Kim DH, Lee HJ. Skin rejuvenation by
m icroneedle fractional radiofrequency treatm ent in Asian
skin: clinical and histological analysis. Lasers Surg Med
2012;44(8):631–636
18. Kim JE, Lee HW, Kim JK, et al. Objective evaluation of the
clinical e cacy of fractional radiofrequency treatment for
acne scars and enlarged pores in Asian skin. Derm atol Surg
2014;40(9):988–995
19. Lee KR, Lee EG, Lee HJ, Yoon MS. Assessment of treatment
e cacy and sebosuppressive e ect of fractional radiofre-
quency microneedle on acne vulgaris. Lasers Surg Med
2013;45(10):639–647
20. White WM, Makin IR, Barthe PG, Slayton MH, Gliklich RE.
Selective creation of therm al injury zones in the super -
cial m usculoaponeurotic system using intense ultrasound
therapy: a new target for noninvasive facial rejuvenation.
Arch Facial Plast Surg 2007;9(1):22–29
21. White WM, Makin IR, Slayton MH, Barthe PG, Gliklich R.
Selective transcutaneous delivery of energy to porcine soft
tissues using Intense Ultrasound (IUS). Lasers Surg Med
2008;40(2):67–75
22. Laubach HJ, Makin IR, Barthe PG, Slayton MH, Manstein D.
Intense focused ultrasound: evaluation of a new treatment
m odality for precise m icrocoagulation within the skin.
Dermatol Surg 2008;34(5):727–734
8. Ortiz AE, Trem aine AM, Zachary CB. Long-term e -
cacy of a fractional resurfacing device. Lasers Surg Med
2010;42(2):168–170
9. Manuskiatti W, Fitzpatrick RE, Goldman MP. Long-term
e ectiveness and side e ects of carbon dioxide laser re-
surfacing for photoaged facial skin. J Am Acad Derm atol
1999;40(3):401–411
10. Ortiz AE, Goldman MP, Fitzpatrick RE. Ablative CO2 lasers
for skin tightening: traditional versus fractional. Derm atol
Surg 2014;40(Suppl 12):S147–S151
11. Bjerring P, Clem ent M, Heickendor L, Egevist H, Kiernan
M. Selective non-ablative wrinkle reduction by laser. J Cu-
tan Laser Ther 2000;2(1):9–15
12. Goldberg DJ, Whitworth J. Laser skin resurfacing with the
Q-switched Nd:YAG laser. Derm atol Surg 1997;23(10):
903–906, discussion 906–907
13. Schmults CD, Phelps R, Goldberg DJ. Nonablative facial remod-
eling: erythema reduction and histologic evidence of new col-
lagen formation using a 300-microsecond 1064-nm Nd:YAG
laser. Arch Dermatol 2004;140(11):1373–1376
14. Mitragotri S. Current status and future prospects of nee-
dle-free liquid jet injectors. Nat Rev Drug Discov 2006;
5(7):543–548
15. Baxter J, Mitragotri S. Needle-free liquid jet injections:
m echanism s and applications. Expert Rev Med Devices
2006;3(5):565–574

349
27 Hair Transplantation in East Asians
Sungjoo (Tommy) Hwang
Hair transplantation among East Asians and Caucasians
is similar in many aspects, but there are several di erences
that must be discussed.

■Characteristics of the
Asian Scalp and Hair
Shape and Hairline
The shape of the Asian skull appears rounder in circumfer-
ence than the usually ovoid Caucasian skull. The forehead
area of the Asian skull also tends to be larger and w ider
than its Caucasian counterpart (Fig. 27.1). These di er-
ences result in rounded fronto-temporal angles and a head
that is atter across the hairline in East Asians.3
Clinical consultations with Asian males have found
that most prefer a low, straight hairline with a rounded
frontotemporal angle. Surgeons occasionally recommend a
frontal recession to patients for a better cosmetic result, as
it is sometimes necessary to modify the patient’s desired

■Introduction
In hair transplantation, the term Asian encompasses indi-
viduals from a wide area located geographically from what
Europeans call the Middle East to the Far East. Ethnic groups
have di erent hair and facial characteristics depending on
their country of origin. In this chapter, the word Asian will
mainly be used in reference to the peoples of East Asia, such
as the Koreans, Japanese, and Han Chinese.
Historically, Asians have been concerned less about male
pattern hair loss (MPHL) than Caucasians. This is mainly
because MPHL was associated with wealth, the wisdom due
to age, and the upper classes.1,2 In today’s society, Asians are
becoming more concerned about their external features and
appearance than they have been in the past. For example, it
is becoming more di cult for Korean males with a Norwood
type IV or greater level of baldness to get married or obtain
employment because these individuals look older than their
actual age. This can lead to feelings of insecurity and shame.
To overcome this, more and more Asians are becoming inter-
ested in hair transplantation surgery.
Pearls
• The East Asian skull tends to be rounder in
circumference and to have a larger and wider
forehead compared with its Caucasian counterpart,
which results in rounded frontotemporal angles and
a atter hairline.
• Asians have fewer hairs and a lower multi-hair
follicular unit (FU) count than Caucasians. The
follicle length from epidermis to dermal papilla is
longer and the average hair shaft diameter is thicker.
• Asians are prone to keloid and hypertrophic
scarring, which is more common in younger patients
due to their higher rate of collagen synthesis.
• Even after patients receive hair transplantation,
the loss of existing hair continues as time goes on.
Therefore, additional medical treatment is necessary
to prevent or limit further hair loss.
• “Depth-controlled transplantation” according to
graft length can help to yield a superior result and
help to minimize complications such as folliculitis,
pitting, and poor survival.
• Applying the vibrator and ice pack during local
anesthesia can be very helpful in reducing pain.
Allowing the patient to grasp the assistant’s hand or
arm can also help to minimize the reaction to pain.
• Vitamin E, omega-3, and herbal medications should
be avoided for at least two weeks prior to surgery to
reduce bleeding during hair transplantation.
• Preoperative oral diazepam may limit the incidence
of syncope and fainting. Taking a break and
consuming cookies and juice would be helpful to the
patient in reducing discomfort during the hours-
long operation.
• Follicular unit extraction (FUE) should be performed
with care in Asians because of their idiopathic
tissue brosis, lower FU density and hair-graft ratio,
high hair-skin color contrast, and a higher risk of
transection due to their longer hair follicle.
• Several factors should be evaluated during
consultation. These include the age of the patient,
donor density, donor hair thickness, extent of hair
loss, and the patient’s expectations.

V Facial Skin and Hair Rejuvenation
350
Hair Density
The hair density of the donor area of an Asian male is usually
lower than that of Caucasian males. Caucasians have hair
density of an average of 200 hairs/cm 2 in the donor area,7
whereas Koreans have ~ 137 hairs/cm 2 in the occipital area
and 118 hairs/cm 2 in the temporal area.1 Ezaki estimates
that the average hair density in Japanese men is 130 hairs/
cm 2, while Pathomvanich reports that Thai men have 170
hairs/cm 2 in the occipital and 127 hairs/cm 2 in the parietal
area.8,9 In general, males in the Far East of Asia have a lower
hair density than those in the Middle East or Southeast Asia.
The occipital follicular units of Koreans are ~ 37% single-
haired, 38% two-haired, and 25% three-haired. According to
Imagawa, the scalp hairs of Japanese men are made up of 30%
single-hair, 50 to 55% two-hair, and 15 to 20% three-hair FUs
on average.1 Pathomvanich states that the scalp hair of Thai
men has 24% single-hair, 64% two-hair, and 13% three-hair
FUs.9 In addition, Thai men have 90 FU/cm 2 or 170 hairs/cm 2
in the occipital area while in the parietal zone, they have 70
FU/cm 2 or 127 hairs/cm 2. This represents 1.8 hairs/FU. Ber-
nstein found that Caucasian men have an average of 25%
one-hair FUs, 50% two-hair FUs, and 25% three-hair FUs.4,5
Caucasians have a similar density of FUs, but have 2.3 hairs/
FU, resulting in a greater total number of hairs.
In general, hair transplantation doctors count the
number of “grafts” transplanted. However, Korean doctors
count the number of “hairs” transplanted. This is because
the ratio of single-hair FUs to multi-hair FUs varies greatly
among patients, and the results are dependent on the num -
ber of hairs and not on the number of grafts.
hairline to produce an aesthetically acceptable cosmetic
result. For patients with Norwood class VI or VII hair loss,
a frontal forelock design connecting the temple areas will
produce aesthetically acceptable results for most Asian
patients, although true isolated frontal forelocks are not
well accepted by the majority of Asians.
Hair Characteristics
Compared with Caucasians, Asian hair is coarser, has a
larger caliber, and is usually straighter. The average hair
shaft diameter of an Asian is ~ 100 mm, versus a maximum
of ~ 70 mm for that of Caucasians.1,2 The larger-caliber hair
shaft contributes to the appearance of greater hair density.
Furthermore, the color contrast between black hair and
light skin is high. Skin color varies from white to dark across
Asia (e.g., Koreans and Japanese tend to have white skin,
whereas Malaysians and Indians tend to have darker skin).
This high skin/hair color contrast also makes it very di -
cult to achieve the illusion of fullness, because the scalp can
be clearly seen through the straight black hair. As a result,
the high color contrast coupled with the larger-caliber hair
makes a transplant more noticeable when mini or punch
grafts are used. Therefore, follicular unit transplantation
(FUT) is the method of choice for Asians for producing a
more natural look.4,5
The follicle length from epidermis to dermal papilla is
5.5 mm on average in Asians compared with ~ 4.5 mm in
Caucasians. This results in a higher risk of transection of
grafts during donor harvesting and graft dissection.6
Fig. 27.1 (a,b) Comparison of Asian and
Caucasian skull shapes. The East Asian skull
is rounder in circumference and has a larger
and wider forehead compared with the Cau-
casian counterpart.
a
b

27 Hair Transplantation in East Asians
351
7. Patients who have been wearing wigs should be
informed that the hair transplant will not result in
the same appearance as that of donning a wig.
8. In the event that a patient received an unsatisfactory
procedure from another clinic, it is important not to
criticize the previous clinic. It is more bene cial for
the patient to receive a detailed explanation about
the improvements achievable from an additional
procedure.
9. Since the aim of a procedure can di er between a
doctor and a patient, it is bene cial to show before
and after photos of previous patients.
10. Though patients prefer to have the maximum
number of hairs to be transplanted, transplantable
hair numbers should be based on scalp elasticity,
family history, and likely future progression.
11. Many Asians routinely consume various herbs
such as ginseng, garlic, and onion, as well as other
supplements. These herbs and supplements may
increase bleeding during hair transplantation
surgery and therefore should be avoided for at least
2 weeks prior to surgery.14
12. A complete blood count, a routine urinalysis,
tests for hepatitis B and C antigen and human
immunode ciency virus (HIV), and tests for liver
and kidney function should be performed before the
surgery.
To evaluate whether a patient is a good candidate for
hair transplantation, we need to take several factors into
consideration.2
1. Age: Am ong all age groups, patients under the
age of 25 years are the m ost difficult to satisfy.
Experienced hair surgeons usually avoid or
delay hair transplantation for young patients.
Male-pattern hair loss starts after adolescence.
Therefore, m any patients w ith advanced hair
loss in their 20s request hair transplantation.
In severe cases, perform ing the transplant is
inevitable. If the hair loss is not very advanced,
it is advisable to delay the transplant as long as
possible, and the donor site should be preserved
as m uch as possible for further transplantation
in the future, even if the transplant is perform ed.
Donor site scarring is m ore com m on in younger
patients, so it is necessary to discuss scarring.
Also, special consideration needs to be given
concerning closure, including sm aller w idths and
internal sutures. Middle-aged or older patients,
however, rarely develop significant scarring on
donor sites, and their expectations about the
transplant tend to be lower. Therefore, their
satisfaction tends to be greater and they are m ore
suitable for the transplant.
Scar Formation
The Asian scalp is thicker and less elastic than the Cauca-
sian scalp and su ers a higher incidence of keloid or hyper-
trophic scarring at the donor site.1,2,9 These scars occur less
commonly in Asians than those from African descent, but at
a higher rate than in Caucasians.1,2 These scars occur in the
donor area and are very rare in the recipient area. The main
cause for hypertrophic scarring in Asians is genetic, and
the problem occurs more commonly in younger patients,
due to their higher rates of collagen synthesis. These scars
can also be aided by excessive tension during donor site
closure. The risk increases if multiple hair transplantation
sessions are necessary, so surgeons should avoid the use of
wide strips and minimize tension during closure.
The Importance of Medications
in Asians
Compared with Caucasians, usually fewer hairs on the East
Asian head are available for harvesting.1 Also, a higher rate
of scarring on the donor site limits the number of proce-
dures available to East Asians.9 Even after patients receive
hair transplantation, the ongoing loss of hair continues as
time goes on. Therefore, it is essential to maintain exist-
ing hair in East Asian patients with medications like oral
nasteride and topical minoxidil, which can slow future
hair loss.10,11,12,13 In addition, by maintaining existing hair
through the use of medication, a patient’s self-esteem can
be greater due to the hair’s higher density.

■Patient Evaluation
The following points should be discussed during consulta-
tion with patients.2
1. Patients need to be informed about the procedure,
expected course after the procedure, and possible
complications.
2. Realistic expectations regarding the number of hairs
and areas to be transplanted need to be explained, as
well as achievable long-term results.
3. It is helpful to draw the achievable hairline with a
colored pencil to show the patient.
4. It is helpful to grade expected results based on the
age, severity, family history, and densitometer result
of the patient.
5. It is important to explain the necessity of medical
treatment to prevent further hair loss.
6. Discussion about future hairstyle can aid patient
satisfaction. A short hairstyle can result in lower
patient satisfaction, while parting can be more
satisfactory cosmetically.

V Facial Skin and Hair Rejuvenation
352
screened for these problems, and old wounds should
be examined. Patients with a personal history of
keloid scar formation are not good candidates for
hair restoration surgery, while those with a family
history of keloid scarring, or a personal history of
hypertrophic scarring, should be cautioned on the
increased risk of abnormal healing.

■Surgical Techniques
Preparation on the Day of Surgery
When the patient arrives for surgery, the author begins
by taking preoperative photographs. If a patient has high
blood pressure, this can lead to excessive bleeding during
surgery. Transient high blood pressure may be caused by
emotional stress, so preoperative sedatives such as diaze-
pam and/or sublingual nifedipine are useful in reducing or
normalizing the patient’s blood pressure. Assistants should
shampoo the scalp before donor harvesting to reduce the
bacterial colony counts in the scalp, thus helping to prevent
or reduce infections that may be associated with surgery.
Hairline Design
The shape of the scalp is generally round and wide among
East Asians. The hairline design in East Asians should be
a wide arc with less central convexity, and frontotempo-
ral recession should be less prominent compared with the
Caucasian’s round, convex hairline.3
The design of the frontal hairline is made using stan-
dard distances and anatomical landmarks. The principle of
three equal distances is the balance between chin and nasal
tip, nasal tip and glabella, and glabella and midfrontal point
of the hairline. In general, the distance between the glabella
and the midfrontal point of the hairline ranges from 6.5 to
8.5 cm.16 A 7.0 to 7.5 cm hairline works well in the major-
ity of patients, and this is where the author places most
hairlines. When designing the hairline it is important to
remember the hairline consists of the frontal hairline and
temples. The frontal hairline has to balance with the tem -
ples to achieve a balanced, natural look. If the temples are
receded and hair transplantation on the temple area is not
indicated because of insu cient donor hair, then a higher
hairline, with an upslope, will create balance.
Generally, in patients with mild hair loss and better
donor hair on average, placing the frontal hairline at 7 to 8
cm is safe. If the patient does not object, the author gener-
ally prefers to design in a small amount of upslope, thus
making it easier to tie the top hairline to the temples with-
out having it extend too far into the temple area. Younger
patients will often push for a lower hairline or a down-
sloping (juvenile) hairline. On an adult Asian this design
looks odd, is di cult to correct, and should be avoided.
2. Donor density: The hair density of the patient’s donor
area should be evaluated using a densitometer.15 This
procedure assesses the number of single-, two-, and
three-hair FUs that will be obtained from the donor
area. Koreans have an average of 130 hairs per square
meter on the occipital scalp. Greater hair number
with higher density tends to have 2- and 3- hair FU,
resulting in a better outcome after the transplant. If
the density is much lower than average in patients
with severe hair loss, hair transplantation should
be avoided because the patient will not be satis ed
with the results.
3. Hair thickness: Thicker hairs on the donor site result
in greater volume and better cosmesis after the
transplant. It is helpful, therefore, to measure the
thickness of the hair during the consultation. If the
hair thickness is less than 60 mm, the outcome of the
hair transplantation will not be as good and patients
usually will not be able to achieve the expected
fullness.
4. Patient’s expectations: Patients with early male-
pattern hair loss tend to have higher expectations,
resulting in lower patient satisfaction. Also,
the progression of alopecia and the survival of
transplanted hairs can result in unusual and
unacceptable hair patterns. In contrast, advanced
male-pattern hair loss patients tend to have lower
expectations, resulting in higher satisfaction. It is
very important to assess the patient’s expectations
from the surgery. Unrealistic expectations will result
in unhappy patients. It is important to adjust the
patient’s expectations prior to the surgery, and it is
wise to delay the surgery if the expectations do not
change.
5. Scalp laxity: A thick and immobile scalp is described
as “tight scalp,” and it can be di cult to close the
donor site wound if the width is greater than 1 cm. It
is safer to operate multiple times with small widths
in cases of tight scalp since a width of 1.5 cm can
result in necrosis and severe scarring. With tight
scalp, the width should be small and the number
of harvested hair follicles lower than usual, or else
satisfaction with the outcome of transplantation also
will be low. Therefore, a scalp that is too tight is a
contraindication for hair transplantation.
6. Past history and fam ily history regarding scarring:
East Asians are genetically susceptible to abnormal
donor area scarring, which a ects their suitability
for hair transplantation. In particular, they are
prone to keloid scarring, which occurs when the
brous tissue expands beyond the boundaries of the
incisional scar, and hypertrophic scarring, which
is characterized by exuberant brous grow th that
does not cross the wound margin. These problems
occur more commonly in younger patients, due to
their higher rates of collagen synthesis. During the
consultation, East Asian patients should be carefully

27 Hair Transplantation in East Asians
353
Donor Harvesting
Strip Surgery
Strip harvesting is performed by the majority of hair resto-
ration surgeons throughout the world. ISHRS 2013 census
results showed 68% for strip harvesting compared with 32%
for follicular unit extraction.17
Laxity of scalp can be assessed easily by moving the
scalp vertically while holding hairs from the donor site. It
can be classi ed into hyperelastic, normal, and tight scalp.
There are other methods to measure the scalp laxity: May-
er’s scalp elasticity scale18 and Mohebi’s laxometer.19 There
are di erent opinions about ideal widths for donor sites.
The optimal width of the donor strip in Asians is 1.5 cm
or less.1,2,6 It can be di cult to close using a 1-cm w idth in
patients with a tight scalp, so it is advisable to minimize
w idths. It can be easy to close a hyperelastic scalp with
w idths of more than 2 cm; however, excess scarring can
result from the stretch-back phenomenon.20 Therefore, it is
advisable to incise within a 1.5-cm width in patients with
hyperelastic scalp. Wide scars tend to occur more readily
in younger patients since the rate of collagen synthesis is
greater. In young patients, therefore, a long and narrow
donor strip is safer than a short, wide strip.
Once this is determined, the hair is trimmed in the
donor area, which is located in the midocciput, extending
slightly into the temporal region. The hair is trimmed to
~ 2 mm in length when employing the Western method,
and 5 to 10 mm in length for the implanter technique.21
Some doctors prefer to use the tumescent technique to
anesthetize the donor area, while others favor a bu ered
solution of 1% lidocaine with 1:100,000 epinephrine with-
out tumescence.2 Allow ing the patient to hold the assis-
tant’s hand or arm during local anesthesia can also help to
soothe the pain. Applying an ice pack and vibrator near the
injection site during local anesthesia can be very helpful
to reduce pain (Fig. 27.3).22 Patting the patient’s back is a
useful method to make the patient feel comfortable during
donor harvesting, especially in the prone position.
To minimize the number of transected follicles, the
incision should be parallel to the direction of the hair fol-
licles. This is important because the length of hair follicles is
greater in Asians than in Caucasians, and thus the probabil-
ity of transection is higher among Asians. For this reason,
the single-blade knife technique is safer for making an inci-
sion than the multi-blade knife technique. More accurate
incisional methods include the open technique suggested
by Pathomvanich: Four skin hooks and two assistants are
required to gain more exposure and to potentially cut
faster.6 He minimized the follicular transection at 1% or less.
In addition, bleeding needs to be controlled completely
before wound closure. Arterial bleeding needs to be con-
trolled with a hemostat. Smaller vessels can be controlled
with a hemostat, but a larger vessel needs ligation with 4–0
Vicryl (Ethicon). It is recommended that the surgeon avoid
or reduce the degree of electro-cauterization to control
Hair shafts of East Asians are coarse, dark, and straight.
It is usually not easy to make a soft and natural-looking
hairline in East Asian patients. Therefore, Asians require
more single-hair units to create a natural-looking hairline.
The author prefers to place a minimum of 400 single-hair
FUs at the frontal hairline.
The routine that the author uses to create the hairline is
simple and is as follows (Fig. 27.2):
1. Note the distance between the chin and nasal tip,
between the nasal tip and glabella, and between
the right and left temples. Using the reference,
mark a short horizontal line 6.5 to 8.5 cm above the
midbrow level.
2. Mark a point on this line dividing the face into equal
left and right halves. This can be done easily by
holding the marking pen over the nose and bisecting
the face into equal halves.
3. From this midpoint draw the top hairline laterally,
keeping it on a horizontal plane or a slight upslope
when viewed from the front.
4. Check from the front to make sure the two sides
are even and from the side to see if the line that has
been drawn balances the existing temples. If the
frontal hairline looks low when viewed from the
sides, you will have to move the top lines up slightly
and redraw the top line with a slight upslope.
5. The straight line looks unnatural. Add a zigzag
pattern line on the straight hairline and implant the
single-hair FUs on the zigzag line to make a natural-
appearing hairline.
Fig. 27.2 Hairline design in Asian male with male-pattern hair
loss. A new hairline is designed considering the vertical and hori-
zontal facial harmony. A zigzag pattern is more natural-looking
than a straight line.

V Facial Skin and Hair Rejuvenation
354
small percentage of patients will develop signi cant scar-
ring, usually due to genetic di erences in skin type.
Follicular Unit Extraction
In 1988 Masumi Inaba in Japan introduced the use of a
1-mm punch for extracting individual follicular units. Body
hair transplantation using a punch was reported by Woods
in 1998. In 2002 Rassman and Bernstein further re ned the
procedure and named it follicular unit extraction.16,27 Harris
later introduced the SAFE system using a blunt punch to free
the follicle.28 Isolating the follicles one by one using a manual
punch was very time-consuming. Motorized FUE machines
were developed to increase the speed of extraction.29 The
latest development, from Robotics, is an interactive, com-
puter-assisted system using image-guided robotics to har-
vest follicular unit grafts.30 The follicular units obtained by
strip surgery and the FUE method are the basic building
blocks of follicular unit transplantation (FUT).
In FUE, the physician removes follicular units one at
a time from the donor site until there are enough for a
transplant session. When using the FUE round punch, the
0.75- to 0.80-mm size should be reserved for one-hair FUs.
The 1.0-mm size can be used for most two- and three-
hair grafts. The larger, 1.2-mm punch, with the potential
to leave a scar and transect adjacent follicles, should be
avoided. The entire donor site should be trimmed, leav-
ing behind 0.3 to 0.5 cm of hair above the skin to guide the
punch. FUE is a technique that requires special skill on the
part of the physician and bene ts the patient with less visi-
ble donor-site scarring, although small polka-dot scars may
appear at sites of follicular unit extraction. FUE procedures
usually require fewer surgical sta members, less surgical
experience on the part of the physician, and no need to
remove sutures.
FUE causes small, polka-dot-like, white scars in the
donor area.16,29 Both the thousands of small round scars
from FUE and the long linear scar from the strip harvest
bleeding in the donor area since it damages the tissue and
interferes with wound healing. It is best to remove all the
damaged follicles to prevent folliculitis or cysts.
The wound may be closed through a variety of meth-
ods. However, it is still controversial whether two-layer
closure has more bene t than single-layer closure, under-
mining versus nonundermining, staple versus suture, and
other options.16 The majority of surgeons use absorbable
stitches (Vicryl or Monocryl, Ethicon) for deep-layer clo-
sures and close the skin with either staples or running non-
absorbable or absorbable stitches.
Damkerng reported that two-layered closure from his
experience failed to minimize scarring, and instead he
closes the wound with 3–0 nylon as retention stitches ~ 1.5
cm apart and a 1-cm bite away from the incision. The skin
is then closed with running 4–0 Vicryl Rapide (Ethicon).16
He reported it produced good results in Asian patients.
The author also had good results with the retention suture
method but prefers nylon suture over Vicryl Rapide because
absorbable suture material has more tissue reaction and a
tendency to leave a worse scar in East Asians (Fig. 27.4).
Retention stitches are usually removed at 3 to 5 days post-
operative and skin stitches are removed at 10 days postop.
Trichophytic closure is highly recommended in East
Asian patients to reduce the donor scarring, especially
in younger patients or patients with hyper-elastic scalp.
There might be some controversy regarding trimming of
the superior or inferior edge, but there has been no vis-
ible di erence in the appearance of scarring. Trichophytic
closure may improve the scar’s appearance, but patients
may also experience a slightly higher incidence of cyst or
ingrown hair formation on the closure site.23,24,25,26
To avoid signi cant scarring in the donor area, risk
factors such as tension and smoking must be reduced as
much as possible; great care must be extended in perform -
ing meticulous surgical techniques. Despite these e orts, a
Fig. 27.3 Applying an ice pack and vibrator near the injection site
helps to reduce injection pain.
Fig. 27.4 Using retention sutures with nylon in closing the donor
site wound helps to minimize suture scarring by reducing tension.

27 Hair Transplantation in East Asians
355
graft depth in the recipient area can occur. For example, if
a single patient has 6-, 5-, 4-, and 3-mm-length grafts in
the donor area, and all incisions are made at a 6-mm depth,
then a 6-mm graft will t in the slit adequately. But a 3-mm
graft will be located 3 mm deeper than the proper depth
and could result in folliculitis, cyst, pitting, and poor sur-
vival (Fig. 27.7).2,34,35
Transection of the grafts can sometimes occur during
graft preparation with FUT and FUE. Transected follicles
should also be placed at the proper level to avoid deeper
location in the recipient site. Therefore, to prevent the
complications mentioned, a surgeon needs to group the
grafts in the same individual by length and make proper
incision depths according to each group. In practical terms,
it takes a lot of time to measure the lengths of 2,000 to
3,000 hair follicles. To reduce this time, the author devel-
are often hard to detect when hair in the donor area is at a
normal length and the extraction is performed by a skilled
surgeon. However, the donor density is much lower in East
Asians than in Caucasians, so to get enough hairs, with FUE
the follicles are harvested from a much greater area of the
donor zone compared with strip harvest, and the chance
of getting hair from a nonsafe donor area is higher.16,27
Because of the high hair-skin color contrast, empty spots,
snail tracks, and mottling occur when adjacent follicles are
extracted in East Asians.
Another drawback is transection (Fig. 27.5). Because the
hair follicle is longer in Asians than in Caucasians, the punch
has to score more deeply to free the follicle, with a higher
risk of transection. Therefore, the FUE technique should be
performed very carefully to avoid transection in Asians.16
A problem of buried grafts can occur during the FUE
technique when the graft is pushed into fat and must be
removed through a small incision. FUE can also be more
expensive and take longer to perform than FUT, so grafts
are usually out of the body longer, risking suboptimal
grow th.27
Graft Dissection and
Graft Preservation
A graft can be prepared by slivering from the strip. Slivers
are further dissected into follicular unit grafts with a dou-
ble-edge razor blade or no. 20 blade.
Graft dissection is usually accomplished under a 3×
magni ed loupe, binocular stereo microscope, Mantis
microscope (New Vision Engineering), or digital moni-
tor microscope with ~ 10× power magni cation.31,32,33
East Asian hairs are larger in caliber and have high skin/
hair color contrast; therefore, this step can be done with
the naked eye. But magni cation is quite helpful in prepar-
ing grafts for East Asians, particular for the gray hairs. One
common problem encountered is gray or white hair that is
di cult to visualize and count on direct inspection. Gen-
tian violet and methylene blue have been used in the past
to dye the hair, but this is messy and not really e ective.
The best solution is to have the patient dye the hair 2 to 3
nights before surgery or, preferably, have the hair colored
before surgery if the patient has no allergic reaction to dye-
ing material. Make sure the color stains the hair close to
the skin.16 There are many hair-coloring products available
on the market. An instant hair coloring preparation works
quickly and is the best do-it-yourself choice. Because it is
very di cult to distinguish the follicle and skin in the case
of gray color, the colored hair can be a guideline for graft
preparation. Without dyeing the hair, it is almost impos-
sible to dissect the hair follicles accurately (Fig. 27.6).
The author reported that there is a signi cant di er-
ence in graft lengths in the same individual, especially in
the East Asian compared with the Caucasian, and if we
make the exact same incision depth throughout, improper
Fig. 27.5 Transection of follicle by follicular unit extraction occurs
more commonly in Asians because the hair follicle is longer.
Fig. 27.6 Gray hair should be dyed before surgery. Dyed hair
helps for better visualization of the gray hair follicle.

V Facial Skin and Hair Rejuvenation
356
is better at 4°C than at room temperature.36 Even though
chilled saline is used, it is best to implant the grafts within
a 6-hour period. Recently, a variety of new storage solu-
tions and materials, such as Plasma-Lyte (Baxter Health-
care), HypoThermasol-ATP (BioLife Solultions), ACell, and
plasma-rich protein (PRP), have been promoted for improv-
ing graft survival, but no study has established the best
storage solution.37,38,39,40
Recipient Site
In Asian countries, both the implanter and Western tech-
niques of implantation are used. The main di erence
between these techniques is that with the Western tech-
nique, most of the recipient site incisions are premade by
the doctor, and grafts are planted later by the assistant nurse.
As a variation of this, the doctor makes a ne slit and imme-
diately places the FU in situ. The implanter techniques were
rst developed in Korea in the 1990s and are widely used
there but are not as popular in other countries. Historically,
Mr. Paek, a Korean medical assistant, developed an instru-
ment for eyebrow hair transplantation for a patient with
madarosis in the 1960s.41 Then Choi modi ed this instru-
ment and developed the Choi implanter in the 1990s.21 Many
types of implanters have since been manufactured. This is
why the implanter technique is so popular in Korea, and it
has recently become more popular in Western countries.
The implanter is shaped like a pencil with a hollow nee-
dle at the tip. There are four sizes (0.6, 0.8, 1.0, and 1.2 mm)
that correspond to one-, two-, and three-hair follicular unit
grafts (Fig. 27.9). A single graft is placed inside the hollow
end of each device. The sharp end of the device can then be
injected into the recipient site, where it simultaneously cre-
ates a slit and inserts the graft inside the slit. On withdrawal
of the needle, the graft is left inside the incision site.2
oped a board for graft length measurement. As shown in
Fig. 27.8, a furrow on the board is made and the end of the
graft is placed on the ledge of the furrow; then individual
hair follicles are grouped by length. Using this device, the
author’s assistants were able to measure the lengths more
e ciently and reduce the time of measurement. With the
“depth-controlled transplantation” technique, the author
has reduced or prevented folliculitis, cyst, and pitting in
most of his personal cases.34
Control of the temperature and prevention of desic-
cation is important. Commonly used solutions are chilled
normal saline or lactate Ringer, and grafts should be
immersed in the solution but just put on wet gauze.36 Stor-
age of prepared grafts on gauze or Telfa pads (Kendall) can
increase the integrity of the hair grafts as compared with
submerged preservation. Survival of preserved hair grafts
Fig. 27.7 A deeply transplanted graft may cause folliculitis on
the recipient site.
Fig. 27.8 Hwang’s board for graft length measurement. The
length of each follicle was measured on Hwang’s board; 3- to 4-mm,
4- to 5-mm, 5- to 6-mm, and 6- to 7-mm grafts were grouped.
Fig. 27.9 Various types of implanters. The sizes of an implanter’s’
needles (0.8, 1.0, and 1.2 mm from left to right) correspond to
one-, two-, and three-hair follicular unit grafts.

27 Hair Transplantation in East Asians
357
showed that survival rates were higher at 20 to 30 grafts/
cm 2 compared with the higher transplanted densities of 40
to 50 grafts/cm 2. The recipient area density suggested for
the implanter is 30 grafts/cm 2.2,44,45
Because the donor supply is limited in Asians com -
pared with Caucasians, a “density gradient” is advisable. If
the patient wants to use a parting, then more density on
the frontal area and part side is necessary. Less density is
needed on the posterior area and nonpart side of the scalp.
Therefore, it is desirable to implant two- and three- hair
FUs in the part site and frontal scalp and one-hair FUs in the
posterior area and nonpart side of the scalp. With this type
of density gradient, combing the hair from the part side
produces a “layering e ect,” making the hair appear fuller
(Fig. 27.11). With this e ect, the light does not penetrate
Hair transplantation should be directed like a nger
of a palm laid on the crown. Also, angles of transplanta-
tion should be carefully chosen and varied according to the
angle of the forehead and scalp (Fig. 27.10).
Each technique has advantages and disadvantages, and
neither method is superior to the other for hair transplan-
tation in Asian patients. It is a fact, however, that most doc-
tors in South Korea and more than half of the doctors in
Japan perform the implanter technique, while doctors in
the other Asian countries prefer the Western method. With
the Western technique, tumescent anesthesia in the recipi-
ent area has the advantage of controlling bleeding from
the premade slits better than simple in ltration. There is
no need to use tumescent anesthesia with the implanter
technique because the immediately transplanted grafts
prevent most of the bleeding that would otherwise occur
from the incision sites. This author uses a solution of 2%
lidocaine with 1:100,000 epinephrine as a ring block along
the anterior hairline and 0.5% lidocaine with 1:100,000 epi-
nephrine as a eld block. Donor site harvesting takes only
~ 30 to 60 minutes. The graft placement, however, usually
takes 2 to 4 hours. It is di cult to sustain the e ect of local
anesthetics longer than 1 hour on the scalp. Therefore, it
is advisable to inject areas that will be transplanted in the
next 30 to 40 minutes, rather than the whole scalp at once.
This also helps to minimize bleeding at the recipient site.
Because of the large hair caliber of Asians, hair trans-
plantation looks unnatural if two- or three-hair follicular
unit grafts are implanted in the anterior feathering zone.
Therefore, three to ve rows of single-hair follicular units are
appropriate to give the patient a natural-looking hairline.1,2
A study done to assess the survival rate of one- and two-
hair follicular unit grafts using the implanter revealed graft
grow th of 92.0% after 6 months and 90.4% after 1 year.42,43
There is controversy regarding the optimal density for high
survival rate. Graft survival at di erent transplanted den-
sities was also studied in Korean patients, and the results
Fig. 27.10 Angles of transplantation should be changed accord-
ing to the angle of the scalp.
Fig. 27.11 More grafts on the part side
makes the hair fuller by a layering e ect. (a)
With this type of density gradient, comb-
ing the hair from left to right produces a
“layering e ect,” making the hair appear
fuller. (b) Combing the hair from right to
left reduces the layering e ect.
a
b

V Facial Skin and Hair Rejuvenation
358
• With this type of density gradient, combing the hair
from the parted side and front produces a “layering
e ect,” making the hair appear fuller.
Preparation of Gray Hair Follicle
• Because it is very di cult to distinguish the follicle
from the skin in the case of gray hair, coloring the
hair can guide graft preparation.
• Without dyeing the hair, it is almost impossible to
dissect the hair follicles accurately.
Scar Revision with W-plasty
• In case of a linear scar, simple excision and closure
can be done, but the scar usually reappears at the
same size or wider due to the stretch-back e ect.
• Instead of linear closure, W-plasty may be the
treatment of choice.
• W-plasty can prevent scar stretching. It cannot
reduce the width of the new scar, but it may
make the scar look less noticeable than its linear
counterpart due to its zigzag pattern (Fig. 27.12).

■Complications and
Their Management
For e ective hair transplantation, it is important to know
not only how to produce good results, but also how to pre-
vent surgical complications.
Necrosis and Dehiscence
Large and wide donor site incision can result in a wound
which cannot be closed, or in a wound closure with too
much tension. This will interfere with circulation, resulting
in complications such as necrosis and dehiscence.1,46 Appro-
priate width is important to prevent these complications,
and widths between 1 and 1.5 cm are generally acceptable.
In cases where there is di culty in closing the wound, it is
better to let the wound heal by secondary intention after
partial closure with moderate tension.
Pain, Numbness, Hypoesthesia,
Hyperesthesia, and Neuralgia
Many patients experience pain on the donor site after
the transplant. In most cases, the pain subsides within 2
days. Occasionally, sensation can be reduced or lost at the
donor site or in areas above the donor site.1,47 Cases usually
the scalp as easily and the lower-density areas become less
obvious. A proper density gradient and layering are critical
elements in the aesthetics of hair restoration in East Asians.

■Postoperative Care
Shampooing is usually resumed 24 hours after surgery and
the donor sutures are removed 10 days following surgery.
Folliculitis on the recipient site, which is more common
in Asians than in Caucasians, can occur between 1 and 3
months after surgery. This condition usually resolves itself
within 6 months postoperatively. An additional hair trans-
plantation session, if necessary, can be performed as early
as 6 months following the initial session. However, it is usu-
ally recommended to wait at least 1 year. By that time, the
surgeon will have a better idea whether additional surgery
is necessary, which donor area will be available, and which
recipient site will receive the transplanted hairs for the best
results.

■Key Technical Points
Depth-Controlled Transplantation
(DCT) According to Graft Length
1. There are signi cant di erences among graft lengths
in the same individual, especially in the East Asian
compared with the Caucasian.
2. It is necessary to sort the grafts according to their
length and to make the proper incision depth
according to the graft length.
3. This “depth-controlled transplantation” technique
can help to minimize complications such as
folliculitis, pitting, and poor graft survival.34
Optimal Density for Best Survival Rate
• Dense packing using more than 40 FUs/cm 2 may
result in poor hair grow th.
• A density of 30 to 40 FUs/cm 2 or less is appropriate
for Asians and permits the best hair survival
rate.42,43,44,45
Density Gradient and Layering E ect
• If the patient chooses to use a parting, then a higher
density on the frontal area and the parted side is
necessary.
• With a part, less density is needed on the posterior
area and on the nonpart side of the scalp.

27 Hair Transplantation in East Asians
359
Facial Swelling
Facial swelling is a common complication, which can last
from 3 to 6 days and can interfere with social activities.49,50
Oral or intramuscular corticosteroids or addition of triam -
cinolone to the local anesthetics for the recipient site can
reduce facial swelling. Also, “gravity position,” as named by
the author, can help. Previously it had been assumed that
head elevation to 45 degrees helps to minimize facial swell-
ing. However, research by the author showed that a supine
or lateral decubitus position without head elevation (grav-
ity position) can prevent lymphatic accumulation in the
forehead, thus preventing facial swelling.51 It is helpful to
maintain gravity position for 1.5 days (operation day plus
1 day after surgery) so that the lymphatic ows downward
due to gravity and the lymphatics accumulate toward the
occipital and temporal scalp instead of the forehead, which
can help to prevent upper eyelid swelling. If there is fore-
head swelling, massaging from the glabella to the lateral
eyebrow can prevent upper eyelid swelling. If upper eyelid
swelling occurs, there is no treatment. The patient has to
wait 2 or 3 days for it to resolve.
Unnatural Hairline
Unnatural hairline can result from transplantation of two-
or three- hair FUs on the frontal hairline, or transplanting
the frontal hairline as a straight line with one-hair FUs. This
can be corrected by further surgery, but it is best to make a
natural-looking hairline using single- hair FUs and a zigzag
hairline in the rst transplant.
Folliculitis
Hair follicles transplanted too deeply can cause in amma-
tion. The reported incidence rate varies from 1 to 20%. Also,
increased sebum production and inappropriate washing of
resolve within a few months, but persist for more than 1
or 2 years in rare cases. Also in rare cases, a patient may
complain of neurologic or electrical pain. These result from
nerve damage during nerve harvesting or abnormal nerve
healing. Generally, these complications occur after FUE.
Undesirable Scar
Scarring can di er due to a patient’s race and age.
Asians and younger people tend to develop m ore scars.
Younger age a ects scarring due to the person’s higher
healing activity. Sm aller w idths, double-layer closure,
and trichophytic closure can help to m inim ize scar-
ring. Patients w ith a tendency to develop hypertrophic
or keloid scars should be treated m ore carefully. Scars
can be helped by transplanting hairs on the scar itself or
using W-plasty to rem ove the scars. The simple excision
of scars is know n to be unhelpful. FUE also leaves a round
hypopigm ented scar.
Temporary Hair Loss
Areas around the wound closure can develop temporary
alopecia beginning 2 weeks after the procedure.1,48 Shed-
ding of existing hair also can develop in the recipient area.
It is speculated that this results from poor vascularity. Most
cases resolve within 3 to 6 months.
Scalp Pruritus
Complications on the transplanted site vary from mild to
severe pruritus. Some of these can be secondary to nerve
damage, crusts, folliculitis, or seborrheic dermatitis. Mild
pruritus can be controlled with topical steroids, but severe
cases may require oral antihistamines. Scalp pruritus usu-
ally disappears in a couple of weeks.
Fig. 27.12 Revision of linear scar using W-plasty. (a) Scar on the donor site. (b) W-plasty postop. (c) Six months postoperative.
a
b
c

V Facial Skin and Hair Rejuvenation
360
injection or surgery. Since patients lie on the bed for many
hours during the transplant, the author recommends per-
forming leg exercises for 1 minute before sitting on the bed
to prevent postural hypotension. Taking a break and eating
cookies and juice can be helpful to reduce the patient’s dis-
comfort during the hours-long operation.16
Hiccups
The cause and physiology of hiccups are not known. It is
speculated that this occurs due to conduction of stimuli
from damaged nerves on the donor site to the phrenic
nerve.52 Hiccups usually occur within 6 to 24 hours and
can last up to 2 days before spontaneously resolving. Chlor-
promazine 50 mg twice daily is known to help ease the dis-
comfort caused by continuous hiccups.

■Case Studies
Hair transplantation can be applied not only to male-pat-
tern hair loss but also to female-pattern hair loss, female
hairline correction, eyebrow/eyelash hair transplantation,
pubic hair transplantation, and beard transplantation. The
author shares two cases: One is about hair transplantation
in a patient with male-pattern hair loss, and the second one
is about female hairline correction.
Case 1
A 47-year-old male patient presented with male-pattern
hair loss, Norwood type V (Fig. 27.13a). He wanted to
cover the hairless area with as much hair as possible. He
had very good donor density and very thick hair on the
occipital scalp. The excised strip size was 1.5 cm × 30 cm.
The donor site was closed with a one-layer closure using
retention sutures. The retention stitches were removed at 4
days postop, and the skin stitches were removed at 10 days
postop. The hairline was made at the height of 8.5 cm above
the midbrow level. A single-hair FU graft was implanted on
the hairline area in a zigzag pattern; a four- and three- hair
FU graft was transplanted on the frontal scalp and right-
side part area; and a two-hair FU graft was implanted on
the posterior scalp and counter-part area to create maximal
fullness. The number of transplanted hairs is 6,636 (497
single-hair FU grafts, 1,425 two-hair FU grafts, 863 three-
hair FU grafts, and 175 four-hair FU grafts) (Fig. 27.13b).
the hair can result in secondary folliculitis, which can be pre-
vented by appropriate washing using shampoos. Topical ste-
roids can relieve symptoms, but oral antibiotics are required
for severe cases. Transplanting to the appropriate depth is
the most important factor to prevent this. The author largely
prevented folliculitis after transplantation with use of the
depth-controlled transplantation (DCT) technique.34
Pitting
Pitting results from the transplant being seated too deeply.
This can be prevented with the DCT technique.
Poor Survival and Loss of
Transplanted Hair
The survival rate of transplanted hair is usually 90% or
above, but an experienced physician can have cases where
most of the transplanted hairs do not survive due to an
unknown factor or X factor. A case of trichorrehexis nodosa
seen on hair shaft examination was reported in a patient
with poor survival of the transplanted hair. This is very
rare, and the cause of trichorrehexis nodosa is unknown.
The survival rate can also be lowered by damage done
during follicle dissection, transection with FUE, dehydra-
tion, damage incurred during the interval between dis-
section and implantation, bending of follicles during
transplantation, and transplants that are too deep or too
shallow.
Arteriovenous Fistula
Arteriovenous (AV) stula develops on the donor or recipi-
ent sites very rarely.1 Pulsation is noted in these cases. Most
cases spontaneously resolve within 6 months, but ligation
of the vessel can be performed if rupture is a concern or if
treatment is required for cosmetic reasons.
Syncope
Occasionally, syncope can result during or after the proce-
dure. Vasovagal reactions are probably the most common
emergency event to occur in the hair restoration practice.1
Preoperative oral diazepam may limit the incidence of this
reaction by decreasing the patient’s anxiety and fear of

27 Hair Transplantation in East Asians
361
removed at 10 days postop. The hairline was made at the
height of 7 cm above the midbrow level. A single-hair FU
graft was implanted on the hairline area in a zigzag pattern,
two-hair FU grafts were implanted posterior to the hair-
line, and three-hair FU grafts were implanted posterior to
the two-hair FU grafts transplanted. The number of trans-
planted hairs is 3,120 (680 single-hair FU grafts, 905 two-
hair FU grafts, and 210 three-hair FU grafts) (Fig. 27.14b).
Case 2
A 28-year-old female presented with an M-shaped hairline
(Fig. 27.14a). She wanted to make the hairline rounder.
She had normal hair density and thickness on the occipi-
tal scalp. The excised strip size was 1.5 cm × 18 cm. The
donor site was closed with a double-layer closure and a
trichophytic closure was performed. The skin stitches were
Fig. 27.13 Case 1. Male hair transplanta-
tion. (a) Before the surgery. (b) One year
after surgery.
Fig. 27.14 Case 2. Female hair transplan-
tation. (a) Before the surgery. (b) One year
after surgery.
a
b
a
b

V Facial Skin and Hair Rejuvenation
362
13. Avram M, Rogers N. Contemporary hair transplantation.
Dermatol Surg 2009;35(11):1705–1719
14. Makheja AN, Bailey JM. Antiplatelet constituents of garlic
and onion. Agents Actions 1990;29(3–4):360–363
15. Bernstein R, Rassm an W. Densitom eter and video-m icros-
copy. Hair Transplant Forum Int 2007;17(2):49–51
16. Pathomvanich D, Im agawa K, eds. Hair Restoration Surgery
in Asians. New York, NY: Springer; 2010:37–39, 91–93,
105, 125–129, 133–140
17. Leonard R, Charles G, Dorin R, et al. International Society of
Hair Restoration Surgery. 2013 Practice Census Results
18. Mayer M, Pauls T. Scalp elasticity scale. Hair Transplant Fo-
rum Int 2005;15:122–123
19. Mohebi P, Pak J, Rassm an W. How to assess scalp laxity.
Hair Transplant Forum Int 2008;18:161, 167
20. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair
Transplant Forum Int 2002;12:9–10
21. Choi YC, Kim JC. Single hair transplantation using the Choi
hair transplanter. J Dermatol Surg Oncol 1992;18(11):
945–948
22. Kakigi R, Shibasaki H. Mechanisms of pain relief by vi-
bration and m ovem ent. J Neurol Neurosurg Psychiatry
1992;55(4):282–286
23. Marzola M. Trichophytic closure of the donor area. Hair
Transplant Forum Int 2005;15:113–116
24. Frechet P. Minimal scars for scalp surgery. Derm atol Surg
2007;33(1):45–55, discussion 55–56
25. Rose P. Ledge closure. Hair Transplant Forum Int 2005;
15:113–116
26. Kim D. Planning o inferior edge in the Frechet and
Rose trichophytic closures. Hair Transplant Forum Int
2008;18(6):211
27. Rassm an WR, Bernstein RM, McClellan R, Jones R, Worton
E, Uyttendaele H. Follicular unit extraction: m inim ally
invasive surgery for hair transplantation. Derm atol Surg
2002;28(8):720–728
28. Harris JA. Follicular unit extraction: the SAFE system . Hair
Transplant Forum Int 2004;14:157–164
29. Onda M, Igawa HH, Inoue K, Tanino R. Novel technique
of follicular unit extraction hair transplantation with a
powered punching device. Derm atol Surg 2008;34(12):
1683–1688
30. Bunagan MJ, Banka N, Shapiro J. Hair transplantation up-
date: procedural techniques, innovations, and applications.
Dermatol Clin 2013;31(1):141–153
31. Kim C, Kim H, Kim D. Follicular unit transplantation: com -
parison of video m icroscopic vs. com bination methods.
Arch Aesthetic Plast Surg 2014;20(1):61–64
32. Limm er B. Bob Lim mer does it all one hair at a tim e. Hair
Transplant Forum Int 1991;1:8–9
33. Keene SA, Gibson GH. New cost-e ective, ergonom ic way
to m agnify donor hair during follicular unit graft dissec-
tion: LCD monitor with video m agni cation. Hair Trans-
plant Forum Int 2003;13:9
34. Hwang S. Intra-patient graft length di erences in uenc-
ing depth controlled incisions. Hair Transplant Forum Int
2012;22:117, 122–123

■Conclusion
Hair transplantation for East Asians presents several
challenges seldom seen in Caucasians. These include an
increased risk of scarring, a limited number of donor hairs,
high skin/hair color contrast, lower hair density, and a
unique frontal hairline. In spite of these challenges, with
the selection of good candidates and use of appropriate
operative techniques, excellent results can be produced in
Asians. Hair transplantation techniques should always be
adjusted depending on the individual being treated. Hair
characteristics, head shape, hair and skin color, and other
features speci c to Asians necessitate certain modi cations
in hair transplantation procedures and treatments.
References
1. Unger WP, Shapiro R, Unger R, Unger M, eds. Hair Trans-
plantation. New York, NY: Marcel Dekker; 2004:568–576,
591–595, 892–897
2. Unger WP, Shapiro R, Unger R, Unger M, Eds. Hair Trans-
plantation, London, UK: Inform a Healthcare; 2011:63–75,
76–81, 235–237, 404–406, 408, 423, 428–430
3. Vong V. Norm al hairline or Norwood class 0, 1. Hair Trans-
plant Forum Int 1999;6:178–181
4. Bernstein RM, Rassm an WR, Szaniawski W, Halperin
A. Follicular transplantation. Int J Aesthetic Rest Surg
1995;3:119–132
5. Bernstein RM, Rassm an WR. Follicular transplantation.
Patient evaluation and surgical planning. Derm atol Surg
1997;23(9):771–784, discussion 801–805
6. Pathomvanich D. Donor harvesting: a new approach to
m inim ize transection of hair follicles. Derm atol Surg
2000;26(4):345–348
7. Arnold J. 6th annual m eeting of the International Society
of Hair Restoration Surgery. Hair Transplant Forum Int’l
1998;6:4
8. Ezaki T. Advantages and disadvantages of hair transplant
surgery on treatm ent of m ale baldness. Jpn J Aesthet Plast
Surg 1997;19:99–117
9. Haber R, Stough D, eds. Hair Transplantation. Seattle, WA:
Elsevier Saunders; 2006:149–156
10. Kaufman KD, Rotonda J, Shah AK, Meehan AG. Long-term
treatment with nasteride 1 mg decreases the likelihood
of developing further visible hair loss in m en with andro-
genetic alopecia (male pattern hair loss). Eur J Derm atol
2008;18(4):400–406
11. Finasteride Male Pattern Hair Loss Study Group. Long-term
(5-year) multinational experience with nasteride 1 mg
in the treatment of men with androgenetic alopecia. Eur J
Derm atol 2002;12(1):38–49
12. Lee WS, Lee HJ, Choi GS, et al. Guidelines for m anagement
of androgenetic alopecia based on BASP classi cation—the
Asian Consensus Com m ittee guideline. J Eur Acad Derm a-
tol Venereol 2013;27(8):1026–1034

27 Hair Transplantation in East Asians
363
44. Seager D, ed. Dense packing techniques. In: Unger WP, Sha-
piro R, Unger R, Unger M, eds. Hair Transplantation. 6th ed.
London, UK: Elsevier Saunders; 2006:127–131
45. Lee W, Lee S, Na G, Kim D, Kim M, Kim J. Survival rate ac-
cording to grafted density of Korean one-hair follicular
units with a hair transplant implanter: experience with
four patients. Derm atol Surg 2006;32(6):815–818
46. Hahler B. Surgical wound dehiscence. Medsurg Nurs
2006;15(5):296–300, quiz 301
47. Stough D, ed. Hair Replacem ent: Surgical and Medical. St.
Louis, MO: Mosby Year Book; 1996:105–110
48. True RH, Dorin RJ. A protocol to prevent shock loss. Hair
Transplant Forum Int 2005;15:197
49. Neidel F. Preventing post-operation swelling. Hair Trans-
plant Forum Int’l 2003;13:50
50. Gholam ali A, Sepideh P, Susan E. Hair transplantation:
preventing post-operative oedem a. J Cutan Aesthet Surg
2010;3(2):87–89
51. Hwang S. Gravity position to prevent facial edem a in
hair transplantation. Hair Transplant Forum Int’l 2009;
77:81–82
52. Arnold J. A neurological explanation for hiccups following
hair transplantation. Hair Transplant Forum Int’l 1995;5:23
35. Cooley JE. Dilemm as in hair restoration. Hair Transplant
Forum Int 2005;15:207–208
36. Hwang SJ, Lee JJ, Oh BM, et al. The e ects of dehydration,
preservation temperature and tim e on the hair grafts. Ann
Derm atol 2002;14:149–152
37. Krugluger W, Moser K, Moser C, Laciak K, Hugeneck J.
Enhancement of in vitro hair shaft elongation in follicles
stored in bu ers that prevent follicle cell apoptosis. Der-
m atol Surg 2004;30(1):1–5, discussion 5
38. Uebel C. A new advance in baldness surgery using platelet-
derived grow th factor. Hair Transplant Forum Int 2005;
15(3):77–84
39. Cole J. The optim al holding solution and temperature
for hair follicle grafts. Hair Transplant Forum Int’l 2012;
22:17–21
40. Cooley JE. Bio-enhanced hair restoration. Hair Transplant
Forum Int 2014;24(4):121, 128–130
41. Ahn S. We salute you, Mr. Paek. Hair Transplant Forum Int
2000;10:151
42. Lee SJ, Lee HJ, Hwang SJ, et al. Evaluation of survival rate af-
ter follicular unit transplantation using the KNU implanter.
Derm atol Surg 2001;27(8):716–720
43. Beehner ML. A comparison of hair grow th between follic-
ular-unit grafts trim med “skinny” vs. “chubby”. Derm atol
Surg 1999;25(4):339–340

364
28 Aesthetic Laser Hair Removal for the Asian Face
Wooseok Koh
lasers with radiofrequency,13,14 with a low uence, and with
a high repetition rate15,16,17 have also become available.
Despite the development of lasers for hair removal,
treatment guidelines have not been established, and con-
troversy exists over the very possibility of permanent hair
removal.18,19 Many physicians who perform hair removal
procedures have not observed su cient e cacy and
believe that permanent hair removal is not possible.
My clinic, specializing in general laser hair removal
procedures for 14 years, focuses on facial hair removal for
men and women. Women seek hair removal because vis-
ible hair on the face is aesthetically undesirable, darkens
the skin, and interferes with makeup application. Men seek
hair removal for a cleaner appearance, to avoid the incon-
venience of daily shaving, and to avoid skin damage from
shaving and folliculitis. Recently, male celebrities with
hairless faces have become popular in South Korea, lead-
ing the trend toward smooth and hairless faces in men.

■Introduction
Permanent laser hair removal became available in clini-
cal practice in 1996 with the advent of the ruby laser,
which had a pulse duration in the millisecond (ms) range
and a skin cooling system.1,2 Alexandrite,3,4 800 to 810 nm
diode,5,6 and Nd:YAG lasers7,8 entered the hair removal mar-
ket soon after. The ruby laser was later withdrawn because
of its instability and high risk in the Asian population; other
lasers are still in use today. Most of the hair removal lasers
currently available were developed in the late 1990s, with
modi cations in power density, uence, or spot size; how-
ever, their basic speci cations have not changed. Recently
introduced diode lasers include the 755-nm,9 940-nm,10
980-nm (e.g., LEDA EPI 980 from Alma Lasers and LinScan
808/980 from GME), and 1060-nm (e.g., LightSheer INFIN-
ITY from Lumenis) models. Vacuum -assisted lasers11,12 and
Pearls
• Women of all races seek hair removal because
visible hair on the face is aesthetically undesirable,
darkens the skin, and interferes with makeup
application. Men seek hair removal for a cleaner
appearance, to avoid the inconvenience of daily
shaving, and to avoid skin damage from shaving and
folliculitis.
• A narrow forehead is one of the major indications for
laser facial hair removal in Korea. More traditionally
minded Koreans and Chinese believe that a
small forehead is aesthetically undesirable; this
contributes to the popularity of facial hair removal.
• Young women in Korea desire men with a hairless
face; this has signi cantly increased their interest in
laser facial hair removal.
• Many factors are involved in the success of laser
facial hair removal; among them, a doctor’s
knowledge from experience performing the
procedure is most important.
• Consultation before the treatment is very important
in setting reasonable goals for facial laser hair
removal, especially if it involves widening the
forehead.
• An 800- to 810-nm diode laser (e.g., LightSheer XC,
Lumenis) with pulse duration of 3 to 30 ms and
an energy density of 23 to 40 J/cm 2 can be used
for facial hair removal. The chances of obtaining a
positive outcome dwindle with a pulse duration
exceeding 30 ms for Asian male facial hair removal.
• Usually, slow treatment with higher uence is more
e ective in facial hair removal. Lowering the skin
temperature before treatment is very important to
reduce the side e ects of laser hair removal.
• In addition to decreased facial hair, an aesthetic
improvement of skin including brighter and soft
skin tone, improvement of folliculitis/acne, and
decreased hyperpigmentation associated with
shaving can be achieved with facial laser hair
removal.
• A new forehead hairline needs to be designed
considering the patient’s wishes, gender, and facial
outline. Actively guiding the patient in regards to the
optimal design and e cacy is important because
patients tend to choose an excessively high or low
hairline. The designing of the forehead hairline is not
designing a beautiful hairline, but redesigning one-
third of the natural facial outline.

28 Aesthetic Laser Hair Removal for the Asian Face
365
other targets, including vessels and melanocytes, or non-
speci c damage to the hair follicle are also considered as
possible mechanisms. However, the exact mechanism of
laser hair removal is still unclear, even though the proce-
dure was developed 20 years ago.

■Factors That Improve the
E cacy of Permanent Hair
Removal
Many factors, including uence, pulse duration, wave-
length, spot size, and treatment interval, a ect the suc-
cess of laser hair removal.25 In addition, the knowledge and
experience of the physician in uence the results. Optimal
factors that improve the success rate are as follows:
1. Proper wavelength: 755 nm or 800 to 810 nm 26,27,28,29,30
2. Proper pulse duration: 20 to 80 ms (from personal
experience)
3. Proper uence: as high as possible without causing
adverse e ects6,31
4. Proper spot size: as large as possible, if applicable32,33
My survey of 100 Korean women revealed that only 16%
regarded facial hair in men as an attraction. It also showed
that women in their 40s (44.5%) showed more preference
to facial hair in men than women in their 20s (10.2%) or 30s
(16.7%). In addition, nearly 80% of respondents answered
that they would be willing to recommend laser hair removal
to their male romantic partners if the result was as good as
shown in the photograph presented in the survey. For this
reason, men are increasingly seeking facial hair removal in
Korea. However, the facial hair of East Asian men is denser
and has thicker shafts than in other areas of their bodies, or
in relation to the hair of Caucasians20; therefore, permanent
removal is very di cult, even with repeated treatments.
In Korea a small forehead is considered unattractive.
Certain facial features are associated with fortune in Korea
and China, and a small or narrow forehead is often associ-
ated with bad fortune. In addition, a narrow forehead dis-
turbs the balance of the face, contributing to an unattractive
rst impression. Removing excess hair from the forehead to
lift the hairline creates a rounded and attractive forehead in
females. Unlike Caucasians, who tend to have a wide fore-
head, many Asians have a narrow forehead. Therefore, laser
hair removal for hairline correction is a popular procedure
in my clinic.21
In the skin, laser radiation is absorbed by the melanin
present in the hair shaft, raising the temperature of the
area and partially destroying follicular cells. However, it
is still unclear whether the most e ective target for hair
removal is the hair stem cell or the papilla cell or both.22
In this chapter, I will discuss my clinical experience and
knowledge in achieving permanent hair removal or aes-
thetic improvement by modifying the density of hair in the
East Asian face.

■Mechanisms of Laser Hair
Removal
The rst hair removal laser was based on the concept of
“selective photothermolysis.”1,23 Years later, this concept
was expanded as the “extended theory of selective photo-
thermolysis.”24 According to these theories, the main chro-
mophore is eumelanin in the hair shaft and hair bulb. Heat
from laser absorption in the melanin pigments of the hair
follicle di uses out to damage the hair follicle, interfering
with regeneration of the visible terminal hair. Recently,
low- uence, high-frequency lasers have been found to pro-
duce results similar to those of high-power, low-frequency
lasers.15,16,17
To remove hair permanently, the targets should be cells
that are biologically necessary for regeneration of the hair
follicles. Based on this hypothesis, the biological targets
should be either the hair stem cell (Fig. 28.1) or papilla cell,
or both.22 However, although this hypothesis is plausible,
no data supporting this have been published. Damage to
Fig. 28.1 ABC staining using CD8/144B antibody for detecting
hair stem cells in vertical section of hair follicle. Hair stem cells
(brown cells, arrows) are located at the outermost part of the outer
root sheath in the hair follicle.

V Facial Skin and Hair Rejuvenation
366

■Procedural Techniques
Facial Hair Removal in
Female East Asians
East Asian women receive hair removal treatments to
create a more feminine appearance, to brighten the skin
tone, and to enable them to apply makeup more easily.
For reasons that are unclear, the facial hair of East Asian
women responds more poorly to laser removal than does
axillary or leg hair, even with optimally adjusted uence
and wavelength. Therefore, more than nine treatments are
necessary in many cases. I recommend setting the uence
based on the patient’s current skin color rather than the
Fitzpatrick skin type. Skin color can change with ultraviolet
(UV) light exposure, and two people with the same Fitz-
patrick skin type can present di erent skin colors depend-
ing on the degree of sun exposure. I have divided the skin
color by gross examination into nine types, and I refer to
the melanin index when gross examination is not de ni-
tive (Fig. 28.2). Because of overseas travel, many people are
exposed to strong UV light during the winter as well as in
the summer. Therefore, skin color should be closely exam -
ined regardless of the season.
Technique
As facial hairs are thin in East Asian women, long-pulse-
duration laser does not su ciently remove the hairs unless
the uence is very high. Therefore, an optimal outcome
depends on a balance between uence and pulse duration.
I prefer to use a high uence despite the possibility of caus-
ing pain, except in patients very sensitive to pain. When the
uence is set low to avoid pain, the chance of permanent
hair removal declines and the therapeutic goal cannot be
achieved. It is helpful to clearly communicate to the patient
that the treatment may be painful and that topical anes-
thetic is available.
From my experience, pulse duration of 3 to 30 ms and
an energy density of 23 to 40 J/cm 2 using an 800-nm diode
laser are e ective. But the chance of obtaining a positive
outcome dwindles with a pulse duration exceeding 30 to
40 ms.
1. Based on the skin color, I use a higher uence in
lighter skin. I start the treatment at 30 ms and 22 to
28 J/cm 2 when using an 800-nm LightSheer XC laser.
When a patient has dark skin due to sun exposure, I
use a lower uence or postpone the next treatment
to 2 to 3 months.
2. After the rst treatment, I increase the parameters
by 5 to 10% if no adverse e ects have been observed
and the skin has not darkened.
5. Proper epidermal cooling: enough contact cooling,
cold room temperature34,35,36,37,38,39
6. Proper coverage rate: 100 to 120% without skipped
areas, depending on hair density and thickness and
laser beam quality40,41,42
7. Proper treatment interval: 4 to 8 weeks, depending
on the treated area43
8. Proper care of adverse e ects: postin ammatory
hyper- or hypopigmentation, scabbing, persistent
erythema, urticarial reaction, the Koebner
phenomenon, laser-induced cataract, and iris
atrophy44,45,46,47,48,49,50,51,52,53
9. Proper physician: one with optimal knowledge and
scrupulousness42
10. Proper evaluation of results: at least 6 months after
the nal treatment 54,55

■Patient Evaluation
Consultation is an important phase in the laser facial hair
removal process, especially for males seeking widening of
the forehead. In male facial hair removal by laser, detailed
explanations about the possibility of temporary side e ects,
including crust, erythema, and hyperpigmentation, before
the rst treatment session are mandatory, because usually
higher uences are used compared with general laser hair
removal of other areas or in female facial hair removal.
In designing to widen a forehead, I consider the jaw
line, shape of the head, and gender of the patient to deter-
mine the extent of forehead expansion. Among these con-
siderations, determining the forehead height that is most
appropriate for the patient’s face is especially important.
The usual height of the forehead is one-third of the facial
height; however, the nal ratio should be decided accord-
ing to the doctor’s or patient’s aesthetic sense. In designing
the hairline, guiding the patient in regards to the optimal
design and e cacy is important because patients tend to
choose an excessively high or low hairline. I always inform
the patients that designing the forehead hairline is rede-
signing one-third of the facial outline, not just redesigning
the hairline.
In facial hair removal by laser, checking the facial skin
color, recent history of sun exposure, daily hair removal
method, thickness of hair, color of hair, and presence of co-
existing facial skin disease is crucial for deciding the exact
treatment parameters and planning the schedule. Taking
the patient’s photographs before and after each treatment
to assess the outcome is important, and the need must be
explained to the patient.
Careful and frank evaluation of the nal result is
required for both the patient and doctors, but it is not
always easy in laser hair removal. The nal outcome should
be assessed at least 6 months after the nal treatment.

28 Aesthetic Laser Hair Removal for the Asian Face
367
removal. Because the e cacy of laser hair removal varies
depending on the race of the patient and the treatment
area, a direct comparison of parameters or devices is inad-
equate for clarifying the e cacy in a certain treatment
site or race. At this time, there are no studies that clearly
describe the e ect on the treatment outcome of the di er-
ent types of laser, treatment technique, uence, interval
and frequency, treated area, or race of the patient.
Facial Hair Removal in Male East Asians
The goals of facial hair removal in East Asian men are as
follows: (1) to eliminate the inconvenience of daily shav-
ing (in men with folliculitis or hyperpigmentation due to
excessive, quickly growing facial hairs that need frequent
shaving); (2) aesthetic improvement (Asians tend to have
thick hair and may still appear disheveled after shaving);
(3) smoother, more youthful-looking skin; and (4) a gen-
eral dislike of facial hair (by patients who do not have
excess hair but still dislike facial hair and choose laser hair
removal as an alternative to using tweezers).
Male facial hair holds di erent meanings across cul-
tures and times. Ample facial hair is encouraged in men
in many cultures throughout the world. However, in Korea
today many popular male celebrities present a clean, hair-
less face and use cosmetics, and women tend to prefer
this type of feminized appearance in men. I believe this is
the main reason many Korean men are seeking facial hair
removal.
East Asian men tend to have thicker facial hair than
do Caucasians. Unlike hair removal in women, facial hair
removal in East Asian men requires considerable experi-
ence and knowledge of adverse e ects, particularly when
using a high uence. The risk of adverse e ects in male
facial hair removal increases w ith inexperienced doctors
because the dense and thick hairs may trigger an overlap-
ping response to laser therapy.24 Therefore, it is important
to prevent adverse e ects and minimize dermal damage.
A contact-type skin cooling system may be useful for pre-
venting adverse e ects.34,35,36
3. I wait for 4 weeks between the treatments for the
rst four sessions and increase the interval after the
fth treatment depending on the outcome. When the
skin is darkened, the risk of adverse e ects increases
w ith higher uence, and the next treatment should
be postponed or the uence should be lowered.
4. I apply laser irradiations thoroughly so that no target
area is missed.
5. I prolong contact cooling time or increase coolant
spray time in areas with thicker and denser hairs.
6. Lowering the ambient room temperature helps to
lower the skin temperature. A topical anesthetic is
applied in patients particularly averse to pain.
E ects
A brighter skin tone and smoother skin can be expected
after laser hair removal. The overall skin tone improves and
the face appears more feminine after treatment (Fig. 28.3).
Very few studies discuss the percentage of Korean
women in whom permanent facial hair removal is achieved
or the number of treatments required for permanent hair
Fig. 28.2 A device for measuring melanin index. (Courage +
Khazaka electronic GmbH, Germany.)
Fig. 28.3 E ect of facial hair removal
in women. (a) Before the treatment.
(b) After three treatments, the overall skin
tone improved and the face appears more
feminine.
a
b

V Facial Skin and Hair Rejuvenation
368
E ects
Aesthetic Improvement and Skin Brightening
According to my subjective assessment, the facial skin
appears to improve in most Asian male patients after laser
hair removal, although the improvement has not been sci-
enti cally measured. The patients themselves feel that their
skin has improved after treatment, and most of the general
population also see an improvement in the “before” and
“after” photographs of patients (Fig. 28.4). Further research
is needed to clarify whether this improvement is due to the
appearance of less hair or to the whitening or rejuvenating
e ects of the laser.56
Reduced Hyperpigmentation
Many Asian men seeking laser hair removal present with
hyperpigmentation of the skin. Postin ammatory hyper-
pigmentation is suspected to arise from shaving-related
skin damage, folliculitis, or aftershave-related dermatitis.
Asian men, who have thicker facial hair, apply more pres-
sure to the skin during shaving than do Caucasians; hence,
they are more likely to experience skin irritation. Asian skin
is also more susceptible to postin ammatory hyperpig-
mentation.57 E ective hair removal reduces the frequency
of shaving and skin irritation during shaving. This results in
a gradual improvement of hyperpigmentation (Fig. 28.5).
Technique
I use a pulse duration of 30 to 50 ms, because most hairs
have thick shafts. I set the uence based on the current skin
color, as with female facial hair removal.
1. I set the uence as high as possible. I start the
treatment at 30 ms and 24 to 35 J/cm 2 when using an
800-nm LightSheer XC.
2. Avoid overlap of irradiation, but do not omit any
target area during treatment. Caution is needed, as
repeated irradiation of the same area may lead to
scarring and other serious adverse e ects.
3. I use only a contact-type skin cooling system.
Removing dense and thick hairs with a high
uence can cause nonspeci c dermal damage, and
protecting deeper layers with contact cooling helps
prevent adverse e ects. To allow su cient cooling,
increase the contact time of the cooling system from
0.5 to 1 second in areas with thick and dense hairs.
4. Frequently check for hairs adhering to the tip of the
contact-type handpiece.
5. Vary the uence under the nose and on the chin,
cheeks, and sideburns, depending on the density
and thickness of the hair shafts. Use a relatively low
uence for denser and thicker hair shafts.
Fig. 28.4 Aesthetic improvement of skin
tone after facial laser hair removal. (a)
Seven years after ve treatments in another
clinic. (b) Six months after additive seventh
treatments in my clinic.
Fig. 28.5 Improvement of shaving-related
hyperpigmentation after laser hair removal.
(a) Before the treatment. (b) Three months
after six treatments. E ective hair removal
reduced the frequency of shaving and
related skin irritation, thus reducing the
hyperpigmentation.
a
b
a
b

28 Aesthetic Laser Hair Removal for the Asian Face
369
The following techniques are used to create an irregular
hairline (Fig. 28.7):
1. Use di erent uences during treatment.
2. Combine various wavelengths and pulse durations
during treatment.
3. To avoid forming a distinct line, do not set a linear
boundary for laser irradiation.
Technique
The hairline generally includes some thick hairs, whereas
the forehead surface is covered with ne hairs. Therefore, the
parameters should be set di erently for the two areas. As
explained previously, the wavelength, uence, and pulse dura-
tion should be varied to avoid forming a distinct line at the hair-
line. The frequency of treatment di ers between individuals,
but at least six treatments are typically needed.
1. For the rst treatment, test various uences (e.g.,
Light Sheer XC, 10–28 J/cm 2) and spot sizes (e.g., 5–12
mm), and use at least two wavelengths (e.g., 800 nm
and 1,064 nm).
2. Adjust the treatment interval (8 to 10 weeks) based
on the degree of hair removal desired.
Improvement of Folliculitis and Acne
I see consistent and repeated outcomes of improved follicu-
litis or acne after laser facial hair removal in Korean men, as
have others.58 After three or four treatments, the frequency
of shaving decreases, and shaving-related folliculitis and
acne improve. In some cases, folliculitis and acne of the
areas not treated by laser also show improvement, but the
reasons are not understood (Fig. 28.6). I believe that the
type of shaving cream may play a role and should be inves-
tigated further.59
Forehead Widening in East Asians
Excess hairs of the forehead are removed to improve the fore-
head shape in patients with a narrow forehead, women with
a masculine forehead shape, or men with a feminine forehead
shape. For Koreans and Chinese, hairline correction to widen
the forehead is a common aesthetic procedure because a
narrow forehead is considered unattractive. The goals of
this treatment are to expand the forehead area, improve the
physiognomic balance of the face, and create a feminine or
masculine forehead shape, depending on the gender.
Forehead Hairline Design
The nal design should be con rmed through multiple con-
sultations (an average of two or three). Patients need suf-
cient time to think over the optimal design while looking
in the mirror. The doctor should lead the design phase but
should ask for patients’ opinions, beginning with the sec-
ond treatment. This helps to increase patient satisfaction.
Hairline design is based on the following factors:
1. Basic design: The shape should be rectangular in
men, round to oval in women.
2. Ratio: Approximately one-third of the facial length is
an appropriate forehead length.
3. Reciprocal design: Consider the jaw line.
4. Irregularity: Mimic a natural hairline, which is
irregularly irregular. Leave random ne hairs in place
according to the patient’s wishes.
5. Fine touch: Leave some ne hairs at the temporal
part of the female hairline.
Fig. 28.6 Improved facial acne after laser
hair removal. (a) Before the treatment.
(b) Three months after sixth treatments
shows improved folliculitis and acne of the
areas not treated by laser.
Laser spot
12 mm
9 mm
5 mm
7 mm
10 mm
12 mm
Treatment diagram
H
a
i
r
l
i
n
e
Fig. 28.7 Diagram used to explain how to make irregular hair-
line using two di erent wavelengths and multiple spot sizes and
shapes. Blue 12 mm; LightSheer XC, Blue 9 mm; LightSheer ET,
Orange 5 mm, 7 mm, 10 mm; CoolGlide Excel, Yellow 12 mm; Nd-
YAG of GentleMax (Candela).
a
b

V Facial Skin and Hair Rejuvenation
370
Patients need to be careful to avoid UV exposure and
skin irritation before and during treatment. Skin darkening
due to UV exposure may reduce the e ect of the treatment
and increase the risk of adverse e ects. Advise patients to
avoid tanning if possible, and to avoid shaving or excessive
cleansing of treated areas for 7 to 10 days after treatment to
reduce the pigmentation response of the skin and increase
the e cacy of the next treatment.

■Case Studies
Case 1
A 27-year-old male patient consulted for laser hair removal
from his face and neck (Fig. 28.9a). He had shaved every
day for 5 years and su ered from irregular, bumpy, dark
skin. He received seven treatments with 800-nm Light-
Sheer XC (30 ms, 12 × 12 mm, 26 J/cm 2 × 4, 28 J/cm 2, 29 J/
cm 2, 33 J/cm 2; treatment intervals of 5, 5, 6, 8, 10, and 12
weeks). Except for a few occasional regrown hairs, a very
satisfactory result was obtained 8 months after the seventh
treatment (Fig. 28.9b). He applied a topical steroid cream
twice because of the erythema reaction after treatments.

■Key Technical Points
1. For East Asian facial hair removal, I choose the
uence based on the current skin color (e.g., 5–30 ms,
10–45 J/cm 2 of LightSheer XC).
2. Apply the laser thoroughly so that no target area is
missed.
3. Prolong contact cooling time or increase coolant
spray time in areas with thicker and denser hair.
Lower the ambient room temperature to lower the
skin temperature. For East Asian male facial hair
removal, use contact-type epidermal cooling and
increase the contact time of the cooling system from
0.5 to 1 second in areas with thick and dense hair to
allow su cient skin cooling.
4. Take a photograph before each treatment to assess
the outcome and use a higher uence in areas with
little change.
5. For widening of the forehead, devote su cient time
to consultation before treatment (10–20 minutes).
The nal design should be con rmed through many
consultations.
6. For the rst treatment to widen the forehead, test
various uences (e.g., LightSheer XC, 10–28 J/cm 2)
and spot sizes (e.g., 5–12 mm) and use at least two
wavelengths (e.g., 800 nm and 1,064 nm).
7. The nal outcome should be evaluated at least 6
months after the last treatment.

■Complications and
Their Management
I have observed the following adverse e ects of facial hair
removal in men and women; persistent erythema, hyper-
pigmentation, depigmentation, aggravation of seborrheic
dermatitis (Fig. 28.8), and folliculitis. I have also seen rare
cases of idiopathic hypertrichosis in the cheek, jaw line,
and neck areas in women. Most adverse e ects resolve nat-
urally without treatment. If idiopathic paradoxical hyper-
trichosis is suspected, increase the uence 20 to 30% above
that of the previous treatment and perform at least three
additional treatments.60 This approach generally resolves
this adverse e ect.
Fig. 28.8 Seborrheic dermatitis after laser hair removal. (a) Seb-
orrheic dermatitis aggravated 4 days after rst treatment. (b) Five
weeks after rst treatment. The erythema resolved within a week
without any treatment.
a
b

28 Aesthetic Laser Hair Removal for the Asian Face
371
• Third treatment: 10/20/27 J/cm 2 30 ms (LightSheer
XC) + 23/28 J/cm 2 15 ms (CoolGlide Excel, 10 mm)
+ 10 J/cm 2 3 ms (CoolGlide Excel, 10 mm) interval;
10 weeks
• Fourth treatment: 12/25/26 J/cm 2 30 milliseconds
(LightSheer XC) + 25 J/cm 2 15 ms (CoolGlide Excel,
10 mm) + 8/9/10 J/cm 2 3 ms (Coolglide Excel, 10
mm) interval; 14 weeks
• Fifth treatment: 25 J/cm 2 30 ms (LightSheer XC)
+ 25 J/cm 2 15 ms (CoolGlide Excel, 10 mm) +
8 J/cm 2 3 ms (CoolGlide Excel, 10 mm) +
5 J/cm 2 2 ms
Five months after the ve treatments, the patient was satis-
ed w ith a natural-looking, widened hairline (Fig. 28.10b).
Case 2
A 34-year-old female patient consulted concerning her nar-
row forehead for widening (Fig. 28.10a). She received ve
treatments, and the treatment schedule and parameters
were as follows:
• First treatment: 10/20/25 J/cm 2 30 ms (LightSheer
XC) + 24 J/cm 2 15 ms (CoolGlide Excel, Cutera,
10 mm) + 10 J/cm 2 3 ms (CoolGlide Excel, 10 mm)
interval; 8 weeks
• Second treatment: 10/20/26 J/cm 2 30 ms
(LightSheer XC) + 25 J/cm 2 15 ms (CoolGlide Excel,
10 mm) + 10 J/cm 2 3 ms (CoolGlide Excel, 10 mm)
interval; 8 weeks
Fig. 28.9 Case 1. Laser hair removal in East
Asian male face. (a) Before the treatment.
(b) Eight months after the seventh treatment.
Fig. 28.10 Case 2. Widening of a female’s
forehead. (a) Before the treatment. (b) Five
months after the fth treatment.
a
b
a
b

V Facial Skin and Hair Rejuvenation
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7. Alster TS, Bryan H, William s CM. Long-pulsed Nd:YAG
laser-assisted hair rem oval in pigm ented skin: a clinical
and histological evaluation. Arch Derm atol 2001;137(7):
885–889
8. Goldberg DJ, Silapunt S. Histologic evaluation of a mil-
lisecond Nd:YAG laser for hair removal. Lasers Surg Med
2001;28(2):159–161
9. Paasch U, Wagner JA, Paasch HW. Novel 755-nm diode laser
vs. conventional 755-nm scanned alexandrite laser: side-
by-side comparison pilot study for thorax and axillary hair
removal. J Cosmet Laser Ther 2015;17(4):189–193
10. Hussain M, Suwanchinda A, Charuwichtratana S, Gold-
berg D. A new long pulsed 940 nm diode laser used for
hair rem oval in Asian skin types. J Cosmet Laser Ther
2003;5(2):97–100
11. Xia Y, Moore R, Cho S, Ross EV. Evaluation of the vacuum -
assisted handpiece compared with the sapphire-cooled
handpiece of the 800-nm diode laser system for the
use of hair removal and reduction. J Cosm et Laser Ther
2010;12(6):264–268
12. Zhou ZC, Guo LF, Gold MH. Hair rem oval utilizing the
LightSheer Duet HS hand piece and the LightSheer ET: a
comparative study of two diode laser system s in Chinese
wom en. J Cosm et Laser Ther 2011;13(6):283–290
13. Sadick NS, Laughlin SA. E ective epilation of white and
blond hair using combined radiofrequency and optical en-
ergy. J Cosmet Laser Ther 2004;6(1):27–31
14. Sadick NS, Shaoul J. Hair removal using a combination of con-
ducted radiofrequency and optical energies—an 18-month
follow-up. J Cosmet Laser Ther 2004;6(1):21–26
15. Braun M. Perm anent laser hair rem oval with low uence
high repetition rate versus high uence low repetition rate
810 nm diode laser—a split leg comparison study. J Drugs
Dermatol 2009;8(11, Suppl):s14–s17
16. Pai GS, Bhat PS, Mallya H, Gold M. Safety and e cacy of
low- uence, high-repetition rate versus high- uence, low-
repetition rate 810-nm diode laser for permanent hair re-
m oval—a split-face comparison study. J Cosm et Laser Ther
2011;13(4):134–137
17. Barolet D. Low uence–high repetition rate diode laser
hair rem oval 12-m onth evaluation: reducing pain and
Case 3
A 35-year-old male patient consulted about widening his
narrow forehead (Fig. 28.11a). He received three treat-
ments; the treatment schedule and parameters were as
follows:
• First treatment: 20/26 J/cm 2 30 ms (LightSheer XC) +
38 J/cm 2 20 ms (CoolGlide Excel, 10 mm) + 29 J/cm 2
15 ms (CoolGlide Excel, 10 mm) interval; 10 weeks
• Second treatment: 16/26 J/cm 2 30 ms (LightSheer
XC) + 43 J/cm 2 20 ms (CoolGlide Excel, 10 mm)
interval; 8 weeks
• Third treatment: 16/25 J/cm 2 30 ms (LightSheer XC)
+ 47 J/cm 2 20 ms (CoolGlide Excel, 10 mm) + 19 J/
cm 2 7 ms (CoolGlide Excel, 10 mm)
Eight months after the three treatments, he was satis-
ed with the result (Fig. 28.11b).
References
1. Grossm an MC, Dierickx C, Farinelli W, Flotte T, Anderson
RR. Damage to hair follicles by norm al-m ode ruby laser
pulses. J Am Acad Derm atol 1996;35(6):889–894
2. Dierickx CC, Grossm an MC, Farinelli WA, Anderson RR.
Permanent hair rem oval by norm al-m ode ruby laser. Arch
Derm atol 1998;134(7):837–842
3. Nanni CA, Alster TS. Long-pulsed alexandrite laser-assisted
hair removal at 5, 10, and 20 m illisecond pulse durations.
Lasers Surg Med 1999;24(5):332–337
4. Görgü M, Aslan G, Aköz T, Erdoğan B. Comparison of al-
exandrite laser and electrolysis for hair removal. Derm atol
Surg 2000;26(1):37–41
5. Ort RJ, Anderson RR. Optical hair rem oval. Semin Cutan
Med Surg 1999;18(2):149–158
6. Campos VB, Dierickx CC, Farinelli WA, Lin TY, Manuskiatti
W, Anderson RR. Hair removal with an 800-nm pulsed diode
laser. J Am Acad Dermatol 2000;43(3):442–447
Fig. 28.11 Case 3. Widening of a male’s
forehead. (a) Before the treatment. (b)
Eight months after the third treatment.
a
b

28 Aesthetic Laser Hair Removal for the Asian Face
373
36. Nelson JS, Majaron B, Kelly KM. Active skin cooling in con-
junction with laser dermatologic surgery. Sem in Cutan
Med Surg 2000;19(4):253–266
37. Ram R, Rosenbach A. E ects of am bient room temperature
on cold air cooling during laser hair rem oval. J Cosm et Der-
m atol 2007;6(3):203–206
38. Klavuhn KG, Green D. Importance of cutaneous cooling dur-
ing photothermal epilation: theoretical and practical con-
siderations. Lasers Surg Med 2002;31(2):97–105
39. Goldberg DJ. E ect of temperature-controlled cooling on
light-based skin treatm ents. J Cosm et Laser Ther 2006;
8(3):155–156
40. Moreno-Arias GA, Castelo-Branco C, Ferrando J. Side-
e ects after IPL photodepilation. Derm atol Surg 2002;
28(12):1131–1134
41. Bernstein EF. Hair grow th induced by diode laser treat-
m ent. Derm atol Surg 2005;31(5):584–586
42. Noh S, Koh WS, Lim HW, et al. Tool to visualize and evalu-
ate operator pro ciency in laser hair-rem oval treatm ents.
Biom ed Eng Online 2014;13:40
43. Bouzari N, Tabatabai H, Abbasi Z, Firooz A, Dowlati Y. Hair
rem oval using an 800-nm diode laser: comparison at dif-
ferent treatm ent intervals of 45, 60, and 90 days. Int J Der-
m atol 2005;44(1):50–53
44. Landa N, Corrons N, Zabalza I, Azpiazu JL. Urticaria induced
by laser epilation: a clinical and histopathological study
with extended follow-up in 36 patients. Lasers Surg Med
2012;44(5):384–389
45. Helou J, Maatouk I, Moutran R, Obeid G. Fox-Fordyce-like
disease following laser hair rem oval appearing on all treat-
ed areas. Lasers Med Sci 2013;28(4):1205–1207
46. Bechara FG, Georgas D, Sand M, et al. E ects of a long-
pulsed 800-nm diode laser on axillary hyperhidrosis: a
random ized controlled half-side comparison study. Der-
m atol Surg 2012;38(5):736–740
47. Desai S, Mahm oud BH, Bhatia AC, Ham zavi IH. Paradoxical
hypertrichosis after laser therapy: a review. Derm atol Surg
2010;36(3):291–298
48. Willey A, Torrontegui J, Azpiazu J, Landa N. Hair stim ula-
tion following laser and intense pulsed light photo-epila-
tion: review of 543 cases and ways to manage it. Lasers
Surg Med 2007;39(4):297–301
49. Doshi SN, Levy ML, Markus R. Koebnerization of reactive
perforating collagenosis induced by laser hair rem oval. La-
sers Surg Med 2003;32(3):177–179
50. Moreno-Arias GA, Camps-Fresneda A. Long-lasting hypopig-
mentation induced by long-pulsed alexandrite laser photo-
epilation. Dermatol Surg 2003;29(4):420–422
51. Weisberg NK, Greenbaum SS. Pigm entary changes af-
ter alexandrite laser hair removal. Derm atol Surg 2003;
29(4):415–419
52. Lanigan SW. Incidence of side e ects after laser hair re-
m oval. J Am Acad Dermatol 2003;49(5):882–886
53. Brilakis HS, Holland EJ. Diode-laser-induced cataract and
iris atrophy as a complication of eyelid hair removal. Am J
Ophthalm ol 2004;137(4):762–763
54. Davoudi SM, Behnia F, Gorouhi F, et al. Comparison of long-
pulsed alexandrite and Nd:YAG lasers, individually and in
com bination, for leg hair reduction: an assessor-blinded,
random ized trial with 18 m onths of follow-up. Arch Der-
m atol 2008;144(10):1323–1327
risks while keeping clinical e cacy. Lasers Surg Med
2012;44(4):277–281
18. Fernandez AA, França K, Chacon AH, Nouri K. From int ra-
zors to lasers: a tim eline of hair rem oval m ethods. J Cosm et
Derm atol 2013;12(2):153–162
19. Wim mersho MB, Scherer K, Lorenz S, Landthaler M, Ho-
henleutner U. Hair rem oval using a 5-m sec long-pulsed
ruby laser. Derm atol Surg 2000;26(3):205–210
20. Vogt A, Mc Elwee KJ, Blum e-Peytavi U. Biology of the hair
follicle. In: Blum e-Peytavi U, Tosti A, Whiting DA, Trueb R,
eds. Hair Grow th and Disorders. Leipzig, Germ any: Spring-
er; 2008:8–9
21. Koh W, Hwang J. New clinical application of laser hair re-
m oval; widening of narrow forehead. Lasers Surg Med
2003;32S15:67
22. Ibrahimi OA, Avram MM, Hanke CW, Kilmer SL, Ander-
son RR. Laser hair rem oval. Derm atol Ther 2011;24(1):
94–107
23. Anderson RR, Parrish JA. Selective phototherm olysis: pre-
cise m icrosurgery by selective absorption of pulsed radia-
tion. Science 1983;220(4596):524–527
24. Altshuler GB, Anderson RR, Manstein D, Zenzie HH,
Sm irnov MZ. Extended theory of selective photothermoly-
sis. Lasers Surg Med 2001;29(5):416–432
25. Koh W. Laser hair rem oval. In: Park S, Yeo U, eds. Laser Der-
m atology Plastic Surgery. Seoul: Koonja; 2014:253–275
26. Sadighha A, Mohaghegh Zahed G. Meta-analysis of hair re-
moval laser trials. Lasers Med Sci 2009;24(1):21–25
27. Erem ia S, Li CY, Umar SH, Newman N. Laser hair rem oval:
long-term results with a 755 nm alexandrite laser. Derm a-
tol Surg 2001;27(11):920–924
28. Handrick C, Alster TS. Comparison of long-pulsed diode
and long-pulsed alexandrite lasers for hair removal: a
long-term clinical and histologic study. Derm atol Surg
2001;27(7):622–626
29. Bouzari N, Tabatabai H, Abbasi Z, Firooz A, Dowlati Y. Laser
hair removal: comparison of long-pulsed Nd:YAG, long-
pulsed alexandrite, and long-pulsed diode lasers. Dermatol
Surg 2004;30(4 Pt 1):498–502
30. Li R, Zhou Z, Gold MH. An e cacy comparison of hair removal
utilizing a diode laser and an Nd:YAG laser system in Chinese
women. J Cosmet Laser Ther 2010;12(5):213–217
31. Polderm an MC, Pavel S, le Cessie S, Grevelink JM, van Leeu-
wen RL. E cacy, tolerability, and safety of a long-pulsed
ruby laser system in the rem oval of unwanted hair. Derm a-
tol Surg 2000;26(3):240–243
32. Nouri K, Chen H, Saghari S, Ricotti CA Jr. Comparing 18-
versus 12-m m spot size in hair removal using a Gentle-
LASE 755-nm alexandrite laser. Dermatol Surg 2004;30(4
Pt 1):494–497
33. Bäum ler W, Scherer K, Abels C, Ne S, Landthaler M,
Szeim ies RM. The e ect of di erent spot sizes on the ef-
cacy of hair removal using a long-pulsed diode laser. Der-
m atol Surg 2002;28(2):118–121
34. Altshuler GB, Zenzie HH, Erofeev AV, Smirnov MZ, Ander-
son RR, Dierickx C. Contact cooling of the skin. Phys Med
Biol 1999;44(4):1003–1023
35. Zenzie HH, Altshuler GB, Smirnov MZ, Anderson RR. Evalu-
ation of cooling methods for laser dermatology. Lasers Surg
Med 2000;26(2):130–144

V Facial Skin and Hair Rejuvenation
374
treatment options in skin of color. J Clin Aesthet Dermatol
2010;3(7):20–31
58. Manuskiatti W, Dierickx CC, González S, et al. Laser hair re-
moval a ects sebaceous glands and sebum excretion: a pilot
study. J Am Acad Dermatol 1999;41(2 Pt 1):176–180
59. de Groot AC. Contact allergy to cosmetics: causative ingre-
dients. Contact Dermat 1987;17(1):26–34
60. Uyar B, Saklam az A. E ects of the 755-nm alexandrite la-
ser on ne dark facial hair: review of 90 cases. J Dermatol
2012;39(5):430–432
55. Lou WW, Quintana AT, Geronemus RG, Grossm an MC. Pro-
spective study of hair reduction by diode laser (800 nm )
with long-term follow-up. Derm atol Surg 2000;26(5):
428–432
56. Dang Y, Liu B, Liu L, et al. The 800-nm diode laser irradia-
tion induces skin collagen synthesis by stim ulating TGF-β/
Sm ad signaling pathway. Lasers Med Sci 2011;26(6):
837–843
57. Davis EC, Callender VD. Postin am m atory hyperpigm enta-
tion: a review of the epidemiology, clinical features, and

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377
29 Aesthetic Facial Use of Botulinum Toxin in East Asians
Kyle Seo

■Introduction
Since Carruthers et al1 rst applied botulinum toxin type A
(BTA) for the treatment of glabellar frown lines in 1987, BTA
injection has gained world-wide popularity as a dynamic
w rinkle reduction treatment because of its easy applica-
tion, convenience, and safety. However, more recently,
the application of BTA for aesthetic purposes has gone far
beyond simply reducing wrinkles. Its application has been
expanded into correction of facial contours caused through
disuse atrophy of the masseter muscle,2,3 correction of the
body contour through disuse atrophy of calf muscles, and
also treatment of focal hyperhidrosis.4
Several papers and consensus publications have pro-
vided guidelines for the aesthetic use of BTA.5,6,7,8 However,
most of these publications have focused exclusively on Cau-
casian subjects, except for recent consensus recommenda-
tions by Korean experts for the aesthetic use of BTA in Asians.9
This chapter focuses on the ethnic di erences between East
Asians and Caucasians for the aesthetic use of BTA in terms
of anatomy, the applicable dose, injection methods, and
Pearls
• The treatment strategy behind botulinum toxin
type A (BTA) in East Asians, regarding dosages and
injection points, should be based on the following
considerations: the patient’s muscle mass, muscle
shape, and pattern of muscle activity; ethnic
di erences between East Asians and Caucasians;
and aesthetic appropriateness in the context of the
patient’s overall facial structure.
• Compared with Caucasians, East Asians have
relatively wide, round, and at faces. The use of
BTA for the treatment of masseter hypertrophy and
enlarged parotid gland, in which a square-shaped
face can be smoothed by decreasing the facial width
and achieving a “V” shape in the front pro le, is
popular among East Asians for this reason.
• BTA injection for the purposes of widening the
palpebral aperture (i.e., the eye opening) by injection
of the lower eyelid is contraindicated in East Asians
because it may remove the pretarsal bulge. However,
East Asians do consider the widened palpebral
aperture a hallmark of female beauty (known as the
“charming roll”).
• Eyebrow “shaping” with BTA, popular in Caucasians,
is also not recommended for East Asians because
prominently arched brows may look especially
unnatural in an Asian face, which is relatively wide.
• Asians generally tend to have a smaller mass, and
less hyperdynamic activity, of facial muscle than
Caucasians. Therefore, lower doses of BTA may
be required in East Asian patients compared with
Caucasians. Generally, in Asians an initial dose of 3
to 6 U is recommended for forehead horizontal lines
and 10 U for glabellar frown lines.
• Most physicians use clinical equivalence at
a conversion ratio of 1:1 for aesthetic use of
onabotulinumtoxinA and other BTA products, except
abobotulinumtoxinA, for which the conversion ratio
is believed to be 1:2.5 for onabotulinumtoxinA to
abobotulinumtoxinA.
• The main target of BTA when reshaping a square jaw
is the lower central belly of the masseter muscle.
Deep injection, su cient to touch the mandibular
bone, is very important to avoid embarrassing
facial expression (e.g., an unnatural asymmetric
smile caused by super cial injection weakening the
rizorius in the anterior part of the masseter). Four
to six injection points (IPs) with 5 U per injection
site are recommended depending on the patient’s
muscle volume.
• Injection of BTA into an enlarged or protruding
parotid gland can reduce the w idth of the lower
face by blocking the action of acetylcholine as
a neurotransm itter in the salivary glands. Deep
intraglandular injection at the m ost protruding
part of the parotid gland around the m andibular
angle is required w ith ve or six IPs and 5 U per
injection site.
• The use of multiple intradermal injections of BTA
(intradermal BTA), under various names such as
“mesobotox,” “dermatoxin,” and “microtoxin,” has
been widely adopted in Asia. The treatment is used
not only to reduce dynamic facial wrinkles but also
to reduce static wrinkles and pore size. An additional
action is creating the so-called perceived lifted e ect
or pseudolift. Thus, intradermal BTA can be considered
to produce a full range of anti-aging e ects.

VI Minimally Invasive Facial Plastic Surgery
378
not only from genetic di erences11 but also from cultural
di erences, since Asians tend to use their facial expression
muscles less than do Caucasians.12 Moreover, Asians have
been described as developing fewer age-related wrinkles
than Caucasians. This may be because, in comparison with
Caucasians, Asians have a thicker dermis,13 increased fat
above and deep to the super cial muscular aponeurotic
system, and denser fat and brous connections between
the super cial muscular aponeurotic system and deep
(parotidomasseteric) fascia.14 Therefore, lower doses of BTA
may be required in East Asian patients than in Caucasians.

■Procedural Techniques
Commercial Products of
Botulinum Toxin Type A
Commercially available BTA products in Asia are ona-
botulinumtoxinA (Botox/Vistabel, Allergan Inc., Irvine,
California), abobotulinumtoxinA (Dysport, Ipsen, Boulogne-
Billancourt, France/Medicis/Valeant, Bridgewater, NJ; also
licensed as Azzalure to Galderma, Lausanne, Switzerland),
and incobotulinumtoxinA (Xeomin/Xeomeen/Bocouture/
XEOMIN Cosmetic); botulinum toxin type A (150 kDa) free
from complexing proteins (Merz Pharmaceuticals GmbH,
Frankfurt, Germany). Other BTA products that have been
approved for use in Asia are Neuronox (Medytox Inc., Seoul,
South Korea; also marketed as Botulift, Cunox, Meditoxin,
and Siax), Prosigne (CBTX-A; Lanzhou Biological Products
Institute, Lanzhou, China) and Regenox (Hugel Pharma,
South Korea; also marketed as Botulax and Zentox).
Another Korean toxin, Nabota (Daewoong Pharmaceutical
Co. Ltd., Seoul, South Korea), is licensed and under investi-
gation in the United States and Europe as Evosyal (Alphaeon
Corp., Newport Beach, California).
In each product labeling, the manufacturer states that
dosage units are not interchangeable because di erent
assays are used to measure the potency of di erent botu-
linum toxin type A products. However, several consensus
papers and clinical studies support clinical equivalence at a
conversion ratio of 1:1 for aesthetic use of onabotulinum -
toxinA and other BTA products except abobotulinum -
toxinA.5,8,15,16 Various dose conversion ratios have been
suggested for onabotulinumtoxinA and abobotulinumtox-
inA. Based on available data and clinical experience, most
physicians apply a ratio for onabotulinumtoxinA to abob-
otulinumtoxinA of 1:2.5 for aesthetic use.17,18
Dilution and Storage of
Botulinum Toxin Type A
Lyophilized BTA powder should be reconstituted with
preservative-free saline to avoid possible reductions in the
potency of BTA. However, some advocates for preservative
containing saline insist that it reduces the pain experienced
indications of BTA, thereby providing some practical sugges-
tions for the aesthetic use of BTA in East Asians.

■Patient Evaluation
Each patient should be examined individually. Individual-
ized assessment and treatment are necessary because there
is signi cant variability among individuals within the same
East Asian population in the shape and function of many
target muscles. Dosages and IPs should be based on the sub-
ject’s muscle mass, muscle shape, pattern of muscle activ-
ity, and judgment of what is aesthetically appropriate in the
context of the individual patient’s overall facial structure.
However some critical ethnic di erences between East
Asians and Caucasians should be kept in mind in developing
a treatment strategy for East Asians using BTA.
Di erences in Aesthetic Ideals
Compared with Caucasians, East Asians have a relatively
wide, round, and at face. For this reason, East Asians con-
sider a smaller, narrower, and more three-dimensional face
to be more attractive, and may w ish to achieve this ideal
using botulinum toxin. One of the most typical examples
of this is treatment for masseter hypertrophy using botuli-
num toxin, which is not popular in Western countries even
though it was rst developed in Western countries more
than 20 years ago.2 This novel treatment with BTA helps
those East Asians with a square-looking face to achieve a
decreased facial width and a “V” shape to the face in front
pro le as well. In a similar context, botulinum toxin treat-
ment for the parotid gland is gaining popularity among
East Asians as a way of decreasing facial width.
BTA injection for widening the palpebral aperture (the
eye opening) is another typical example of the di erence
in treatment approaches between Asians and Caucasians.
BTA injection can remove the pretarsal bulge and slightly
lower the inferior ciliary margin to w iden the palpebral
aperture.10 However, it is important not to diminish the
pretarsal muscular bulge in East Asians, who consider it
a hallmark of female beauty (the “charming roll”). They
may also believe that the “charming roll” brings the optical
illusion of a “big eye” (like double-eyelid surgery does in
Asians with inherently smaller eyes). The roll can even be
enhanced by the injection of hyaluronic acid ller. In such a
context, BTA injection for widening the palpebral aperture
is therefore a contraindication in East Asians.
Anatomic Di erences between
East Asians and Caucasians
Asians generally have a smaller muscle mass and less hyper-
dynamic activity compared with Caucasians. Speci cally,
Asians tend to have shorter corrugator muscles than Cau-
casians. The smaller muscle mass of Asians seems to come

29 Aesthetic Facial Use of Botulinum Toxin in East Asians
379
because eyebrow ptosis is a fairly embarrassing side
e ect from the aesthetic viewpoint in Asians, who
have a wider distance between the eyebrow and the
palpebral ssure compared with Caucasians. Typical
at-risk patients for eyebrow ptosis are older people
(i.e., in their 50s and above); these patients require a
low initial dose from 2 to 3 U.
2. Many Asians require lower doses of BTA since Asians
have a smaller muscle mass and less hyperdynamic
activity than Caucasians.
The microdroplet technique at the intradermal level may
be of value to preserve expressivity. Generally, two rows
of six or seven IPs are recommended (Fig. 29.2a). Alterna-
tives include three rows of injections for people with a high
forehead (Fig. 29.2b). Low initial doses from 3 to 6 U are
recommended and no more than 12 U in total because of
the risk of eyebrow ptosis.
Glabellar Frown Lines
The target muscles are the corrugators and procerus (and
sometimes the orbicularis oculi) (Fig. 29.3). The consider-
ation points are as follows:
1. Asians have shorter and narrower corrugator muscles
compared with Caucasians.11 Asians also have
less hyperdynamic activity than Caucasians12 and
consequently require lower doses of BTA. Therefore, a
four-point injection pattern (rather than the standard
ve-point pattern for Caucasians), with injection of
the procerus and the medial corrugators (but not the
lateral corrugators), is generally appropriate for Asian
females. Of course, a ve-point injection pattern could
be appropriate for Asian males and other subjects with
a greater muscle mass. To prevent “samurai eyebrow”
(a weird expression especially seen in Asians with a
wide face), an additional injection of 0.5 U BTA into
the frontalis at 2 cm above the eyebrow in line with a
lateral canthal line can be of bene t in subjects aiming
to achieve a standard Caucasian pattern.
2. Stretch tests will help to identify subjects for whom
the combination of BTA with a soft tissue ller,
versus BTA alone, is the most appropriate strategy.
by patients from the injection of BTA without in uencing
the potency of BTA.19,20 Various volumes of normal saline
have been used for the reconstitution of BTA powder, from
1 to 10 mL, with 2.5 mL and 3.3 mL being popular dilutions,
with respective concentrations of 4 U/0.1 mL and 3 U/0.1 mL.
Various results have been suggested for the e ect of
refrigerator storage on the potency of BTA following the
reconstitution of BTA. Based on available data and clinical
experience, however, most physicians store the reconsti-
tuted BTA in the refrigerator for up to 4 weeks.21,22,23
Landmark of Injection
The determination of BTA injection sites should be based on
muscular and bony landmarks, rather than on cutaneous ones.
The eyebrows are a particularly unreliable cutaneous landmark.
This is especially so in older people with eyebrow sagging, and
in women, due to their propensity to modify the eyebrow
shape by tweezing, plucking, etc. Examination of the overlying
soft tissues—fat and skin—may be useful as an adjunct.
Injection Levels
While intradermal injection has the bene t of less bruis-
ing, precise injection into thin dermis, such as that found in
the lower eyelid, is di cult. Moreover, intradermal injec-
tion is much more painful than subdermal or intramuscu-
lar injection. Therefore, it is more realistic to describe the
placement of BTA required for deep muscles, such as the
masseter and corrugator, as subdermal or intramuscular.

■Site-Speci c Techniques
Forehead Horizontal Lines
The target muscle is the frontalis (Fig. 29.1). Consideration
points are as follows:
1. Screening for those at risk of eyebrow ptosis, (e.g.,
patients with ptosis, or people who congenitally
open their eyes with the frontalis) is a prerequisite
Fig. 29.1 BTA injection for forehead horizontal
lines. (a) Before the injection. (b) Two weeks
after injection.
a
b

VI Minimally Invasive Facial Plastic Surgery
380
Lateral Canthal Rhytides
(Crow’s-Feet)
The target muscle is the orbicularis oculi (Fig. 29.5). Con-
sideration points are as follows:
1. It is important to preserve the expression lines at
the lateral canthal lines to some extent to maintain a
natural look.
2. It is also important, prior to injection, to distinguish
between orbicularis activity and zygomaticus
activity as the cause of wrinkles around the lateral
canthal area. Horizontal lines under the eyes and
descending lines at the lateral malar area are caused
Intramusclular injection into four IPs should be used (2 U in
two IPs in the procerus and 4 U in two IPs in the medial part of
the corrugator) (Fig. 29.4a). The standard Caucasian pattern for
glabellar frown lines requires an additional 1 to 2 U at the mid-
pupillary line for the lateral part of the corrugator (Fig. 29.4b).
Occasionally, an additional injection of 1 U at the lateral
canthal line immediately above the eyebrow is necessary
for those patients with a hyperactive orbicularis oculi.
To avoid ptosis, one of the most serious and uncomfort-
able adverse e ects of BTA, take the IP for the corrugator
head above the bony orbital rim by palpating the bony rim,
and then inject it slowly with a nondominant nger, com -
pressing the bony orbital rim so as to prevent the spread of
BTA into the orbital part below.
Fig. 29.2 Injection points and dose of BTA for forehead horizontal lines. (a) Injection points and dose of BTA for two rows with six to seven
IPs. (b) Alternatives include three rows of injections for people with a high forehead. (Used with permission from Seo KK. Botulinum Toxin
for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Fig. 29.3 BTA injection for glabellar frown
lines. (a) Before the injection. (b) Two weeks
after injection.
a
b
a
b

29 Aesthetic Facial Use of Botulinum Toxin in East Asians
381
ing vessels. At least three IPs with 2 to 3 U per IP should be
used, with an optional one or two IPs, depending on the
wrinkle pattern (Fig. 29.6).
Eyebrows (Brow Lifting and Shaping)
The target muscles are brow depressors (corrugators,
procerus, orbicularis oculi). Consideration points are as
follows:
1. It is important to preserve or achieve a natural
eyebrow position because eyebrows tend to droop
with aging in Asians.
by zygomaticus activity and, consequently, are not
indications for BTA. This should be communicated
in advance to patients prior to treatment so that
expectations are appropriate.
3. Following BTA for crow’s-feet, Asians with
prominent zygoma and abundant premalar fat above
the nasojugal groove tend to readily show more
prominence of the lateral malar area, which Asians
generally hate. In these patients, injection at a lower
part is unnecessary; alternatively, a lower dose (i.e.,
only 0.5 U of BTA) is required.
To avoid bruising, subdermal injection technique is useful
for this treatment area as the area has abundant underly-
Fig. 29.4 Injection points and dose of BTA for glabellar frown lines. (a) Intramusclular injection into four IPs should be used (2 U in two
IPs in the procerus, and 4 U in two IPs in the medial part of the corrugator). (b) The standard Caucasian pattern for glabellar frown lines
requires an additional 1 to 2 U at the midpupillary line for the lateral part of the corrugator. (Used with permission from Seo KK. Botulinum
Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Fig. 29.5 BTA injection for lateral canthal
rhytides. (a) Before the injection. (b) Two
weeks after injection.
a
b
a
b

VI Minimally Invasive Facial Plastic Surgery
382
Infraorbital Wrinkles
The target muscle is the lower part of the orbicularis oculi,
preseptal and orbital part. Consideration points are as follows:
1. The infraorbital area should not be injected in those
patients who have poor skin elasticity.
2. It is important not to inject the pretarsal part of the
orbicularis oris close to the lower ciliary margin
because injection of BTA into this area diminishes the
pretarsal muscular bulge in East Asians, who consider
it a hallmark of female beauty (the “charming roll”).
3. Caution should be taken when injecting patients
with infraorbital fat bulging because of the risk of
deterioration of the fat bulge.
IPs are usually recommended between the preseptal part
and the orbital part of the orbicularis oris. One row of ve
or six IPs per eye, with a total dose of less than 2 U, is rec-
ommended (Fig. 29.7).
Infraorbital Eye Opening
The target muscle is the orbicularis oculi, pretarsal part.
Consideration points are as follows: BTA injection would
remove the pretarsal bulge and slightly lower the inferior
2. Eyebrow “lifting” with botulinum toxin, by leveraging
the mechanism of botulinum rebalancing and
weakening depressor muscles such as the corrugator,
procerus, and orbicularis, has been described as a
rejuvenative procedure.24 While youthful eyebrows
in Caucasians rarely sit high on the forehead, and
eyebrows often become elevated with age due to
partial compensation for upper eyelid ptosis,25
eyebrow lifting would make sense in Asians who
have a wider distance between the eyebrows and the
palepebral ssure than in Caucasians, and who show
brow drooping with aging.
3. Eyebrow “shaping” with botulinum toxin has been
described extensively in the Caucasian literature.26
However, prominently arched brows may look
especially unnatural in Asians since their faces are
relatively wide. The preferred Asian female brow shape
is usually atter and lower in the lateral two-thirds
than that described for Caucasians. This does not
detract from facial harmony and, in fact, may enhance
it. Asian subjects in their native countries, and most
Asian immigrants in other countries, especially dislike
the laterally elevated “Samurai eyebrow.”
Typical schemes involve combination treatment with BTA
at the glabella and orbicularis oculi.
Fig. 29.6 Injection points and dose of BTA for lateral canthal rhyt-
ides. At least three IPs should be used with an optional additional
one or two IPs (purple) above and/or below these depending on the
wrinkle pattern. (Used with permission from Seo KK. Botulinum
Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publish-
ing; 2014.)
Fig. 29.7 Injection points and dose of BTA for infraorbital wrin-
kles. One row of ve or six IPs per eye, with a total dose of less than
2 U is recommended between the preseptal part and the orbital
part of the orbicularis oris. (Used with permission from Seo KK.
Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books
& Publishing; 2014.)