Video Atlas Phẫu Thuật Tạo Hình Thẩm Mỹ (Aesthetic Plastic Surgery Video Atlas)

Operative Approach
37
Horizontal frowners
● For a horizontal frowner, I displace the forehead and brow ceph-
alad and then with my non-injecting hand fi x it in position by
placing pressure across the superior orbital rim.
● The patient is again asked to frown.
● This reveals an indentation in the skin corresponding to where the
tail of the corrugator inserts into the dermis of the skin of the
brow.
● I begin injecting in this area and progress medially with small
injections to the procerus, which receives little Botox.
● The same procedure is repeated across the other brow, moving
lateral to medial.
● Most men have signifi cantly longer corrugators than women with
the tail extending lateral to the mid-pupillary line.
Vertical frowners
● Vertical frowners have much more Botox injected into the medial
(dominant) portions of the corrugators and heavy injection of the
procerus.
● Often, I do not inject the lateral tail of the corrugators in male
patients to leave them with less brow lateralization.
Optimizing outcomes
●
Using the minimum volume and dose of injection necessary in
the frontalis to achieve the outcome will reduce the potential
and duration of eyelid ptosis.
●
The more inferior the injection of the corrugator and glabellar
group, the less chance for eyelid ptosis.
FOREHEAD
OPERATIVE APPROACH
The frontalis muscle is injected to partially weaken the forehead to
relieve horizontal forehead rhytids. The frontalis has highly variable
functional anatomy. Despite its appearance in most anatomy texts, the
frontalis is usually continuous across the forehead, with muscle even
in the midline.
Operative technique
● My dosage range for the frontalis is 3.75–30 units, though most
injections fall within the range of 5–7.5 units.
● Observe patients in normal animation and then ask them to
raise and lower their brows several times, almost to the point
of exhaustion. Upon observation of this motion, the strongest por-
tions of this muscle are targeted, not the rhytids. No standard
pattern of injection is used and these are mentioned only to be
condemned.13
COMPLICATIONS
Care must be taken to not overly denervate the frontalis, which can
lead to an overly smooth, artifi cial appearance, brow ptosis, and eyelid
ptosis in the patient who has been using his frontalis as an accessory
eyelid elevator.
CROW’S FEET AND LOWER EYELID
OPERATIVE APPROACH
The lateral and inferior orbicularis oculi is weakened to diminish
crow’s feet and lower eyelid rhytids in selected patients. The effects
of surgically weakening the lateral orbicularis had been known for
several years prior to the cosmetic use of Botox injections.14
In my practice nearly all patients who have their crow’s feet
treated have some injection into their lower lids as well.
The functional anatomy of this area leads to a classifi cation of
crow’s feet patterns.15 The most common pattern is the full fan pattern
where the lateral orbicularis contracts and wrinkles the overlying skin
from the lateral brow to the lower lid/upper cheek junction, yet even
this pattern occurs in less than 50% of patients. The exact incidence of
each pattern is not as important as the recognition of different patterns
in different patients and asymmetry in individual patients. Treatment is
based on the functional anatomy of the orbicularis oculi (Fig. 4.1A–D).
Operative technique
● Although there are no standard doses or dosing patterns, most patients
that I inject currently receive between 3.75 and 5 units per side.
● I try to not waste Botox on relatively adynamic sections of the
muscle. To do this, it is necessary to recognize that the functional
anatomy of the lateral periorbita varies widely. I inject the most
dynamic area of the muscle fi rst, followed by smaller injections
radiating out from this point. The idea is to create a gradient of
motion to avoid having an area of no motion directly bordering an
area of extreme, compensatory hypermotility, which produces an
unattractive line of demarcation.
COMPLICATIONS
Mild overzealous injection can yield an unpleasant deer-in-the-head-
lights look and cheek ptosis at the opposite end of the spectrum.
Although most plastic surgeons are aware that the upper lateral
orbicularis oculi is a brow depressor, many fail to realize that the lower
lateral portion is an important cheek elevator. Over-denervation in its
lower lateral section, can therefore result in malar fl attening as well
as an extra ‘roll’ of skin between the lower lid and cheek.
Injection of elevator muscles should either be eschewed or done
extremely conservatively or done in combination with their
counterpart depressors.
Excessive chemodenervation of the orbicularis oculi across the
lower lid can have several unaesthetic results:
● in the patient with a relatively lax lower eyelid, frank ectropion or
lower lid retraction may result;
● in the patient with minimal to borderline orbital fat prolapse,
weakening the middle lamella can exaggerate and hasten the
appearance of fat ‘bags’ of the lower lids;
● because this sheet of muscle also functions as a pump, extreme
denervation can result in lymphedema.
BROW ELEVATION
OPERATIVE APPROACH
Brow elevation by the injection of Botox was once considered contro-
versial, with publications in both the plastic surgical and dermatologic

4
BOTULINUM TOXIN
38
press saying that Botox could only depress the brows or at best that
it was an illusory brow lift created by dropping the medial brow.
Botox can easily and reliably lift the brows in excess of 6 mm in
my practice.
The concept is remarkably easy. To lift the brows, one concentrates
on injecting muscle segments that actively and even at rest depress the
brows, allowing the brows to raise.
The other concept of increasing the lift of the brows by weakening
the only muscle that lifts them is not so frequently understood. This
seeming paradox is explained by the simple observation that non-
weakened sections of muscle react to weakened sections by increasing
their pull in compensatory fashion. This explains why:
● when the lateral orbicularis is strongly injected, lower lid rhytids
increase – this is not simply an illusion caused by smoothing of the
skin laterally, but results from an increase in resting tone of the
non-injected portion of the muscle across the lower lid.
● when the central frontalis is injected strongly, the lateral brows
often peak in an unattractive ‘Mr. Spock’ appearance with con-
comitant worsening of lateral suprabrow rhytids.
When portions of the frontalis are weakened, the other portions of
the frontalis lift more strongly. To maximize brow lift, injecting the
portions of the frontalis not responsible for raising brows, will induce
the frontalis responsible for brow elevation to pull harder. Usually
this means injecting the frontalis strongly centrally, in the zone above
and medial to the brows. The frontalis lateral to the brows is also
injected, causing the frontalis directly over the brows to lift more
strongly.
Eleven muscle segments can depress the medial brow:
● the procerus;
● transverse heads of the corrugator;
● oblique heads of the corrugator;
● depressor supercilii;
● medial orbicularis oculi;
● and in some patients, the nasalis muscles.
In most patients, the effect of the nasalis on brow position is negligible.
However, in a small number of patients I have fully injected the other
medial brow depressors and been disappointed in the ensuing brow
elevation. With the other segments completely non-functional, these
patients were able to depress their brows by wrinkling their nasalis.
Subsequent nasalis injection gave the brows additional elevation.
There is no standard pattern of injection for brow elevation. The
key is individualizing treatment based on each patient’s functional
anatomy.
The lateral brow is depressed by the cephalad portion of the lateral
orbicularis oculi. The dynamics of this differ greatly among patients,
and there is no single point that can be injected to reliably elevate the
lateral brow.
Some patients who do not depress their brows when smiling will
not reliably achieve brow elevation by simply injecting the upper
lateral orbicularis.
The key is individualizing treatment based on each patient’s func-
tional anatomy. There is no standard pattern of injection for brow
elevation.
For a unilateral brow lift (Fig. 4.2A–F), in addition to the zones
directly over the brows, weaken the frontalis slightly over the higher
brow, inducing the frontalis over the lower brow to pull harder.
A
B
C
D
Fig. 4.1 Use of Botox for crow’s feet.
A, Early static rhytids in the crow’s feet area.
This patient has a full fan pattern of motion.
B, Full effacement of these nondynamic
rhytids in repose by injection of 5 units of
Botox along the full pattern of motion with
less injection along the lower eyelid/upper
cheek border. C&D, The patient smiling
before and after injection of 7.5 units to her
left lateral periorbital area. Her primary
complaint on this side was of the curl of
muscle that raises up along the lower lid
margin. If she were injected in a ‘standard’
pattern not only would this lump of muscle
not have been addressed, but by weakening
the rest of the lateral orbicularis oculi, it
would have been made worse. Botox was
injected directly into the very active area of
muscle along the lower lid and in lesser
doses radiating out from this point to create a
gradient of motion.

Operative Approach
39
NECK
OPERATIVE APPROACH
Platysmal bands are another area where Botox injections can yield
excellent results. Two articles on neck injection were published simul-
taneously in 1999 with drastically different dosage, patient popula-
tions, results, and complications.16,17 One paper advocated up to 250
units to be injected, had better results in patients with greater skin
laxity, and reported dysphagia as a complication.16 I would caution
against injecting such high doses in the neck. In addition to dysphagia,
high doses can also lead to dry mouth by affecting the salivary glands.
The key to evaluating the neck as a potential site for cosmetic
improvement lies in the relative contributions of the skin and the pla-
tysma to banding. The best patients have minimal skin excess and
relatively strong bands. Despite the results (based on 1500 patients)
of the aforementioned paper,16 the patient with lax neck skin is a poor
candidate for injection. Even with the bands completely paralyzed, the
lax neck skin will continue to hang.
Good candidates for injection fall into two basic categories. The
relatively young (35–45 years) patient with strong bands and minimal
skin laxity is an excellent patient (Fig. 4.3A&B). Likewise the patient
of any age who has had a surgical procedure on the neck and has
relatively little excess skin and recurrent bands is a good candidate.
A smaller class of patients, but one that is seen more frequently is the
young patient who has had an aggressive fat removal procedure in the
neck and now has visible bands.
Operative technique
● My current dose range is 15–30 units for the neck, with around 20
units for most patients.
● Ask the patient to show the lower teeth with the teeth clenched.
● The platysma band becomes apparent and is grasped between the
thumb and index fi nger of the non-injecting hand.
● The patient is told to relax and the muscle is injected starting just
below the mandibular border and progressing inferiorly to the
point at which the band is visible.
● The horizontal ‘necklace’ rhytids can also be very mildly improved
by injecting toxin just above and below them.
NASOLABIAL FOLD
OPERATIVE APPROACH
The nasolabial fold is an excellent area for injection in the right
patient who has been instructed what to expect.
The levator labii superioris alaeque nasi muscle is the muscle
mainly responsible for the medial nasolabial fold and the fi nal 3–4 mm
of central upper lip elevation.18 Weakening of this muscle smoothes
the medial nasolabial fold and changes the smile pattern of the
patient.
Rubin described the three major smiling patterns in 1974.
● The most common or ‘Mona Lisa’ smile pattern is dominated by
the zygomaticus muscle and elevates the oral commissures to the
highest point of the smile.
● The canine smile pattern is dominated by the levator labii superi-
oris and the highest part of the smile is the central upper lip. This
pattern occurs in 35% of the population and these people are the
potential candidates for this procedure. Because injection of this
muscle results in a drop of the central upper lip upon smiling, it
A
B
C
D
E
F
Fig. 4.2 Use of Botox for brow lift. A, Relatively strong but short corrugators. B, After treatment with a total of 17.5 units injected into the
medial brow depressors. No fi llers were used. Note the partial recruitment of the left orbicularis oculi in an attempt to frown. C, The frontalis
pre-treatment. D, The frontalis was treated with a total of 5 units strategically placed in the strongest parts of the muscle not directly over
the brows. A small amount (<1 unit) was placed over the right brow. Note the peaking of the left brow. E&F, The patient at rest showing
that due to the differential injection of her frontalis based on her functional anatomy, she has a left-sided brow lift stronger than on her right
side. The glabella and forehead are also rejuvenated. The patient had a left pre-injection brow and borderline eyelid ptosis. If given a
‘standard’ frontalis injection, she would have gone on to develop frank eyelid ptosis.

4
BOTULINUM TOXIN
40
converts canine smilers into Mona Lisa smilers. Injecting Mona
Lisa smile patients results in an exaggerated Mona Lisa smile that
most patients fi nd unattractive.
● Patients with gummy smiles are basically extreme canine smile
pattern patients. This group benefi ts the most from Botox injection19
(Fig. 4.4A&B). Gummy smilers often smile asymmetrically, requir-
ing asymmetric injection. They also tend to have deeper medial
nasolabial folds, which is the area of primary improvement with
this technique. The resulting drop of the upper lip hides the gingiva
and results in a more pleasing smile.
Operative technique
The technique for this injection is relatively straightforward once the
patient has been determined to be a candidate. It changes the func-
tional anatomy of patients by changing their smile pattern.
● Before injection, the patient is given a preview of the proposed
change. The patient looks into a mirror at eye level and smiles.
Using a cotton applicator stick, I push the upper lip down 3–4 mm,
giving the patient a rough approximation of the change to be
expected to the smile as well as the nasolabial fold.
● For injection, the index fi nger of the non-injecting hand is pressed
fi rmly against the inferior portion of the nasal bone where it meets
the maxilla. Thus, half of the fi nger is falling into the pyriform
aperture while the other half lies in the groove between the nasal
bone and maxilla.
● The patient is then asked to smile strongly.
● The levator labii superioris alaeque nasi can usually be felt just
lateral to the groove and is injected once on each side, just above
the periosteum. My dose range for this muscle is 5–15 units, with
most patients falling in the 5–7.5 unit range.
LOWER FACE
OPERATIVE APPROACH
Perioral rhytids, dimpled chin, and downturned oral commissures are
all amenable to improvement by Botox injection.20
Understanding the functional anatomy of each patient’s muscles is
the key to achieving reproducibly good results and avoiding the disas-
trous sequelae of a few misplaced units.
Slight weakening of the superfi cial fi bers of the orbicularis oris
muscle helps to alleviate the overlying rhytids caused by this sphincter
with or without concomitant fi ller injection.
Around 1998 I changed from the more popular point technique to
a threading injection a few millimeters above the vermilion border.
This results in a more even appearance and avoids compensatory
areas of hypermotility.
Weakening of the mentalis must be done with caution because
this muscle raises the chin pad and lower lip and is critical for oral
competence. A few units are threaded along the superfi cial aspect
of the muscle to effect weakening and smoothing of the muscle’s
surface.
Injection of the depressor anguli oris muscle can bring about an
upturn to the oral commissure, a decreased apparent volume defi cit
in the labiomental area, and a prolonged duration of fi ller material
placed in the same area.
Injection of the mentalis is often paired with depressor anguli oris
injection to maintain the height of the lower lip (Fig. 4.5A–J).
Extra care must be taken when injecting mentalis and depressor
anguli oris because a few stray units placed or diffused into closely
adjacent muscles can result in a crooked smile, speech diffi culty, and
even oral incompetence. Despite these risks, over half of my Botox
patients receive injections to the lower face or neck.
A
B
A
B
Fig. 4.3 Use of Botox for strong platysmal
bands. A, Patient in her mid 30s with strong
platysmal bands and minimal excess skin.
This large amount of muscle mass in a young
patient required a high dose. B, She was
treated with 20 units to her right primary
band and 7.5 units to her right secondary
(lateral) band.
Fig. 4.4 Use of Myobloc for a gummy smile.
A, Smile before injection. B, Smile after 750
units of Myobloc was injected into the levator
labii superioris alaeque nasi muscles and 500
units into the upper orbicularis. This patient
is in her mid 30s with minimal ptotic cheek
skin, a sharp medial nasolabial fold, and a
gummy smile making her an excellent
candidate for injection. The botulinum toxin B
has dropped her upper lip and softened her
folds. She is seen at 2 months after injection
and she subsequently lost her correction. The
shorter duration of action of toxin B limits its
cosmetic usefulness.

Operative Approach
41
A
B
C
D
E
F
G
H
I
J
Fig. 4.5 Use of Botox for the lower face. A, The patient is seen trying to push her lower lip up,
thereby straining her mentalis. B, After injection, the dimpling and irregularities of the skin
surface are greatly improved. C, The patient is asked to show her lower teeth, contracting her
depressor anguli oris muscles. She received a total of 7.5 units injected symmetrically. The
horizontal fold below her right commissure is apparent and is the sight for the fi rst injection.
The second injection on each side lies midway between the fi rst injection and the lower
border of the mandible. D, Note that this patient is unable to crease the skin below her
commissures and show her lower gingival after injection. E&F, The patient is attempting to
purse her lips after a total of 4 units of Botox were injected in equally divided doses in her
upper and lower lips (sparing the philtrum). Her ability to create radial lines around the lips is
compromised. The areas seen where most motion resides will be the areas of least
improvement in repose. Although I have never achieved it, it is always my goal to effect a
uniform circumferential mild weakening of the sphincter. G, The patient at rest before her
lower face injections. H, The patient at rest after her lower face injections. The chin is not
only less dimpled and wrinkled, but appears more refi ned and less boxy from the weakening
of the lateral mentalis. The commissures have been raised and the subcommissure depression
has been lessened by depressor anguli oris injection. The areas of suboptimal lip improvement
(right upper lip) correspond to the less weakened segments as seen in Fig. 4.5F. No fi llers
were used and the horizontal width of the mouth appears less. The lower face has been re-
shaped. I, The patient smiling before her lower face injections. J, The patient smiling after her
lower face injections. The smile is still natural in appearance. When injecting many areas of the
lower face simultaneously, the patient usually experiences a feeling of weakness that persists
for about 2 weeks. Notice the raised position of the lower lip which protects oral competence.

4
BOTULINUM TOXIN
42
COMPLICATIONS
Complications may occur from drift of the toxin to adjacent muscles,
thereby weakening them. This is especially hazardous when injecting
the perioral musculature. Other complications include headache,
ecchymosis, and eyelid ptosis.21
Avoiding aspirin and NSAIDs which alter platelet function will
reduce ecchymosis. Avoiding too superfi cial, or dermal, injection will
reduce the risk of unaesthetic changes to the skin. Although it does
reduce and prevent cystic acne,22 it often leaves the skin overly dry and
shiny. Pitfalls to avoid are listed in Box 4.1.
POSTOPERATIVE CARE
Generally, there is no need for any post-injection care. Application of
cold packs may reduce the post-injection ecchymosis.
CONCLUSION
Injections of botulinum toxin type A are the dominant procedure in
aesthetic plastic surgery today. When properly placed in appropriately
selected individuals, the toxin can have a rejuvenating effect on nearly
the entire face and neck. Careful observation of the patient’s functional
anatomy is the key to determining how much toxin to place where.
Fine control can be achieved by partially weakening various muscles
of the face to induce neighboring musculature to compensate for the
ensuing weakness.
REFERENCES
1. Osako M, Keltner JL. Botulinum A toxin in ophthalmology. Surv
Ophthalmol 1991; 36:28–46.
2. Scott AB, Rosenbaum A, Collins CC. Pharmacologic weakening of
extraocular muscles. Invest Ophthalmol Vis Sci 1973; 12:924–927.
3. Scott AB. Botulinum toxin injection into extraocular muscles as an
alternative to strabismus surgery. Ophthalmology 1980; 87:1044–1049.
4. Clark RP, Berris CE. Botulinum toxin: a treatment for facial asymmetry
caused by facial nerve paralysis. Plast Reconstr Surg 1989; 84:353–355.
5. Carruthers JDA, Carruthers JA. Treatment of glabellar frown lines with
Clostridium botulinum A exotoxin. Dermatol Surg 1992; 18:17–21.
6. Kane MAC. Muscle atrophy after repeated Botox injections. American
Society for Aesthetic Plastic Surgery Meeting, Los Angeles, May 2, 1998.
7. DePaiva A, Meunier F, Molgo J, et al. Functional repair of motor
endplates after botulinum neurotoxin type A poisoning: biphasic switch
of synaptic activity between nerve sprouts and their parent terminals.
Proc Natl Acad Sci USA 1999; 96:3200–3205.
8. Hexsel DM, Almeida ATD, et al. Multicenter, double-blind study of the
effi cacy of injections with botulinum toxin type A reconstituted up to six
consecutive weeks before application. Dermatol Surg 2003; 29:523–529.
9. Kane MAC. Discussion: effi cacy of reconstituted and stored botulinum
toxin type A: an electrophysiologic and visual study in the auricular
muscle of the rabbit. Plast Reconstr Surg 2003; 111:2430.
10. Santo JL, Swenson P, Glasgow LA. Potentiation of Clostridium
botulinum toxin by aminoglycoside antibiotics: clinical and laboratory
observations [Abstract]. Pediatrics 1981; 48:951–955.
11. Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and
immunology. Muscle Nerve Suppl 1997; 6:146–168.
12. Rubin LR. The anatomy of a smile: its importance in the treatment of
facial paralysis. Plast Reconstr Surg 1974; 53:384.
13. Rohrich R, Janis J, Fagien S, Stuzin J. The cosmetic use of botulinum
toxin CME. Plast Reconst Surg 2003; 112(suppl 5):177–188S.
14. Aston SJ. Orbicularis oculi muscle fl aps: a technique to reduce crow’s
feet and lateral canthal skin folds. Plast Reconstr Surg 1980; 65:206.
15. Kane MAC. Classifi cation of crow’s feet patterns among Caucasian
women: the key to individualizing treatment. Plast Reconstr Surg 2003;
112(suppl 5):33–39S.
16. Matarasso A, Matarasso S, Brandt F, et al. Botulinum A exotoxin for
the management of platysma bands. Plast Reconstr Surg 1999;
103:645–652.
17. Kane MAC. Nonsurgical treatment of platysmal bands with injection of
botulinum toxin A. Plast Reconstr Surg 1999; 103:656–663.
18. Pessa J. Improving the acute nasolabial angle and medial nasolabial fold
by levator alae muscle resection. Ann Plast Surg 1992; 29:23–30.
19. Kane MAC. The effect of botulinum toxin injections on the nasolabial
fold. Plast Reconstr Surg 2003; 112(suppl 5):66–72S.
20. Kane MAC. The functional anatomy of the lower face as it applies to
rejuvenation via chemodenervation. Facial Plast Surg 2005; 21:55–64.
21. Kane MAC. Eyelid ptosis following botox injections to the face.
American Society of Plastic Surgeons Meeting, Los Angeles, October 13,
2000.
Box 4.1 Potential pitfalls when using botulinum
toxin
Patients who have severe dry eyes with lid lag
●
May experience a deterioration of this condition following
injection
Patients who have pre-existing eyelid ptosis
●
Usually compensate by elevation of the eyebrows
●
Over weakening of the frontalis muscle will unmask the ptosis
by eliminating the compensation
Point injection of the upper lip
●
May cause asymmetric lip motion and visible irregularities
Deep and caudal injection of crow’s feet
●
May paralyze zygomaticus major muscle and result in ptosis of
the oral commissure.
Paralysis of the platysma muscle
●
May reveal a ptotic submaxillary gland

43
CHAPTER 5
Laser Facial Resurfacing and Dermabrasion
Richard O Gregory
INTRODUCTION
While skin rejuvenation dates back to the Egyptian era, laser facial
rejuvenation is a recent innovation. It is said that Cleopatra used
soured milk (lactic acid) to rejuvenate her skin. Thus chemical peels
as well as a variety of mechanical exfoliations have been practiced for
thousands of years. The laser, however, is a recent addition to the skin
rejuvenation armamentarium. In 1960, Theodore Maiman produced
the fi rst laser energy, utilizing a Ruby crystal.1 New laser development
was primarily a product of the communications industry, and in fact
much of the early work was done in Bell Laboratories. Many of the
lasers used in medicine today were developed for industrial use and
later adapted to medical applications. Patel published his discovery of
the carbon dioxide laser in 1964.2
Laser application in medicine gained momentum in the late 1960s
and early 1970s. Dr Leon Goldman commonly considered ‘the father
of laser medicine’ and many other pioneers recognized the value of the
laser in treating a variety of medical conditions.3 Ophthalmology was
one of the early adopters of laser energy for treating intraocular neo-
vascularization. The technology was soon applied to vascular birth-
marks, such as port-wine stains. These early lasers, however, were very
crude devices with poor control of the laser parameters, thus leading
to mixed results. Commonly a port-wine stain was exchanged for a
scarred, hypopigmented area of skin. The satisfactory treatment of
many skin conditions awaited the development of new technology and
understanding.
The concept of selective photothermolysis (SPTL) was introduced
by Anderson and Parrish in 1983 and proved to be a turning point in
the laser treatment of skin conditions.4 This theory recognized that
the optimal treatment of a variety of skin disorders was dependent on
optimization of several factors related to the target tissue and the laser
parameters. The target of vascular disorders for instance, was the
hemoglobin inside the vessels. The laser wavelength that was prefer-
entially absorbed in hemoglobin was that wavelength which was
heavily absorbed by hemoglobin and minimally absorbed by other
competing pigments in the tissue. Absorption curves which plot
percent absorption versus wavelength for a single tissue are not linear
but have many peaks and troughs. When the absorption curves for the
various absorbers, termed chromophores, in the target area are overlaid
it is possible to choose optimal wavelengths that are heavily absorbed
by the target (e.g. hemoglobin) and minimally absorbed by other chro-
mophores such as water, xanthophyll, and melanin that would compete
with the hemoglobin to absorb the laser energy. Since nearly all laser–
tissue interaction is thermally induced, the controlled heating of the
target tissue is created by the absorption of the laser energy which is
induced by photons impacting the molecules of the tissue. Vibrational
energies disrupt the molecules and the cells of the tissue target.
As part of the SPTL theory, the concept of thermal relaxation time
was introduced to explain the selective heating of the various tissue
components. In essence, this concept states that the confi nement
of energy (heat) within a structure can be controlled by limiting the
exposure time. This thermal relaxation time is proportional to the size
Summary
1. The concept of selective photothermolysis (SPTL) opened the
door to many successful laser treatments.
2. Recent innovations in the major facial rejuvenation have
involved other wave lengths and other sources of radiant
energy. Examples of these include the intense pulsed light
(IPL) as well as radiant energy sources such as microwave and
radiofrequency excited sources.
3. The carbon dioxide (CO2) laser with a wave length of
10,600 nm in the far infrared portion of the spectrum is capable
of coagulation and ablation of tissue.
4. It is not advisable to treat potentially malignant, pigmented
lesions with the laser.
5. The UltraPulse laser by Coherent Inc. is capable of delivering
5 j/cm2 in a suffi ciently short period of time in order to allow
vaporization of 20 to 30 μ of tissue and residual thermal
damage of 40 to 120 μ depth after two or three passes. Type I
collagen is denatured between 60º and 70ºC, causing it to
shorten.
6. Patients with Fitzpatrick skin type IV and higher are subject to
developing hyperpigmentation, particularly in low latitudes
with heavy sun. For this reason a pre-treatment course of
hydroquinone or other bleaching agent is advisable.
7. When treating the periorbital area, intra-ocular eye shields
should be used and care should be taken to protect the
airway, as well as any source of oxygen, as fi res have resulted.
Smoke evacuation of the laser plume is necessary.
8. A third or subsequent passes may lead to a tan or ‘chamois’
color which is as deep as the treatment should be pursued.
This is in the deep reticular dermis. Further treatment beyond
this point only contributes to the thermal wound and potential
complications without adding to the benefi t.
9. Care should be taken to feather or blend the edges of the laser
treatment in order to avoid abrupt changes from rejuvenated
skin to non-treated skin.
10. In a few patients, typically Fitzpatrick skin types I and II, a
delayed hypopigmentation is sometimes seen. This may not
appear until a year or more following the laser resurfacing
procedure and generally is resistant to treatment.
11. One has to avoid laser resurfacing or dermabrasion within 6
months and preferably 1 year after completion of Accutane
treatment course.

5
LASER FACIAL RESURFACING AND DERMABRASION
44
of the structure, meaning that extremely small tissue components
such as melanosomes have an extremely short thermal relaxation
time, and thus should be treated with extremely short pulse duration.
Typically these nanometer structures would be treated with a nano-
second pulse duration. By limiting the pulse duration the energy is
thus inhibited from spreading to surrounding structures causing
unwanted damage.
Energy loading or heating of target tissue to achieve a specifi c goal
such as disruption of the cells tends to be an all-or-none phenomenon.
Thus, like the high jumper who has to jump 6 feet to clear the bar,
the ablation threshold has to be reached in order to achieve cell disrup-
tion. Below the ablation threshold nonselective heating of the tissue
can occur, which will lead to untoward results. This ablation threshold
is also related to the size of the target structure. The concept of selec-
tive photothermolysis (SPTL) opened the door to many successful laser
treatments.
In SPTL laser treatments, combining the proper wavelength
(selective absorption), the proper pulse duration (energy
confi nement to the target tissue) and the energy level (ablation
threshold) facilitates achieving the desired effect on the target
tissue while minimizing unwanted changes in surrounding tissue.
The result of the SPTL theory led to the development of the fi rst
laser which was specifi cally designed and produced to treat a medical
condition. This was the pulsed dye laser used for treating port-wine
stains. The pulsed dye laser was almost instantly accepted in treating
port-wine stains in very young patients which had hitherto been very
problematic.5 It was not long before new lasers were introduced, having
been designed according to the theory of SPTL for treating a variety of
ailments such as lentigines, tattoos, and skin aging.5,6
Unfortunately the theory of selective photothermolysis is not ideal
in every situation. While it has led to a greater understanding and thus
more effective treatment in most lesions, there are exceptions to this
generalization. For instance, the original fl ash lamp pulsed dye laser
was designed to deliver energy at 577 nm, a peak in the absorption
curve of hemoglobin. Because of the considerable variation in size,
color, and depth of vessels within a port-wine stain, the newer lasers
have emitted wavelengths at 585 to 595 nm. In addition the pulse
duration of the original pulsed dye laser, 450 ns has been extended to
the millisecond range for the same reason. This compromise from the
SPTL theory ideal has led to a much improved outcome while mini-
mizing undesirable side effects.
Recent innovations in the major facial rejuvenation have involved
other wave lengths and other sources of radiant energy. Examples of
these would include the intense pulsed light (IPL) as well as radiant
energy sources such as microwave and radiofrequency excited sources.
The intense pulsed light is a noncoherent light source consisting of a
broad spectrum emission of relatively modest energy. The function of
the microwave and radiofrequency sources is to stimulate collagen
tightening and deposition.
The carbon dioxide (CO2) laser with a wave length of 10,600 nm
in the far infrared portion of the spectrum is capable of coagulation
and ablation of tissue. Thus it is used to remove lesions by evaporation
as well as to thermally stimulate the tissue. The normal response can
therefore be quite varied, depending on a large number of factors such
as tissue hydration as well as the laser parameters such as pulse dura-
tion and energy density. Although the traditional carbon dioxide laser
does not meet any of the parameters of the theory of selective photo-
thermolysis, nevertheless this laser can be designed to achieve satisfac-
tory ablation or cutting while minimizing thermal damage.8
As an ablative instrument the carbon dioxide laser has been used
to remove a variety of benign and malignant lesions.9 These include
verrucae, syringomas, seborrheic keratoses, and other benign lesions.
Actinic keratoses as well as superfi cial basal cell carcinoma can be
removed with these lasers, however, due to a lack of histologic confi r-
mation one can never be certain that the lesion is totally removed by
the laser.10
It is not advisable to treat potentially malignant, pigmented lesions
with laser.
Two conditions which respond extremely well to the carbon dioxide
laser treatment are rhinophyma and actinic cheilitis.11,12 A generic
treatment regimen for these types of lesion would include the use of
a 1 mm handpiece with a focused and defocused beam, usually pulsed
mode with suffi cient energy to evaporate the tissue. Coagulated tissue
may require removal by wiping between passes. Commonly some
minor scarring and hypopigmentation can be seen at the site of
treatment.
LASER SKIN RESURFACING
METHODS
As mentioned above, a variety of chemical and mechanical processes
have been used in the past to rejuvenate the skin. Most of these
required removal of a large portion of the epidermis as well as portions
of the dermis, anticipating that the healing process would rejuvenate
the epidermal elements including pigment, and contraction of the
dermal collagen elements with additional collagen being deposited
during the healing process. It was quickly recognized that the laser
could produce a similar effect. In particular the carbon dioxide laser
was used for treating photoaged skin in the 1980s. Early attempts with
conventional carbon dioxide lasers however led to many unsatisfactory
results, including scarring.13 With the advent of high peak power,
rapidly pulsed or scanned carbon dioxide lasers, this diffi culty was
overcome in accordance with the theory of SPTL, mentioned above.
There are generally two methods of achieving the necessary energy
in a suffi ciently short time frame in order to achieve evaporation/
coagulation with minimal thermal damage. These would be the
extremely short pulsed, high energy lasers as well as the rapidly scanned
continuous-wave laser. The super pulsed carbon dioxide laser was a
step in the direction of satisfactory laser rejuvenation. The UltraPulse
laser by Coherent Inc. was capable of delivering 5 j/cm2 in a suffi ciently
short period of time in order to allow vaporization of 20 to 30 μ of tissue
and residual thermal damage of 40 to 120 μ depth after two or three
passes.14 Most of the laser resurfacing is accomplished with a robotic
scanner which Coherent termed the computerized pattern generator
(CPG). Histologically much of the epithelium is removed. Although
elastin may persist, type I collagen is denatured between 60º and 70ºC,
causing it to shorten.15 Epithelialization was complete in seven days,
but total healing as indicated by an abating of the erythema required
several weeks. In fact, collagen deposition may be seen for many
months following the laser resurfacing. Comparison of laser resurfac-
ing with chemical peel and dermabrasion showed similar healing and
results, with the exception of the phenol peel which required consider-
ably longer to heal. No scarring was observed in this treatment study.16
A competing technology for laser resurfacing is the rapidly scanned
carbon dioxide laser produced by Sharplan called the Silk Touch. This
continuous wave CO2 laser is rapidly scanned across the skin surface,
thus reducing the swell time and therefore the effective pulse duration.
INDICATIONS AND CONTRAINDICATIONS
Although virtually every patient would receive some benefi t from laser
resurfacing, choosing the appropriate patient and preparation for treat-
ment will achieve the optimal results. Most forms of photoaging

Postoperative Care
45
including pigmentation disorders, as well as elastosis and laxity of the
skin, will improve with laser resurfacing, although some lesions will
not totally disappear. A suffi ciently educated patient who has been
informed of the procedure, alternatives and risks, and has a realistic
expectation, is undoubtedly the best candidate. Patients who are prone
to form keloids or aggressive scars are probably not good candidates.
Other skin conditions such as scleroderma, and patients who have
been treated within the past year with isotretinoin, are also probably
not good candidates for laser resurfacing. In addition, patients who are
receiving simultaneous cosmetic surgery such as facelifts are at risk of
developing scars in the portion of skin that is undermined. Although
there are reports describing treatment of the neck and other areas of
the skin with the carbon dioxide laser, these generally require extreme
care, because they are very susceptible to scarring and signifi cant pig-
mentation changes. There are better modalities for treating these areas
including the erbium laser, fractional laser or others.
The ideal areas for laser resurfacing would include the periorbital
area as well as the perioral area. Neither of these areas is particularly
improved by facelift procedures. A conservative approach is generally
recommended, especially in instances where the patient response may
be questionable. It is possible to repeat the laser resurfacing after three
to six months and the results should be additive.
PREOPERATIVE CONSIDERATIONS
Preoperative treatment with tretinoin and possibly skin bleaching
agents for a few weeks is frequently benefi cial. It is generally thought
to be benefi cial to relax the muscles in the laser treatment area with
botulinum toxin, for instance the ‘crow’s feet’ and glabellar frown lines
a few days prior to the laser resurfacing procedure. However, there are
no studies at present that have confi rmed this benefi t of muscle relaxa-
tion prior to the treatment.
Prophylactic treatment with antibiotics and antiviral medications
preoperatively are advised.
As tretinoin preparations seem to speed epithelialization, many
would administer these topically for a few weeks prior to the treat-
ment. Patients with Fitzpatrick skin type IV and higher are subject to
developing hyperpigmentation, particularly in low latitudes with heavy
sun. For this reason a pre-treatment course of hydroquinone or other
bleaching agent is advisable. Many patients unknowingly carry the
herpes simplex virus and thus antiviral medications are almost always
given, especially for treatment in the perioral area. These should be
started a day before treatment, and continued throughout the healing
phase. Antibiotics also are advisable as a number of bacterial infections
have arisen after the treatment. In rare cases, hospitalization for intra-
venous antiviral drugs or antibiotics has been necessary. Although this
is uncommon, the therapist should closely observe the patient in the
post-treatment period. If the patient seems to be progressing nicely,
but takes an abrupt turn for the worse by developing ulcers in a previ-
ously healing area, this is an indication that infection may be starting.
Laser resurfacing requires some form of anesthesia. While other
laser procedures may be adequately performed with only topical anes-
thesia, the carbon dioxide laser treatment usually requires something
more. Nerve blocks for limited resurfacing can be helpful, but if the
patient is undergoing entire face or large areas of resurfacing, a heavy
sedation is probably advisable. Even then, the patient will awaken with
a stinging sensation which may necessitate oral pain medication.
These medications should be given to the patient in the preop visit.
It is also advisable to encourage the patient to minimize chewing,
prepare ice packs or other cold compresses, as well as soaks and other
postoperative necessities. These will be discussed below.
OPERATIVE APPROACH
After adequate anesthesia, it is necessary to protect the patient’s eyes.
Especially when treating the periorbital area, intra-ocular eye shields
should be used. These will necessitate an ophthalmic lubricant and
perhaps an ophthalmic anesthetic. The area to be treated is usually
prepped within antiseptic solution to cleanse the skin, chloroxyenol
3% being an excellent cleanser. It is obvious that at best this is a clean
procedure and not a sterile procedure; nevertheless prepping the skin
is advisable. Care should be taken to protect the airway, as well as
any source of oxygen, as fi res have resulted. Smoke evacuation of the
laser plume is necessary.
If there are specifi c lesions requiring ablation, these should be
treated before generalized resurfacing. This may require a focused
handpiece with either pulsed or continuous-wave energy. The robotic
scanner or pattern generator may then be substituted to accomplish
the generalized resurfacing. Entire aesthetic units of the face should
be resurfaced before moving to other areas. Sometimes, starting on
the forehead is easiest because of the broad fl at surface area. Care
should be taken to preserve the eyebrows and hair line, although these
will certainly grow back during the healing phase. Usually two or
three passes of aggressive resurfacing are necessary for each area.
After the fi rst pass, the desiccated epithelium can be wiped away
with a moist cloth. It has been shown however that vigorous rubbing
of the skin deepens the effect of the laser treatment. Some therapists
would leave the epithelium in place after the fi rst pass as a dressing,
which is acceptable unless one is pursuing an aggressive treatment.
Experience gained from doing laser resurfacing is a valuable asset in
recognizing the depth of treatment. Clinical indicators of the depth of
penetration can be seen following each pass. Generally speaking, after
the fi rst pass when the epithelium has been wiped away the upper
dermis will be pink and moist. Wiping the surface with saline soaked
gauze not only removes the keratin debris but also rehydrates the skin.
The skin area to be resurfaced should be dried prior to proceeding.
When the second pass has been accomplished, this may turn gray and
appear dry. A third or subsequent passes may lead to a tan or ‘chamois’
color which is as deep as the treatment should be pursued. This is in
the deep reticular dermis. Further treatment beyond this point only
contributes to the thermal wound and potential complications without
adding to the benefi t.
Care should be taken to feather or blend the edges of the laser
treatment in order to avoid abrupt changes from rejuvenated skin to
non-treated skin. This is of particular importance when doing only
portions of the face or when resurfacing the face of a patient with a
badly photoaged neck. The feathering can be accomplished by decreas-
ing the energy, the density of the pulses, or by making fewer passes.
Specifi c areas of need such as isolated perioral wrinkles, the lateral
commissure lines, etc. may be addressed with an additional pass,
usually with a single spot handpiece. At the conclusion of the resurfac-
ing the skin should be cleansed again with a gentle antiseptic and
rinsed.
POSTOPERATIVE CARE
The postop dressing or treatment is probably one of the more contro-
versial issues of laser resurfacing. A variety of treatment protocols have
been promoted over the years. In general they can be divided into two
categories, open treatment which usually means topical ointment or
cream, and a closed treatment which is frequently a membrane or
mask. The open treatment will frequently consist of periodic soaks
and or gentle cleansings followed by application of a topical antibiotic
or burn cream/ointment. This should be done several times a day.
Crusty areas can be soaked with cool compresses consisting of ¼%
acetic acid in distilled water or saline. After the crusting and weeping
has abated, the patient can start using a gentle moisturizer cream. The
closed method consists of application of a mask or membrane in the
immediate postop period. The skin is usually dried, following which
the material is applied. This should be left in place for approximately
5 days, although some therapists advocate changing it the day follow-
ing the resurfacing. The reasoning behind changing the mask is to
detect any infections early.

5
LASER FACIAL RESURFACING AND DERMABRASION
46
A recent innovation is a silicone sealant which is applied immedi-
ately after the procedure. This is a two-part, epoxy-like, clear, fl exible
silicone material (Innovation Alley, Lyndhurst, OH). It is diffi cult to
get this material to adhere to the skin, and the patient is advised to
minimize movement such as talking and chewing. Frequently it will
separate in the immediate postop period. Nevertheless, it is left in
place for approximately 5 days unless it develops a green drainage
underneath, possibly indicating infection, in which case it is removed
and soaks are started with appropriate therapy. It is also sometimes
removed around the mouth if food collects under the mask. The fi fth
day the patient is advised to sit in the shower soaking the face. The
mask can be elevated from the skin with a cotton tip applicator lubri-
cated with antibiotic ointment. Portions of the mask which are strongly
adherent are left in place until they spontaneously loosen and fall
off.
The results are often gratifying, especially when the laser resurfac-
ing is combined with facial rejuvenation (Fig. 5.1A&B). In patients
who undergo facial rhytidectomy at the time of facial laser resurfacing,
the laser energy level should be reduced in the undermined area to
minimize the potential for deeper thermal damage.22,23 The fl uence
will be set at a lower level on the lateral portion of the face (settings
such as a density of 3, 60 watts, and 100 mJ). The density will be
increased as the laser is advanced medially. It is also be safer to
minimize the undermining of the skin during the rhytidectomy.
COMPLICATIONS AND SEQUELAE
As previously mentioned, pigmentation changes are the most common
sequelae following a laser resurfacing. Hyperpigmentation is frequently
seen in Fitzpatrick skin types III and greater, especially during the
summer in the southern latitudes. This is frequently self-limiting, but
should be treated with tretinoin and bleaching agents. In a few patients,
typically Fitzpatrick skin types I and II, a delayed hypopigmentation
is sometimes seen.13–17 This may not appear until a year or more
following the laser resurfacing procedure and generally is resistant to
treatment. Inclusion cysts or milia are frequently seen, particularly in
the periorbital area. These will usually spontaneously open, but some-
times have to be pricked. Infection, as indicated by ulcers or a worsen-
ing of the infl ammation, may appear up to a week or more following
the resurfacing procedure, and should be aggressively treated with
cleansing, soaks and antibiotics in order to avoid scarring. Staphylo-
coccus, Pseudomonas, Candida, and herpes simplex are among the
more common pathogens. Conjunctivitis may result from the intra-
ocular eye shields or topical ointments applied around the eye. In
rare instances, these may require treatment with ophthalmic anti-
infl ammatory drugs. Ectropion can result from aggressive resurfacing
of the lower eyelid in susceptible individuals. Rarely, scarring results
from overly aggressive laser treatment, secondary infections, or the
patient traumatizing the skin. Pruritus is common in the postop period
and should be treated with topical creams or antihistamines.
ALTERNATIVE APPLICATIONS/
TECHNOLOGIES
Alternative technologies which have arisen to replace or supplement
the carbon dioxide laser will be mentioned below. Most of these have
a reduced healing time and sequelae, but they also have reduced
results. Patients’ expectations need to be tempered in this regard. The
carbon dioxide laser will remain a useful tool in the armamentarium
of the plastic surgeon for many years.
In patients who need a combination of lower lid and periorbital
laser resurfacing, it is more advisable to offer full-face laser resurfacing.
This will facilitate the patient’s recovery by avoiding early postopera-
tive and long-term discoloration in this region and provide more
uniform long-term color improvement.
LASER BLEPHAROPLASTY
I have been using the laser in blepharoplasty for over 12 years and
have done approximately 1000 cases with it.17 Almost all of my bleph-
aroplasties involve carbon dioxide laser for excision, transconjunctival
fat removal, and laser resurfacing of the upper and lower eyelids.
Although this lengthens the healing time, there are many advantages
to it. It is simpler, safer, and faster. The technique will be described
below.
Fig. 5.1 A&B, Pre and postoperative result,
patient had laser resurfacing combined with
facial rejuvenation.
A
B

47
Methods Other than Co2 Laser Technique
OPERATIVE APPROACH
The concept of laser blepharoplasty was introduced by Baker in
1992.18 Roberts collected a series of 907 laser blepharoplasties with
a 95% satisfaction rate in wrinkle reduction and a 0.3% ectropion
incidence.19 The advantages were pointed out that this procedure was
faster, safer, with less bruising than conventional blepharoplasty. The
disadvantages include the cost of the equipment, a learning curve and
a longer healing time. The exceptional patient with considerable fes-
tooning or marked laxity of the lower lid may not be a candidate for
transconjunctival blepharoplasty, but these patients may still be can-
didates for the standard transcutaneous lower lid blepharoplasty with
a subciliary incision made by the laser. Seckel, using the CO2 laser,
was able to tighten the orbicularis oculi muscle through the transcon-
junctival approach.20
The technique involved is very similar to conventional transcon-
junctival blepharoplasty. Selection of the patient involves screening
for other eye conditions as well as laxity of the lower lid with a snap
test. Appropriate tightening of the lax lower eyelid can be done in
conjunction with the laser procedure. Based on the orbital anatomy,
patients have to have realistic expectations as to the fi nal result.
Although removal of the ROOF tissue can be done easily with the
laser, it is not possible to give a ‘deep set’ result in a patient with a
shallow orbit and a full upper lid. Other adjunctive procedures for the
lower eyelid could involve transconjunctival fat transposition utilizing
the laser in the patient with a deep tear trough.
Under general anesthesia or intravenous sedation the face is
prepped and draped. Local anesthesia is injected into the upper and
lower eyelids including transconjunctival injection. Eye shields are
placed to protect the eye. Laser resurfacing of the eyelid and perior-
bital skin is usually done prior to the blepharoplasty. Eyelid skin which
is thinner shrinks much more than does other facial skin. It is not
uncommon to see a 20–30% shrinkage of the eyelid skin which is
frequently enough to avoid skin excision of the upper lid. Some of this
shrinkage is reversible, perhaps 10%, for a few days following the
treatment. Anticipating this relaxation of the skin tension, it is safe to
tighten the upper eyelid skin somewhat more than the fi nal desired
result. Usually it is suffi cient to have a small gap in the palpebral
fi ssure of perhaps 2 to 3 mm, which will then allow adequate eye-
closure as the healing proceeds.
Having completed the resurfacing of the periorbital skin, the lower
transconjunctival incision is made by retracting the lower lid margin
and incising the conjunctiva approximately 6–8 mm inside the lash
line. This was carried from one end of the eyelid to the other. With
proper retraction, the bulging fat can be seen through the septum of
the lower eyelid. The lower eyelid retractors can be gently teased from
the wound. Incising the septum with the laser allows the bulging fat
to protrude. The fat can then be grasped with the forceps and tran-
sected with the laser handpiece and a slightly defocused mode. Only
that amount of fat which ‘volunteers’ should be excised, in order to
avoid a hollow-eyed appearance. Defocusing the laser beam will allow
coagulation of any vessels which can be seen as the fat is excised.
Care should be taken to avoid injuring the inferior oblique muscle.
Residual herniated fat which should be excised can be detected by
allowing the lower eyelid to relapse into its normal position. Slight
pressure on the globe will then reveal any bulging fat. After the fat is
adequately excised, the eyelid is allowed to resume its normal position.
No sutures are placed in the conjunctival incision.
Having completed the lower eyelid portion attention is turned to
the upper eyelid. The amount of skin to be excised from the upper
eyelid can be estimated by grasping the excess skin with the forceps
and marking it with a skin marking pen. Utilizing an UltraPulse mode
to incise the skin will minimize thermal damage at the incision site.
Deeper tissue excision can be accomplished with a continuous wave
beam. Portions of the orbicularis ocular muscle can be excised as part
of the skin muscle island. The septum is then opened with the laser
following which the excess fat of the upper eyelid is excised. ROOF
fat can be excised with the laser at this time. Care should be taken to
avoid the supraorbital nerve and the branch of the lachrymal artery
in the lateral portion of the ROOF fat. Should the artery be injured,
it usually can be coagulated with the laser. Only on a very rare occa-
sion is cautery necessary during a blepharoplasty with the laser. Once
the fat is excised, the upper eyelid incision can be closed in the usual
manner. The incision can be closed with sutures. It has been recom-
mended to leave sutures closing a laser incision a day or two longer
to achieve greater wound tensile strength which might be retarded by
the laser. This has not been my experience.
Postoperative care is the same as with conventional blepharo-
plasty, except that the laser resurfaced area should be treated as noted
earlier with appropriate creams or mask dressings.
METHODS OTHER THAN CO2
LASER TECHNIQUE
Erbium laser
Any discussion of laser skin rejuvenation would not be complete
without considering other modalities than the carbon dioxide laser.
Because of the prolonged healing as well as other sequelae from carbon
dioxide laser treatment, attempts were made to develop alternative
means of skin rejuvenation. The erbium laser, wavelength 2.94 μ, is
also heavily absorbed by water. Early versions of this laser were pulsed
rapidly and became useful for ablating lesions. Because there was very
little thermal damage to the tissue there was also almost no coagula-
tion and consequently bleeding was somewhat of a problem. In addi-
tion, the tissue did not seem to shrink so readily with this version of
the erbium laser. A more recent erbium laser has introduced the
concept of longer pulses. In fact the Sciton erbium laser combines a
long-pulsed erbium as well as a short-pulsed erbium laser in one
instrument. It was possible then to achieve both ablation and coagula-
tion with the erbium laser. This has become useful in treating not only
the face, but other areas including the neck and chest areas. By variably
mixing the pulses of these two erbium lasers it is possible to achieve
very thin layers of ablation or deeper layers of thermal coagulation
comparable to the carbon dioxide laser. Multiple treatments spaced by
a few weeks with this particular laser can achieve cumulative effects
without having a single long period of recovery similar to the carbon
dioxide laser.
Intense pulsed light
Other devices have been devised to assist in improving the skin appear-
ance. More recently a noncoherent light source, the (IPL) has been
used to treat a variety of conditions. In addition to being useful for
treating hair removal, it can be used for reducing pigmentation as well
as fi ne vascular lesions. There is a very slight improvement in texture
which has been termed photo facial treatment. None of these lasers
however have measured up to the improvement of the carbon dioxide
laser.
Fractionated laser
A very recent development in laser skin rejuvenation is the fraction-
ated laser. This is an entirely new concept and laser treatment. Lasers
in the past have been generally a surface phenomenon in which the
entire surface of an area is treated. This means that frequently there
is choroids elation or even ablation of the epidermal layer as well as
deeper fracture on the dermal layer secondary to heat transfer. The
fractionated laser however honeycombs the skin with individual pulses
of energy, penetrating much more deeply. Pulse effects as deep as
1.5 mm can be achieved with this fractionated laser, depending on the
wavelength and other factors. Only a small percentage, perhaps 15–
25% of the surface area, is treated at any one treatment because of the
effect. These treatments then are administered every few weeks,
perhaps monthly. The repetitive nature, however, generates new

5
LASER FACIAL RESURFACING AND DERMABRASION
48
collagen as well as removing hyperpigmentation and other surface
phenomena. Because a large percentage of the surface goes untreated
with each treatment, there is essentially no crusting or weeping as with
the other resurfacing lasers. There usually is some mild pigmentation
change as well as infl ammation which will disappear within a few days
and generally is not incapacitating. As with these other lesser skin
rejuvenation lasers anesthesia requirements are usually less than with
the carbon dioxide laser. The technology of fractionated laser resurfac-
ing is very much in its infancy, and has created somewhat of a para-
digm shift in the science of laser skin rejuvenation. New protocols are
currently under development, as well as refi nements in technology
which will extend the scope of this laser energy.
Dermabrasion
With the advent of laser, the use of dermabrasion has become extremely
limited. There are 2 occasions where dermabrasion delivers unmatched
outcomes. One is the deep circumoral lines and the second is deep
acne scars.
Technique: Under local, deep sedation or general anesthesia the
target site is infi ltrated with Lidocaine containing 1:000,000 epineph-
rine. The area is then painted with brilliant green and sprayed with
etyhlchloride to freeze the skin to facilitate planning of the skin. The
brilliant green paint aids detection of deep lines around the mouth and
the depth of the acne scars. This is a powerful technique and can result
in scarring if the dermabrasion is done too aggressively or the patient
has consumed Accutane for treatment of acne. It is crucial to ensure
that the acne is under control before proceeding with dermabrasion.
THE FUTURE
It is fair to say that the laser skin rejuvenation is here to stay. Although
we have come a long way in utilizing this new technology, there is still
much to be learned. For instance, virtually all of the laser effects that
have been utilized for skin rejuvenation in the past have been ther-
mally mediated. That is the laser energy is absorbed by tissue which
then heats it, thereby creating both desirable as well as undesirable
effects. It has been termed a ‘controlled burn’. It has long been known
that subcellular effects can regulate certain cell processes without
heating the tissue. An example of this is blue light therapy for neona-
tal jaundice. The science of ‘low-power lasers’ which alter metabolic
processes within the cell without physically damaging it, is emerging.
In addition, new wavelengths as well as pulsing technologies will be
developed to the extent that the laser can be fi nely tuned to treat
specifi c entities. Side effects or sequelae will be minimized. Finally,
the laser can be used in conjunction with topical medications to
enhance their effects. This may be accomplished by increasing the
penetration of the medication, activating the medication by the light
interaction, or synergistically altering the tissue.
Many excellent articles and textbooks have been published, exhaus-
tively discussing the concepts which have been superfi cially treated
here. An example of these would be Lasers in Cutaneous and Aesthetic
Surgery edited by Arndt, Dover and Olbricht.21 Clinicians wanting to
become involved in laser medicine and keep abreast of the latest devel-
opments in this growing fi eld would be well advised to attend the
annual meeting of the American Society for Laser Medicine and Surgery
().
CONCLUSION
In summary, carbon dioxide laser skin resurfacing remains the gold
standard for skin rejuvenation. There have been many new technolo-
gies which have arisen to replace this, but none have measured up.
The greatest problem with resurfacing is the healing associated with
crusting and redness. This is because healing involves regeneration of
not only the epithelium, but a large portion of the dermis. This of
course involves complex metabolic pathways as well as increased cir-
culation, and takes many months to complete. Patients should not be
concerned if their result is not seen in the fi rst few weeks following
resurfacing. On occasion, it is wise to supplement the initial treatment
with follow-up touch-ups, which may be of a lesser degree.
REFERENCES
1. Maiman TH. Stimulated optical radiation in ruby. Nature 1960;
187:493.
2. Patel KNC. Continuous-wave laser action on vibrational-rotational
transitions of CO2. Phys Rev 1964; 136A:1187.
3. Goldman L, Rockwell JR Jr. Laser reaction in living tissue. In: Lasers in
medicine. New York: Gordon and Breach; 1971:163–185.
4. Anderson RR, Parrish JA. Selective photothermolysis: precise
microsurgery by selective absorption of pulsed radiation. Science 1983;
220:524–527.
5. Tan OT, Sherwood K, Gilcrest BA. Treatment of children with port-
wine stains using the fl ashlamp-pulsed tunable dye laser. N Engl J Med
1989; 320:416–420.
6. Goldberg DJ. Treatment of pigmented and vascular lesions of the skin
with the Q-switched Nd:YAG laser. Laser Surg Med 1993; 13(suppl
5):55.
7. Taylor CR, Gange RW, Dover JS, et al. Treatment of tattoos by Ruby
laser: a dose–response study. Arch Dermatol 1990; 126:893–899.
8. Walsh JT, Flotte TG, Anderson RR, Deutsch TF. Pulsed CO2 laser tissue
ablation: effect of tissue type and pulse duration on thermal damage.
Lasers Surg Med 1988; 8:108–118.
9. Ohbricht SO. Use of the carbon dioxide laser in dermatologic surgery: a
clinically relevant update for 1993. J Dermatol Surg Oncol 1993;
19:367.
10. Lanzafame RJ, Rogers DW, Naim JO, et al. Reduction of local tumor
recurrence by excision with the CO2 laser. Lasers Surg Med 1986;
6:439–441.
11. Greenbaum SS, Krull EA, Watnick K. Comparison of CO2 laser and
electrosurgery in the treatment of rhinophyma. J Am Acad Dermatol
1988: 18:363–368.
12. Whitaker DC. Microscopically proven cure of actinic cheilitis by CO2
laser. Lasers Surg Med 1987; 7:520–523.
13. David LM, Lask GP, Glassberg E, et al. Laser abrasion for cosmetic and
medical treatment of facial actinic damage. Cutis 1980; 43:583–587.
14. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed carbon
dioxide laser resurfacing of photoaged facial skin. Arch Dermatol 1996;
132:469–471.
15. Brugmans MJP, Kemper J, Gijsbers GHM, et al. Temperature response
of biological materials to pulsed non-ablative CO2 laser irradiation.
Lasers Surg Med 1991; 11:587–594.
16. Fitzpatrick RE, Tope WD, Goldman ME, Satur NM. Pulsed carbon
dioxide laser, trichloroacetic acid, Baker–Gordon phenol, and
dermabrasion: a comparative clinical and histologic study of cutaneous
resurfacing in a porcine model. Arch Dermatol 1996; 132:469–471.
17. Gregory RO. Laser skin rejuvenation. Presented at the annual meeting
of the American Society of Plastic Surgeons, 1997.
18. Baker SS. Carbon dioxide laser upper lid blepharoplasty. Am J Cosmet
Surg 1992; 9:141.
19. Roberts TL. Laser blepharoplasty and laser resurfacing of the periorbital
area. Clin Plast Surg 1998; 25:95–108.
20. Seckel BR. Management of orbicularis hypertrophy with the CO2 laser.
Presented at the annual meeting of the American Society for Aesthetic
Plastic Surgery, New York, May 3–7, 1997.
21. Arndt KA, Dover JS, Olbricht SM, eds. Lasers in cutaneous and
aesthetic surgery. Philadelphia: Lippincott-Raven; 1997.
22. Wald D, Michelow BJ, Guyuron B, Gibb A. Fire hazards and CO2 laser
resurfacing. Plast Reconstr Surg 1998; 101(1):185–188.
23. Guyuron B, Michelow B, Schmelzer R, Thomas T, Ellison M. Delayed
healing of rhytidectomy fl ap resurfaced with CO2 laser. Plast Reconstr
Surg 1998; 101(3):816–819.

49
CHAPTER 6
Management of Alopecia
Jack Fisher
IMPORTANCE OF TYPE OF GRAFT AND
DESIGN OF A NATURAL HAIRLINE
A discussion of transplantation usually refers to micro or mini grafts.23
Current nomenclature uses the term follicular grafts,24–26 which are
clusters of one to three hairs that emerge from the scalp as a unit.
Grafts often used to contain 10, 20, and even 40 hairs per each graft,
so creating an unnatural appearance (Fig. 6.1A&B), and the hairline
was often poorly designed. A successful and aesthetically pleasing hair
restoration is as demanding as any other aesthetic facial procedure.
The frontotemporal recession is an important component of creat-
ing a mature natural hairline in males.27 This anatomic landmark is
formed by the junction of two lines, consisting of the frontal and
temporal hairlines, which converge in an acute angle. It is critical in
creating a natural-appearing male hair transplant to maintain this
normal frontotemporal recession. In hair restorations where the
frontotemporal angle is not created, the patient frequently has an un -
natural result, creating either a feminine or immature male hairline.
Other important components of a natural hairline include the
transition anteriorly from fi ne to thicker hair with increasing density,
and a signifi cant degree of irregularity along the hairline margin.
Normal hairlines should not appear straight and regular. Perfectly
straight hairlines are characteristic of unnatural-appearing hair trans-
plants. Unsatisfactory results with hair transplants usually demon-
strate a fundamental lack of knowledge of these critical points required
to create a natural-appearing hairline.28
INDICATIONS
●
Primary alopecia:
●
genetic hair loss (85% are men)
●
Previous hair transplantation:
●
to remedy unnatural large plug grafts
●
to improve hairline
●
Secondary or traumatic alopecia:
●
after procedures such as facelifts or forehead lifts
Most patients seeking hair restoration due to genetic hair loss are
male. Approximately 15% of patients who have primary alopecia in
my current practice are women and demonstrate typical genetic pattern
hair loss. The other main group of patients have had previous hair
transplantation with poor results;29–31 these patients are more diffi cult
to treat and fall into two groups:
● those who have been treated with unnatural large plug grafts;
● those in whom the hairline was poorly designed at the time of the
original procedure (they are the most diffi cult to treat).
Summary
1. A follicular graft refers to the transfer of clusters of one to
three hair follicles emerging as a unit.
2. It is important to maintain the acute ‘frontotemporal’ angle on
a male.
3. The natural hairline is not straight and follicles should be
placed in an irregular fashion.
4. The natural hair is inclined forward in the frontal area, caudally
and posteriorly in the temporal area, and posteriorly in the
occipital area.
5. Male pattern baldness is the consequence of testosterone
conversion to dihydrotestosterone (DHT) through an enzymatic
action mediated by 5-alpha reductase, which targets the hair
follicle.
6. The number of hair follicles in the donor area is 150–400/cm2.
7. In most patients, the frontal hairline should be 8–10 cm
cephalad to the glabella.
8. The harvested follicle unit should include the shaft, the follicle,
and a small amount of fat.
9. The most common complication of the hair transplant is the
development of inclusion cysts, which are commonly related
to placement of the hair follicle too deeply.
10. The best indication for the excision and scalp advancement
technique is to eliminate the site of a previously placed poor
hair transplant.
INTRODUCTION
With current techniques, hair transplants can look totally natural and
without signs that a procedure has been performed.1 Hair transplanta-
tion has, however, a poor reputation because so many patients in the
past have had less than acceptable results.2 Scalp reconstruction with
fl aps and excisions and the use of tissue expanders for male patients
with genetic hair loss are now rarely used except in the management
of diffi cult secondary cases.3–20
Improvements in results in the past 15 years are due to the work
of many in the fi eld, and in particular, Dr Carlos Uebel from Brazil,21,22
who was one of the fi rst to popularize the use of small natural-
appearing grafts in large numbers performed at a single session. Today,
rather than transferring a few hundred grafts at each session requiring
numerous procedures, it is not unusual to transfer 1500, 2000, and
even 3000 grafts in a single session.

6
MANAGEMENT OF ALOPECIA
50
Most women with hair loss may not be good candidates for hair
transplants and may suffer from metabolic autoimmune disorders
One of the main indications in women is secondary or traumatic
alopecia after procedures such as facelifts or forehead lifts. In these
patients hair loss results from excessive tension or undermining of the
hair follicle.32 Such women are ideal for hair transplantation because
scars or abnormally high hairlines can be readily corrected. The most
common area needing hair transplantation is probably the temporal
and preauricular area.
MALE ANDROGENIC ALOPECIA
In most men, hair loss is related to androgenic alopecia. This form of
alopecia is a response to androgens, which reduce the rate of hair
growth as well as the diameter of the hair shaft.33 Also, the growth
phase of hair referred to as anagen is shortened. It is believed that
testosterone is converted by the enzyme 5-alpha reductase to dihy-
drotestosterone (DHT),34 which targets the hair and causes genetic hair
loss. In most men with hair loss, the hair follicles in the frontal and
crown regions appear to be most susceptible to DHT, leading to andro-
genic alopecia. In most patients, 30–50% of the hair has been lost
before it becomes apparent. As the average normal head has 100 000–
150 000 hairs, a signifi cant amount of hair loss is necessary before it
becomes apparent.
FEMALE HAIR LOSS
Female hair loss is frequently more diffuse, and many women are not
good candidates for hair restoration because of a lack of good donor
hair.35 However, a subgroup of women present with hair loss similar
to androgenic alopecia36 and usually have good hair density in the
lateral and posterior areas of the scalp. Many of these women have a
history compatible with that seen in male pattern hair loss and report
many family members with either thin hair or balding scalps.
Unlike male pattern hair loss of the genetic form, women with
genetic hair loss tend to maintain a low frontal hairline with an
anterior margin of hair (Fig. 6.2A&B). This is very different from men
where there is progressive elevation of the frontal hairline and increas-
ing temporal recession over time. Women, however, frequently main-
tain a frontal hairline for life, and this factor requires hair
transplantation to be performed, beginning from the frontal hairline
and continuing posteriorly to fi ll in the defect.
Most women who present with hair loss are not candidates for hair
transplantation because the hair loss is usually caused by a metabolic
disorder, autoimmune disease or other factors.
PATIENT SELECTION
One factor that makes hair restoration unique compared to other areas
of aesthetic surgery is the unpredictability of future hair loss. Evalua-
tion and prognosis of male pattern hair loss can be diffi cult. It is
critical to take into consideration not only the family history, but also
the patient’s age. Patients in their early 20s often have a signifi cant
amount of unpredictable future hair loss, and it is important to explain
the possible effects of hair transplantation at too early an age:
● young patients often have the desire to create juvenile hairlines,
which will be inappropriate as they age and cause problems;
● patients who have hair transplants too young, especially if the
temporal recession is fi lled in, may be destined to wearing a hair
piece as a result of progressive hair loss.
Fig. 6.1 Unsatisfactory hair transplants.
A, Patient who had hair transplantation
20 years previously. The large plug grafts
and hairline that is too straight create an
unnatural result. B, Due to the natural
progression of hair loss, the plug grafts
placed 20 years previously are several
centimeters in front of the receding hairline.
A
B
A
B
Fig. 6.2 Female genetic-pattern hair loss:
appearances before and after transplantation.
A, Pre-transplantation. typical female hair
loss pattern in 47-year woman, demonstrating
maintenance of a frontal hairline fringe.
B, Appearance 1 year after second session of
transplantation with a total of 2000 grafts.
The grafting began at the anterior hairline.

51
Preoperative History and Considerations
As in all areas of aesthetic surgery, realistic expectations of what can
be accomplished with hair restoration are important.
Hair transplants to the existing hairline at a young age may cause
signifi cant undesirable patterns after the patient loses more hair at
a later age.
Because hair loss is progressive, it is often better to wait until the
third and fourth decades before considering transplantation. Also, as
a young patient ages, there may also be recession of the hairline.
Another factor that must be carefully considered is hair transplan-
tation of the occipital region. If the patient is relatively young or
destined to have signifi cant hair loss in the occipital area, overtrans-
plantation centrally in the occipital area can lead to a bizarre appear-
ance as he ages. Typically, there is hair loss in a coronal pattern around
the area of transplantation, which leads to a halo of baldness. This
will require further procedures to maintain a reasonable appearance.
It is therefore important to evaluate the patient’s future hair loss based
upon their hair characteristic and family history.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
Hair normally passes through three cycles (Fig. 6.3A&B).37
● Anagen is the growth phase. During this phase the follicular cells
are actively reproducing. This growth phase lasts 2–5 years, and
most of the hair is in this active phase.
● Catagen is the regression phase and lasts 2–3 weeks.
● Telogen is the fi nal phase of hair growth and lasts approximately
3–4 months. During this phase, follicles are inactive and hair
growth stops.
After the hair is transplanted, it goes into a telogenic phase for a
period of 3–4 months. The patient should be informed about this.
Approximately 10% of hair is in the telogen phase at any one
period. Therefore, most individuals with 100 000 or more hairs tend
not to notice hair loss during the telogen phase. However, in the
patient who has already lost a signifi cant amount of hair, the telogen
phase may be far more important.
After a hair transplant the hair transferred goes into a 3–4-month
resting phase. It is important to inform patients that it will therefore
take months to see the fi nal result because of the delayed hair growth
after transplantation.
CLASSIFICATION OF ALOPECIA
The major classifi cation of alopecia used by most physicians today is
the Norwood classifi cation, which is a modifi cation of Hamilton’s
original description (Fig. 6.4).38 There are many other classifi cations,
but most divide baldness into six to seven primary groups, with sub-
groups included.39,40 These classifi cations can be useful, but most
patients do not fi t into a single specifi c classifi cation or hair loss type
exactly.
Ludwig has described a system for classifying androgenic alopecia
in women.41
All techniques that attempt to classify hair loss have limitations
and can only be used as guidelines, but can be useful tools in planning
a hair restoration.
HAIR TYPE
An important component of the initial patient evaluation includes an
assessment of hair type. This includes the color, texture, density, and
curling or straightness of the hair.
● The hair shafts are often thinner in fair skinned individuals and
thicker in Asians and Africans. Thin hair gives less coverage,
whereas thick hair gives greater coverage.
● Wavy hair has an oval appearance on cross-section under the
microscope, whereas straight hair demonstrates a round appear-
ance. In patients with curly hair, it is possible to get greater density
or the appearance of greater density with fewer transplants because
curly hair gives greater coverage of the scalp. Straight hair does not
create as much density for coverage of the scalp.
● Hair density in a patient with male pattern or androgenic alopecia
rapidly drops off with age and hair loss. Transplantation of large
unnatural grafts containing 20–60 hairs looks unnatural in these
patients because hair normally emerges from a single orifi ce as one
to three hairs, and occasionally, four. A graft that has been trans-
planted with 20–60 hairs violates the basic principal of normal hair
growth.
● The angle at which the hair exits the normal scalp varies. In the
normal frontal area, the hair is angled slightly forward, while in
the temporal area, it is angled slightly downward and backward,
and in the posterior scalp, it is angled downward toward the neck.
If the hair is put in at an unnatural angle, it will be obvious.
● In people with light hair and light scalps, or people with dark hair
and dark scalps, a relatively moderate amount of hair in these
patients may give adequate coverage. However, more hair may need
to be transplanted to give a satisfactory result in patients who have
dark hair with light scalps or patients with light hair and dark
scalps, because of the greater color contrast. Variegated hair color,
such as salt and pepper, gives a slightly more natural result because
it creates irregularity based upon color variation (Fig. 6.5A&B).
The less the color contrast between the hair and skin, the better
the results.
GOALS OF TRANSPLANTATION
On initial consultation, certain variables must be considered to assist
the patient in making the appropriate decision and to set realistic goals
concerning hair transplantation.
● Family history is useful, especially on the maternal side, but hair
patterns are determined by a multifactorial inheritance. A strong
history of hair loss among brothers, uncles, and grandfathers pro-
vides some ability to predict future hair loss.
● Another key factor is the availability of the donor hair. Patients
may have only minimal hair loss but if they have little donor hair,
the procedure and the fi nal results can be limited. On the other
hand, a patient with extensive hair loss who has extremely thick
donor hair may be an excellent candidate for hair transplantation.
The amount of hair in the donor area is quite variable and often
ranges from 150 to 400 hairs/cm2. The patient’s with greater hair
density are more able to have future multiple procedures to con-
tinue transplantation as hair loss progresses. However, a conserva-
tive approach is necessary for the patient with limited donor hair,
especially if the patient is relatively young.
● One of the most diffi cult areas to deal with is the occipital region
if a halo of alopecia develops around previous transplants. Many
therefore prefer not to be aggressive in transplanting younger

6
MANAGEMENT OF ALOPECIA
52
patients in the occipital area until the area of hair loss is well
demarcated or established. One method to reduce problems is to
transplant only in the anterior area of occipital hair loss to limit
the number of grafts required. Patients may elect to fi ll in the
occipital area provided they understand the signifi cance of this
decision and that it will lead to the need for further grafting as hair
loss progresses.
Hairline
It is important that the patient understands that the goal is to create
a hairline that is harmonious with their facial characteristics and to
create balance. One term that is frequently used is facial framing (Fig.
6.6A&B). This creates a more balanced appearance in the anatomic
components of the face. Typically, the face can be divided into equal
thirds, but in a patient who has a receding hairline, the eyes appear to
have a more centralized appearance; creating a lower hairline produces
better balance by framing the facial characteristics.
Patients in their 20s and 30s often dislike their bald appearance,
not only because of the hair loss but also because they often look years
or decades older than their actual age. Framing of the face improves
the appearance, making the individual appear years younger.
Taking a family history and explaining to the patient what can be
realistically accomplished with hair transplantation is important in
achieving a successful outcome.
During the consultation, it is useful to draw the proposed trans-
plantation pattern on the patient’s scalp and to allow the patient to
see it (i.e. the most appropriate hairline) in a mirror. Patients given a
marking pen will frequently draw the hairline in a relatively low posi-
tion, which is usually not appropriate because a relatively youthful
hairline now may lead to problems and dissatisfaction later. A dem-
onstration of the Norwood classifi cation allows patients to understand
the normal nature of androgenic alopecia as hair recedes. A natural
hairline will age appropriately with the patient as temporal recession
The cycles of hair growth
A
Club hair
Hair matrix forming
new hair
Secondary
germ cells
Dermal
papilla
Anagen active growth
phase (2−6 years)
Catagen involution phase
(1−2 weeks)
Telogen resting phase
(3−6 months)
Return to anagen
Anatomy of human hair
B
Erector pili muscle
Sebaceous gland
Hair shaft
Follicle
Fig. 6.3 Hair. A, Cycles of growth.
B, Anatomy.

53
Preoperative History and Considerations
I
II
III
III Vertex
IV
V
VI
VII
Norwood classification of hair loss
Fig. 6.4 Norwood classifi cation of hair loss.
and elevation in the frontal hairline progresses. For most patients the
frontal hairline should be at least 8–10 cm above the glabella (Fig.
6.7A&B).
Appropriate angulation
It is critical when the hairs are transplanted to create the appropriate
angulation in the different areas of the scalp. The frontal area should
have slight anterior angulation, while the temporal area should have
a slightly downward and posterior appearance. Creating angulation in
any area of the hair restoration that is too oblique can produce an
unnatural or inappropriate appearance.
The angulation of the grafts is extremely important in achieving a
natural outcome.

6
MANAGEMENT OF ALOPECIA
54
A
B
Fig. 6.6 Appearances before and after
transplantation. A, A high forehead with
temporal recession distorts the facial
components, creating the illusion that the
eyes are centrally located on the vertical
plane. B, Transplantation of the anterior
hairline and temporal areas create enhanced
facial framing. Although the hairline has been
lowered only 15 mm, there is a better
aesthetic balance.
A
B
Fig. 6.7 Appearances before and after
transplantation. A, Patient has Norwood III
hair loss pattern. B, Result after 3200
follicular grafts in two sessions. The new
hairline is 9 cm above the glabella. Also, an
acute frontotemporal angle is maintained.
A
B
Fig. 6.5 Appearances before and after
transplantation. A, 52-year-old with salt and
pepper colored hair (Norwood classifi cation
V). B, Result after 2550 grafts. The variegated
color of the hair enhances the naturalness of
the result. The greater the amount of gray
hair, the less the color contrast between hair
and scalp.

Operative Approach
55
SPECIAL CASES
Isolated frontal forelock
An isolated frontal forelock is a characteristic hair pattern and in these
patients connecting a frontal forelock with hair posteriorly can create
an improvement with only a moderate amount of transplantation
(Fig. 6.8A&B).
Norwood 6 or Norwood 7 hair loss
Because of the extent of the hair loss, it can be diffi cult to satisfy the
expectations of patients classifi ed as Norwood 6 or Norwood 7, even
in those with a signifi cant amount of donor hair.
PREVENTION OF COMPLICATIONS
Patients are advised to avoid anything that could increase bleeding
during the procedure, for example not to take aspirin or any aspirin-
related products for at least 2 weeks prior to the surgery. Also, patients
with hypertension must be managed appropriately to reduce a hyper-
tensive phase during the procedure, which can complicate the insertion
of the graft or lead to a hematoma in the donor site.
OPERATIVE APPROACH
SURGICAL ANATOMY
The concept of donor or recipient site dominance introduced by Orent-
rich in 1959 is important for successful hair transplantation. Donor
dominant grafts maintain the characteristics of the donor site in the
new recipient site. For example hair taken from the back of the scalp
maintains its characteristics when it is moved to the frontal area and
will continue to be relatively permanent hair in its new site because it
is rare for men to lose hair in the very posterior scalp area.
Initially, Orentrich used large round punch grafts 3.5–5 mm in
diameter. These grafts with multiple hairs in a clustered pattern
created a doll’s hair or cornrow appearance. Over time, smaller plugs
were developed containing 6–10 hairs, but these also resulted in an
unnatural appearance. It was not until micrografting with one and two
hairs per graft became the standard that more natural results were
obtained.
Hair is now known to grow in follicular units in which there is a
clustering of 1–4 hairs (Fig. 6.9). The number of hairs varies greatly,
based on the patient’s hair type and hair characteristics. To create a
natural result, it is critical to use these follicular units to avoid unnat-
ural bunching of hair, and to use magnifi cation during the dissection
and preparation of these grafts to create appropriate follicular units
(Figs 6.10 and 6.11). A team approach is therefore required with
skilled individuals who cut the grafts and assist in their placement
during procedures that often entail 2000–3000 grafts per session.
A
B
Fig. 6.8 Appearances before and after
transplantation. A, Preoperative view of a
patient with an isolated frontal forelock with
posterior alopecia. B, By connecting the
isolated forelock to the surrounding hair,
even limited grafting can give signifi cant
improvement.
Follicular units
Hair shaft
Follicle
Two hair unit
Three hair unit
One hair unit
Fig. 6.9 Follicular units.
Fig. 6.10 Preparation of grafts. The grafts are prepared under
magnifi cation to ensure proper preservation of the follicular units.
The quality of the grafts is crucial.

6
MANAGEMENT OF ALOPECIA
56
Fig. 6.11 Magnifi ed view of prepared grafts on the tongue blade.
The grafts will be transferred to a towel soaked in cool saline and
sorted by size.
SURGICAL TECHNIQUE
Although the equipment and instrumentation for hair transplant is
relatively simple, the technique itself can be relatively complex, espe-
cially when large numbers of grafts are being transplanted at one
time. The technique described here has been developed by Carlos
Uebel of Brazil and has signifi cantly simplifi ed the performance
of large transplantation sessions using small, natural-appearing
grafts.
● Multi-blade knives used to harvest the donor tissue in the poste-
rior scalp in the past often lead to signifi cant transection rates
of the grafts. Today, most surgeons remove the posterior scalp
donor area as a single strip using a #10 knife. A key component
is proper angulation of the blade to reduce follicle transection
(Fig. 6.12).
● Strip width can vary by 1–2 cm. Most of the donor hair is obtained
by taking relatively long strips 12–15 cm in length (Fig. 6.13). In
most patients, a strip greater than 1.6–1.8 cm wide will require
mobilization of the scalp for proper closure without tension. There
is signifi cant mobility of the posterior neck, which allows a rela-
tively easy closure in most patients. Another important aspect is to
harvest future donor strips using the same original incision to
avoid multiple scars.
● Hemostasis of the scalp is relatively easy to obtain because the
dissection is carried out just below the fatty area well above the
galea, avoiding the occipital vessels and nerves (Figs 6.14 and
6.15). Injection of lidocaine with epinephrine as well as tumescent
fl uid aids in hemostasis of this area.
● Closure can be achieved in a variety of ways. My preferred tech-
nique is a double layer closure of 3-0 Vicryl sutures in the deep
layer and 3-0 nylon on the surface (Figs 6.16 and 6.17). Although
the staple will give a rapid closure, the resulting scar in the pos-
terior scalp tends not to be as good as that resulting from a running
surgical closure.
Fig. 6.12 Harvesting of the donor strip. The #10 knife blade is
angled parallel to the hair shafts to reduce transection of the follicles
during harvesting of the donor strip.
Fig. 6.13 A typical donor site measuring 1.6 × 16 cm. The lower
edge of the donor site is 6 cm above the posterior hairline margin. A
donor site of this dimension can be closed with minimal tension.
The most important factor in harvesting the donor site is
appropriate angulation of the knife blade to reduce transection of
hair follicles.
● After the strip has been removed (Fig. 6.18), it is cut horizontally
in a bread loaf fashion into cross-sectional segments several mm
wide (Fig. 6.19). These are cut by the assistants (Box 6.1) into the

Operative Approach
57
Fig. 6.14 Donor strip dissection. Care is taken by staying just deep
to the fatty layer containing the hair follicles. The deep structures,
including the occipital neurovascular bundles, are avoided.
Fig. 6.15 Entire donor strip has been removed. Hemostasis is
obtained with limited use of the cautery to reduce damage to the
remaining follicles.
individual grafts under magnifi cation (Fig. 6.20). Each graft should
contain the hair shaft, follicle and surrounding fat, and should be
kept on ice-chilled moist saline towels and trays to prevent desic-
cation (Fig. 6.21). The hair follicles are then viable for several
hours.
● Prior to insertion of the grafts the recipient area is infused with
tumescent fl uid. This elevates the soft tissues off the scalp, making
insertion easier and also creates appropriate hemostasis.
● A #11 blade is used to make a small slit in the recipient area and
the opening is held open while an assistant places the graft along
Fig. 6.16 Temporary stay sutures align the donor site closure. A
deep layer of 3-0 Vicryl is followed by a running 3-0 nylon.
Fig. 6.17 Completed donor site closure. In most patients, the donor
site is concealed by the patient’s hair. Sutures are removed 10 days
postoperatively.
the edge of the blade, and then like a piston, the blade is partially
withdrawn (Fig. 6.22).
● The graft is positioned and then pushed in into the appropriate
depth (Fig. 6.23). Placing the graft too deep will result in inclusion
cysts. Proper placement, rotating the graft into its proper align-
ment, is also important. The slits are made at a specifi c angle to
allow growth of the hair in the appropriate direction and angula-
tion. I make a slight modifi cation of the #11 blade to approximate
the size of the graft to reduce popping out (Fig. 6.24). The graft is
held in place initially by only a little thrombin, and the more that

6
MANAGEMENT OF ALOPECIA
58
Fig. 6.18 The harvested donor strip. This is ready to be cut into
individual thin cross-sections.
Fig. 6.19 Under magnifi cation, the donor strip is cut into cross-
sections or bread loaf segments. The segments are then cut into the
individual grafts. Cutting these cross-sectional pieces at the proper
angle reduces follicle transection.
the graft is equivalent to the size of the slit made by the #11 blade,
the less the grafts pop out and the better the fi xation.
● As the grafts are placed from anterior to posterior, initially creat-
ing the anterior hairline, they are placed as close as possible to
create maximal density. In patients with thick scalps with no previ-
ous scarring, this can frequently be done at 1 mm intervals or
less.
● The transfer of large numbers of small grafts at one time is the key
to a successful procedure. Once the grafts have been inserted, an
appropriate dressing is applied and then removed the next day.
● Most patients can wash their hair the next day, and the donor site
sutures are removed at approximately 10 days.
Once the Uebel technique has been mastered by two individuals
working together, 600–700 grafts can be inserted per hour.
Fig. 6.20 Division into individual follicular units. The bread loaf
segments positioned for division into the individual follicular units.
Fig. 6.21 Prepared grafts awaiting transplantation are kept on
chilled saline-soaked towels. During the insertion process, the
assistant holds the towel in one hand and picks up the individual
grafts near the follicle with fi ne pickups in the other hand. The
assistant then holds the grafts against the #11 blade for insertion.
The best techniques require the simplest instrumentation. The use
of punches and electrical coring devices to create punch grafts are no
longer considered acceptable because of the size of the grafts obtained
and the fi nal appearance of the result.
ANESTHESIA
Hair transplantation can be carried out in the offi ce with local anes-
thesia and acquiring good anesthesia is relatively simple. Knowledge
of the anatomy of the nerves in the scalp allows a satisfactory level of
local anesthesia in both the donor and the recipient areas (Fig. 6.25).
Anesthesia is achieved with a dilute epinephrine solution, initially
blocking the occipital nerves posteriorly in the donor site (Fig. 6.26).
This is followed by tumescence of a very dilute solution in the area to
distend the posterior scalp off the galea.

Operative Approach
59
Fig. 6.22 Insertion of graft 1. A modifi ed #11 blade makes a small
slit in the scalp and the blade tip is used to open the slit while
partially removing the blade. Several hundred grafts have already
been inserted.
Fig. 6.23 Insertion of graft 2. The assistant slides the graft along the
tip of the #11 blade toward the opening. At the same time, the
surgeon inserts the grafts controlling depth and orientation.
Fig. 6.24 #11 blade with notch cut into side opposite the cutting
surface. This changes the blade tip from a wedge to a cylindrical
confi guration, matching the shape of the graft. This creates a slit
matching the size and depth of the grafts. (Blade design, Val
Lambros, MD)
Box 6.1 Logistics of hair transplantation
●
Although hair transplantation is relatively simple, the logistics
of setting up a hair transplant service can be quite complex.
●
Most plastic surgeons do not carry out hair transplants for
logistic reasons.
●
Successful hair transplantation requires a team approach with
highly skilled individuals.
Creating an appropriate environment
●
In a procedure of 2000 grafts, typically four skilled people are
preparing and cutting the grafts while one is assisting the
surgeon in graft insertion.
●
It frequently takes at least 6 months for a person to become
skilled at cutting follicular grafts at a reasonable rate (i.e. 100–
150 grafts per hour) to make large volume procedures possible.
●
Maintaining a large team of individuals skilled in hair
transplantation in the offi ce when other procedures are being
performed is not fi nancially feasible unless the skilled staff are
primarily maintained on call for the procedure and used only
during the actual hair transplantation process.
Starting a hair transplantation service
●
Start with relatively limited numbers of grafts: carrying out
2000 grafts as a fi rst procedure would cause signifi cant
frustration.
●
One way to begin is to deal with patients who have had
limited hair loss after cosmetic surgery, where 500–700 grafts
will provide a signifi cant improvement.

6
MANAGEMENT OF ALOPECIA
60
Fig. 6.25 Nerve and blood supply of the
scalp.
Nerve and blood supply of the scalp
Supratrochlear nerve
Greater occipital nerve
Lesser occipital nerve
Third occipital nerve
Occipital artery
Posterior auricular
artery
Superficial temporal
artery
Supraorbital artery
Supratrochlear artery
Auriculotemporal nerve
Supraorbital nerve
In the recipient area anteriorly, anesthesia is accomplished with
both a ring block and occasionally, supraorbital nerve blocks, which
facilitate the injection of the ring block.
Because the anatomy of the scalp nerves is so predictable, it is
relatively easy to gain rapid anesthesia during these procedures.
Occasionally, the patients can be given a small dose of oral diaz-
epam; however, most patient are completely comfortable during the
procedure once the blocks and tumescent fl uid are inserted. The addi-
tion of bupivacaine can extend the duration of anesthesia to the scalp
area, especially when large numbers of grafts (2000–3000) are done
during a single procedure.
SCALP EXCISIONS
In general, scalp excisions are now primarily used for diffi cult or
secondary cases, and few patients receive a scalp excision in the
standard management of male pattern baldness.
In the past, however, scalp excisions were often performed in
conjunction with hair transplantation42–45 to reduce the total surface
that required transplantation. The most frequent technique was midline
excision of non-hairbearing scalp with advancement of the lateral
hairbearing scalp fl aps toward the midline. Usually this only partially
reduces the area requiring transplantation and creates several prob-
lems. Advancing lateral fl aps superiorly creates an abnormal hair
pattern with divergence of the hair away from midline, resulting in a
midline scar, which creates a slot deformity; even with aggressive
mobilization there is signifi cant stretch back, leading to a wide scar,
with hair diverging away from the scar.46 The fi nal result was often
far less than optimal. Attempts have been made to reduce the amount
of stretch back or scar widening using various techniques47,48 by reduc-
ing the tension of the incision closure with unique sutures and elastic
membranes internally.
Fig. 6.26 Anesthesia. Initially the occipital nerves are blocked,
followed by a ring block using diluted lidocaine with epinephrine.
The donor tissue is then tumesced to facilitate elevation along the
fatty layer containing the follicles deep to the skin. Tumescence in
the proper plane aids dissection and enhances hemostasis.

Operative Approach
61
Scalp excisions for secondary alopecia
Scalp excisions are particularly useful in secondary cases. Patients
who have had large plug grafts placed too low on the forehead or
temporal region cannot usually be treated with just further hair graft-
ing. Patients who have had plug grafts can be treated with:
● regrafting using small grafts between the larger ones for camoufl age;
● excision of selective plugs with recycling of the hairs for further
grafting.
In selected patients, the best option is complete excision of the
unsightly anterior plugs with superior advancement of the forehead
followed by regrafting (Fig. 6.27A–D). At the time of the excision,
the large plug grafts are recut into micrografts and reinserted at the
same time.
Secondary procedures consist of further grafting to conceal the
scar and to thicken up the transplanted hair. This excisional technique
combined with forehead advancement can give dramatic results. To
prevent widening of the scar and to stabilize the forehead position, it
is helpful to use bony fi xation.
The procedure requires mobilization of the entire forehead to the
level of the eyebrows. Unlike a forehead lift, however, where the goal
is elevation of the eyebrows, the goal is elevation of the abnormally
low hairline leaving the eyebrows in their original position. Several
methods are used to accomplish bony fi xation, including bony tunnels,
Mitek sutures, and Endotyne devices. All these work well to maintain
forehead elevation.
Excisional technique for a temporal alley
These excisional techniques can be used elsewhere on the scalp to
reduce areas of alopecia that develop years after hair transplantation.
One of the more common types is referred to as a temporal alley. This
is a gap that occurs over time in the temporal region as the height of
the temporal hair recedes inferiorly, while the area of previous trans-
plantation above remains constant. The two options are:
● further grafting if donor hair is adequate to reconnect the previ-
ously transplanted area to the receding hairline;
● excision of the intervening area of alopecia to reconnect the
transplanted superior area to the residual hair inferiorly
(Fig. 6.28A&B).
TISSUE EXPANSION IN ALOPECIA
MANAGEMENT
Tissue expansion is no longer considered to be a primary modality for
the treatment of male pattern baldness, and is mainly used for recon-
structed scalp surgery. Although several authors have developed
specifi c expanders for hair restoration and specifi c fl aps to be used
in conjunction with the expansion process (Fig. 6.29A&B), none
of these techniques are in mainstream use.
Optimizing outcomes
Two major factors are key to a successful
hair transplant
●
Use of small, natural-appearing grafts of one to three hairs.
●
Designing a natural-appearing hairline appropriate for the
patient’s face (Table 6.1).
A
B
C
D
Fig. 6.27 Complete excision of the unsightly
anterior plugs with superior advancement of
the forehead followed by regrafting. A,
Complete excision of anterior scalp
containing large unsightly plugs.
B, The excised strip will be divided into
cross-sections followed by dissection into
individual grafts. C, Mitek sutures placed into
the outer table of the skull for suture
elevation of the forehead. Four Miteks were
placed for incision closure. D, Closure of
defect using Mitek sutures with insertion of
recycled grafts into scalp.

6
MANAGEMENT OF ALOPECIA
62
Fig. 6.28 Reconnecting a transplanted
superior area to residual hair. A, Previous
hair transplants on top of scalp. Over time,
the lateral hair has receded inferiorly,
creating a temporal alley or gap. B, The area
of alopecia was excised and Mitek sutures
used to reduce stretch back of the closure.
A
B
A
B
Fig. 6.29 Flaps used in conjunction with the
expansion process. A, Expanded bilateral
advancement transposition (BAT) fl aps
created with tissue expanders laterally and
posteriorly. B, Result after removal of
expanders and fl ap advancement superiorly
and anteriorly. (Photos courtesy of Dr Robin
Andersson.)
PRIMARY HAIR TRANSPLANTATION:
CASE STUDY 1 (Figs 6.30 and 6.31A–C)
Preoperative considerations
● 38-year-old male with a Norwood IV hair loss pattern and an iso-
lated frontal forelock.
● The patient has excellent donor hair density and reports minimal
advancement of the degree of alopecia over the past 4 years.
● Family history is important: he reports most males in his family
have a limited degree of alopecia.
● The patient is on fi nasteride (a DHT blocker) to reduce the rate of
future hair loss.
OPERATIVE APPROACH
● To optimize this patient’s outcome it is imperative to create a high
hairline with temporal recession. A low hairline in this patient
would look artifi cial. Many patients with this type of hair loss
pattern have had a high hairline with signifi cant temporal reces-
sion, even in their youth. A discussion of this patient’s hairline as
a young man as well as photos can be very useful. A patient with
this hair pattern, who requests a low rounded hairline and fi lling
in at the temporal recession, is not suitable for the procedure. As
with any aesthetic procedure, realistic expectations are critical.
The hairline should be at least 8–10 cm above the glabella.
● In this patient, the anterior extent of the hairline has already been
created by his frontal forelock. No hair transplants should be
placed anterior to this forelock. The vertical anterior temporal line
is left alone and the transplants connect the isolated forelock to
the temporal hair at a high and acute angle. In this patient a total
of 3200 grafts in two sessions were placed to give him this excellent
result.
PRIMARY HAIR TRANSPLANTATION:
CASE STUDY 2 (Fig. 6.31A–D)
Preoperative considerations
● 58-year-old woman with a high anterior hairline and marked tem-
poral recession (Fig. 6.32A&B), creating distortion of normal facial
components.
● Typically, the face can be divided into thirds. The lower third is
between the inferior aspect of the chin and the base of the nose.
The middle third extends from the inferior nose to the eyes, while
the upper third extends from the eyes to the hairline. This relation-
ship is distorted if there is excessive temporal recession and a high
anterior hairline, especially in women.
OPERATIVE APPROACH
● Optimizing results in this situation entailed fi lling in the temporal
recession and creating a rounded temporal margin, which is nor-
mally seen in women (Fig. 6.31C&D).
● To balance the face the anterior frontal hairline was lowered
1.5 cm with transplants.

Operative Approach
63
DISCUSSION
● Postoperatively the patient has had a dramatic change in both
frontal and side appearance.
● A key factor in obtaining a successful outcome includes adequate
donor hair. Many middle-aged women with this type of hair appear-
ance have limited donor hair, making the transplantation proce-
dure or process diffi cult. Fortunately, this patient had excellent
donor density.
● Another fact enhancing the result is the light color of the hair.
Hair color and skin color contrast are important components
of a successful result. The less the contrast, the better the fi nal
appearance.
SECONDARY HAIR TRANSPLANTATION:
CASE STUDY 3 (Fig. 6.32A–C)
Preoperative considerations
● This patient demonstrates many important components of an
unsatisfactory hair transplant:
● large plug grafts inserted at a young age
● grafts placed too low and too straight
● altered frontotemporal angle resulting in an unnatural
appearance.
This patient had to wear a hairpiece to cover his scalp.
● Numerous factors must be assessed before embarking on this dif-
fi cult case.
Is there adequate donor hair?
● Patients who have had previous plug grafts have signifi cant scarring
at the donor site. The technique that was used consisted of coring
out the plug grafts from the donor site with a punch device. The
donor sites were left open to heal by secondary intention, resulting
in signifi cant scarring. It is therefore imperative to fi rst confi rm the
presence of adequate donor hair.
Need for multiple procedures
● In the preoperative discussion with this patient it is important for
him to thoroughly understand the surgical process. A single proce-
dure will not give the fi nal result. This situation requires multiple
procedures over an extended period of time.
OPERATIVE APPROACH
● The fi rst operation requires a radical excision of the anterior hair-
line, including the previously inserted plug grafts, with recycling
of the plugs into small micrografts.
Table 6.1
Follicular unit
Hair transplantation
Male
(Norwood
Classification)
Female
(Ludwig
Classification)
Genetic hair loss
(etiology)
Primary cases
Origin of hair loss
Gender
Management
Scalp excision
Plug graft excision
Recycling of plug grafts
Follicular unit transplantation
Male
Female
Unsatisfactory
previous hair
transplants
(etiology)
Problems after
facelifts-browlifts
(etiology)
Secondary cases
Management of alopecia (primary vs secondary)
A
B
C
Fig. 6.30 Case study 1. A, Norwood IV hair loss pattern with isolated frontal forelock. B, Result after 3200 grafts in two sessions.
C, Hairline is 9 cm above glabella.

6
MANAGEMENT OF ALOPECIA
64
A
B
C
D
Fig. 6.31 Case study 2. A&B, 58-year-old
woman with high anterior hairline and
marked temporal recession. C&D, The
anterior hairline on frontal view has been
lowered 15 mm. The temporal area has been
fi lled in creating a rounded margin.
A
B
C
Fig. 6.32 Case study 3. A&B, Patient had large plug grafts in his early 20s. These grafts were placed in a straight line and too low. The
frontotemporal angle is obliterated. Over time, he went bald behind the plug grafts, creating a bizarre appearance. C, Final result after
excision of the anterior scalp with the plug grafts. The forehead was advanced superiorly with boney fi xation of the scalp. The patient also
had two large sessions of grafting to create the fi nal result. A normal frontotemporal angle was created, producing a more aesthetic result.
● Next, after the scalp has healed, approximately 6–8 months later,
further grafting is performed: in this case, it consisted of two
separate graft sessions to create the fi nal result.
● The patient now has a properly contoured hairline with a
normal temporal recession and removal of the unsightly plug
grafts.
SECONDARY HAIR TRANSPLANTATION:
CASE STUDY 4 (Fig. 6.33A&B)
Preoperative considerations
● This patient has the typical problem with hair loss and hairline
elevation seen after a facelift.

Postoperative Care
65
● Previous attempts to camoufl age these areas in front of and behind
her ears with tattooing have made the areas of hair loss even more
noticeable.
OPERATIVE APPROACH
● Improvement is relatively easy to obtain because only limited hair
transplantation is required.
● The most important factor is proper angulation of the grafts in
these two sites:
● in the frontotemporal area and extending down toward the preau-
ricular area, hairs normally grow downward and posteriorly – it
is imperative to place the grafts at these acute angles in these areas
to create a natural result
● behind the ears, the grafts must be angled downward and slightly
posteriorly to follow the normal pattern.
With proper attention to the angle of the grafts, the appearance can
be dramatically improved.
COMPLICATIONS AND SIDE EFFECTS
Hair transplantation has a low incidence of complications when
properly performed.
DONOR SITE COMPLICATIONS
Hematoma is rare and can be managed with simple aspiration unless
there is a signifi cant amount of blood and/or recurrence of the bleeding.
Other problems are associated with the neurovascular bundles,
primarily in the posterior neck area. The occipital nerves run directly
at a right angle to the donor site excision. It is important during the
donor site excision to stay superfi cial to the occipital nerves, otherwise
there will be numbness in the posterior scalp area. The use of tumes-
cent fl uid just deep to the fatty layer will separate the hair follicles and
underlying fat from the underlying neurovascular pedicle. Dissection
is then performed just along the deep portion of the fatty layer with
care taken to protect follicles but staying superfi cial to the occipital
nerve and vessel.
All patients have a degree of superfi cial numbness above the
incision due to division of superfi cial cutaneous nerves. This usually
resolves after several months. If the occipital nerves are completely
divided the patient may have an area of permanent numbness.
RECIPIENT SITE COMPLICATIONS
Complications in the recipient site are minimal. The most common
problem is the development of an inclusion cyst if the grafts are placed
too deep. This occurs when the epithelium of the scalp covers the
epithelium of the graft prior to the hair growing above the surface of
the scalp. Usually, these can be treated by simply opening any develop-
ing cysts.
OTHER COMPLICATIONS
Other risks or complications result from creating an abnormal hairline
or using large grafts (Fig. 6.34). The use of large plug grafts is no longer
acceptable and the surgeon performing the hair transplant must be
knowledgeable about creating a normal-appearing hairline.
POSTOPERATIVE CARE
IMMEDIATE POSTOPERATIVE PERIOD
Once the grafts have been inserted, an appropriate dressing is often
applied and then removed after 24 hours. Most patients can wash their
hair within 24 hours: carefully at the recipient site, and normally at
A
B
Fig. 6.33 Case study 4. A, Patient had a
previous facelift with loss of hair behind the
ear and elevation of the temporal–
preauricular hairline. Tattooing the area did
not improve the appearance. B, Postoperative
appearance after grafting in the postauricular
area and the temporal and preauricular area,
creating a more natural hairline.
Graft compression
Graft compression at orifice
creates abnormal appearance
Fig. 6.34 Bouquet deformity. If large grafts containing multiple hairs
are placed in a small slit, the hairs are compressed at the base. This
leads to a bouquet deformity, with hairs spreading out from a
central orifi ce. This problem is avoided by using grafts containing
one to three hairs (i.e. follicular units).

6
MANAGEMENT OF ALOPECIA
66
the donor site. For the fi rst 6 days after the transplant the patient is
instructed to blot soap on to the recipient site and rinse it with a cup.
After 6 days, a normal stream from the shower can hit directly onto
the recipient site. It is important for the patient to progressively
increase their aggressiveness in washing.
It is important for patients to minimize exercise or any events that
will increase their blood pressure. For the fi rst few days the graft is
held in place by thrombin only. Straining or excessive exercise can
create not only a hematoma in the donor site, but cause problems with
the grafted area. Typically, the patients are instructed on care of
the graft area and to avoid excessive straining for the fi rst 4–6 days
postoperatively.
10–12 Days Postoperatively
When the patient is seen 10–12 days postoperatively for removal of
the donor site sutures, if their scalp is covered with hundreds of little
scabs or crusts, the patient is not being aggressive enough in washing
the hair. Patients are instructed that after 2 weeks most of the little
crust should be gone from the recipient site and there should be
minimal crusting.
CONCLUSION
Hair transplantation can produce a dramatic improvement in aesthetic
appearance. A successful outcome requires knowledge of the anatomy
of a normal hairline and a team approach: a highly skilled group of
individuals is required to cut large numbers of follicular grafts under
magnifi cation to create a state of the art result. Understanding the
components of a natural hairline and the complexity of creating appro-
priate grafts are key to successful outcomes.
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13. Argenta LC, Marks MW, Anderson RRD. Treatment of male pattern
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transplantation. Head Neck Surg 1985; 7:303.
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the relevant literature and presentation of an improved technique.
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67
CHAPTER 7
Forehead Rejuvenation
Bahman Guyuron
INDICATIONS
Injection of botulinum toxin A or fi llers
●
Temporary improvement for patients who exhibit forehead
wrinkles but are not ready to undergo surgery
Fat injection
●
Patient who is not ready for a more invasive procedure but
desires camoufl aging of the lines with the potential for longer
lasting results than attained with the shorter term fi llers
●
Elimination of lines that are ordinarily not erased with more
invasive techniques such as endoscopic or open forehead
rejuvenation and laser resurfacing procedures
Transpalpebral corrugator resection
●
Signifi cant glabellar frown lines and corrugator hyperactivity
with minimal or no eyebrow ptosis
●
Those undergoing blepharoplasty who manifest hyperactive
corrugators
●
Male patients with a receding frontal hairline and deep frown
lines
●
Patients with deep frown lines who do not desire a full
forehead rejuvenation
●
Those with proptosis and deep frown lines with eyebrow
ptosis in whom elevation of the eyebrows may render the
proptosis more noticeable
Endoscopic forehead rejuvenation
●
Procedure of choice for patients with optimal or even
borderline forehead length, eyebrow ptosis and hyperactive
forehead muscles without deep horizontal forehead
wrinkles
Subcutaneous forehead rhytidectomy
●
Better choice than endoscopic forehead rejuvenation for
patients with borderline to mild forehead elongation,
a receding hairline and extensive deep wrinkles13
●
Deep lines in the forehead area that cannot be eliminated
successfully by endoscopic forehead rejuvenation alone or
even endoscopic forehead rejuvenation with laser
resurfacing
Scalp advancement with or without
a forehead lift
●
A superior choice for a patient with signifi cant forehead
elongation
Summary
1. Patients often do not realize the paramount role that ptotic
eyebrows or eyelids play in periorbital aging.
2. Eyebrow ptosis usually leads to subconscious compensatory
elevation of the eyebrows.
3. As the patient smiles naturally, the frontalis muscle
compensation is reduced or eliminated.
4. The supraorbital nerve in the adult exits the supraorbital
foramen or notch 2.7 cm from the midline. The supratrochlear
nerve is located 1.7 cm from the midline and lies 0.8 cm
anterior to the supraorbital nerve.
5. Injection of 12.5 units of botulinum toxin A not only eliminates
the frown lines, but in most instances can stop frontal
migraine headaches for 6–8 weeks.
6. The options for forehead rejuvenation techniques include
injection of botulinum toxin, fi llers, transpalpebral corrugator
removal, endoscopic forehead lift, and open forehead lift with,
or without, forehead shortening.
7. The attachments of the periosteum in the glabellar area should be
kept intact to avoid excessive medial elevation of the eyebrow.
8. Release of the lateral eyebrow and periosteal attachments is
far more important in elevation of the eyebrows than the
fi xation technique.
9. Elevation of the eyebrows on a patient who has proptosis
should be conservative.
10. Often, fascia fi xation without bone fi xation is suffi cient to satisfy
the intended aesthetic goals provided the release is suffi cient.
INTRODUCTION
The plastic surgery armamentarium for forehead rejuvenation has
expanded considerably during the past 15 years.1–12 Whereas the focus
of rejuvenation in the past was focused mainly on the face and neck,
it has now become widely recognized that rejuvenation of the forehead is
essential to produce a natural, well-balanced result. There is now greater
emphasis on minimizing incisions and long-term side effects, such as
numbness, while achieving a superior aesthetic outcome with improved
patient satisfaction. Less invasive techniques have also emerged.
The senescent changes refl ected in the forehead area may range
from barely discernible glabellar lines to the full gamut of eyebrow
ptosis, deep frown lines, elongation of the forehead, and deep horizon-
tal lines. Not every patient who has been affected by gravity desires a
complete forehead rejuvenation for a variety of reasons. The aesthetic
surgeon must therefore be equipped with a gamut of techniques that
will offer solutions to satisfy every patient’s needs.
This chapter reviews most of the techniques available for forehead
rejuvenation.

7
FOREHEAD REJUVENATION
68
PREOPERATIVE HISTORY
AND CONSIDERATIONS
Patient assessment
A proper forehead length and eyebrow position with a smooth and
properly contoured forehead is an integral part of facial beauty (see
Chapter 1). Any disturbance of this balance undoubtedly detracts from
the pulchritude of the face.
Slight elongation of the forehead is a fairly constant component of
the aging process for both men and women. Male pattern baldness
resulting in receding frontal hair not only affects men, but may
also alter the forehead length in women. The elongated forehead by
itself denotes aging, and correcting it will yield a more rejuvenated
appearance.
The main complaint of a patient with forehead aging is the frown
lines. These wrinkles bestow a tired and perturbed appearance.
Although these patients may not be truly angry or unhappy, they are
commonly asked why they seem vexed.
Patients often incorrectly attribute the periorbital aging condition
to excess eyelid skin rather than ptosis of the eyebrows, and demon-
strate what they wish to achieve through surgery by manually raising
their eyebrows. The surgeon should use this occasion to point out that
it is the elevation of the eyebrows rather than the stretching out of
redundant eyelid skin directly that is improving the eyelid appearance.
Patients with eyebrow and eyelid ptosis either consciously or sub-
consciously may recruit the frontalis muscle to aid in opening their
eyelids.14 These two conditions should be differentiated in one of the
following two ways:
● one of the most effective means for discerning between the two
is to ask the patient to smile – as the patient smiles, frontalis
compensation is often eliminated;
● the patient can also be asked to close the eyelids tightly and then
gradually open the eyes until the patient can see the examiner. The
eyebrows will assume an uncompensated position at this point. As
soon as the patient is allowed to open the eyelids freely, the eye-
brows will rise dramatically.
For a complete evaluation the eyebrow and eyelid imperfections are
reviewed as a unit and the abnormal fi ndings should be categorized
and clearly explained to the patient. Flaws related to the forehead
include:
● length disharmony or a receding hairline;
● frontal bossing;
● glabellar fl attening;
● horizontal, oblique and vertical wrinkles;
● eyebrow ptosis;
● misshaped eyebrow arch.
It is important to inquire about and record the frequency, severity and
duration of frontal and temporal migraine headaches in patients who
are undergoing forehead rejuvenation. Many of these patients will
enjoy the potential elimination or reduction of migraine headaches
resultant from forehead injection of botulinum toxin A.
Patient information
The patients should be informed of the fi ndings, the available tech-
niques, the advantages and disadvantages of each technique, and the
surgeon’s own opinion as to which treatments may provide the best
results. Patients will then choose the technique that they feel is best
suited to their aesthetic objectives. If a patient selects a procedure
that will provide a suboptimal outcome, this should be adequately
discussed with the patient, and the limitations of the procedure clearly
reiterated. This explanation may reduce the potential for postoperative
discontent.
FAT INJECTION
Loss of subcutaneous volume is a signifi cant factor in the process of
aging, and results in ptosis of the skin and the development of lines
and folds. Any modality that restores the thickness of the skin and
subcutaneous tissue invariably reduces the visibility of these lines.
Since the introduction of fat injection as the means to eliminate
facial lines, there has been a longstanding debate about its effi cacy
and reliability. In 1911 Brunings3 injected small cubes of autologous
adipose tissue under the skin during rhinoplasty, but there was sig-
nifi cant absorption of the injected fat.2 Interest in fat injection for facial
rejuvenation has recently re-emerged as a result of the refi nement of
techniques and more reliable outcomes.15
OPERATIVE APPROACH
Relevant surgical anatomy
The forehead is a dynamic zone of the face, especially in expressive
people. Frequent use of the muscle often results in lines and creases.
For instance:
● contraction of the frontalis muscle may cause horizontal lines;
● contraction of the corrugator muscle may result in vertical lines;
● the depressor supercilii muscle is often responsible for the creation
of oblique lines in the medial eyebrow area;
● creases at the root of the nose are a product of procerus muscle
overactivity coupled with forehead ptosis.
The anatomic layers of the forehead are both continuous and analo-
gous to the fi ve layers of the scalp.16 There is a gradual decrease in
sebaceous gland content of the skin in a cephalad direction.
As with the scalp, the forehead skin is fi rmly adherent to the under-
lying epicranial layer. The epicranial layer is formed by the vertical
fi bers of the frontalis muscle anteriorly (Fig. 7.1) and the occipitalis
muscle posteriorly. The galea aponeurotica spans these muscles.
Fig. 7.1 Anatomy. Artistic illustration of muscles, nerves, and
vessels of forehead.
Muscles, nerves, and vessels of forehead
Supraorbital artery
Orbicularis muscle
Supraorbital nerve
Zygomatico -
temporal nerve
Frontalis muscle
Corrugator supercilii
muscle
Depressor supercilii
muscle
Superficial
temporal
artery
Supratrochlear artery
Supratrochlear nerve

Operative Approach
69
OPERATIVE TECHNIQUE
● Before injecting the recipient site, the target area is outlined and
any furrows are precisely marked.
● The procedure is performed under local anesthesia with or
without intravenous sedation. Lidocaine hydrochloride containing
1 : 100 000 epinephrine should be used for both the donor site and
the recipient site. It is advisable to use 3 units/mL hyaluronidase
to ensure faster diffusion of the anesthetic in the injected site and
elimination of the injected volume. This allows for a more precise
judgment about the necessary volume of fat to be injected.
● The ideal donor site is the lower quarter of the abdomen or gluteal
region, which should fi rst be infi ltrated with a generous amount of
the anesthetic solution. Fat is then aspirated using a 14-gauge
cannula and a 1 cc syringe. Gentle rotation and advancement of
the cannula, while simultaneously applying external pressure to
the abdomen with the non-dominant hand, avulses fat tissue, and
signifi cantly facilitates the harvesting process.17
● Next, an 18-gauge needle is connected to a Coleman cannula, and
the sharp, beveled end of the needle is inserted in the skin caudal
to the target area. Advancing the needle to the injection site with
a gentle side-to-side motion of the needle, the fi brous bands con-
necting the dermis to deeper tissue layers are released. This process
is repeated until unencumbered movement of the needle is achieved
in an area approximately 4–5 mm wide centered under the deep
portion of the frown line.
● With multiple passes, the surgeon injects the fat into the subcuta-
neous layer.
Optimizing outcomes
●
When injecting fat into the frown line, overcorrection should
be minimal because the success rate is high in this site.
COMPLICATIONS
A distinct disadvantage of fat injection is its unpredictability, but
multiple passes and injections in different planes may improve the
predictability and reliability. Another disadvantage is its failure to
eliminate the muscle function, thus its inability to avoid recurrence of
lines.
Fat injection is generally an uncomplicated procedure, but over-
or under-injection may occur.
One serious complication of fat injection, which is extremely rare,
is blindness.11,12 The loss of eyesight is probably related to emboliza-
tion of the injected fat into the retinal artery. If this complication
develops, immediate consultation with an ophthalmologist is neces-
sary. Intentional overcorrection may result in longlasting glabellar
fullness, which may ultimately resolve. This site is more privileged as
a fat recipient site than most sites in terms of retention of the injected
volume, and complete fat absorption is unlikely, which reduces the
need for an overcorrection.
POSTOPERATIVE CARE
Advantages of fat injection are the ease of the technique and a lack
of any incisional scars. Usually the patient recovers quickly and
may be presentable the next day, provided there is no signifi cant
ecchymosis or edema. The results are commonly longlasting (Fig.
7.2A&B).
FAT GRAFT
OPERATIVE APPROACH
Since its introduction by Neubeur in 1893, the use of an autologous fat
graft has been consistently popular.18 The degree of fat graft take is:
● inversely infl uenced by the volume of transferred fat;
● directly affected by vascular integrity of the recipient sites.
After a large volume of fat is grafted, it undergoes distinct cytologic
changes resulting in a peripheral zone of viable adipocytes, an inter-
mediate zone of infl ammation, and a central zone of necrosis. There-
fore, the larger the volume of grafted tissue, the higher the percentage
of the graft absorbed. In fact, if a large graft is used, one should expect
a volume loss of 50% or more.
When a fat graft is thinner than 1 cm, a larger percentage of tissue
will be revascularized and retained.
The amount of fat necessary to fi ll the glabellar frown lines is
minimal, and this results in a high success rate.
Using fat grafts becomes a particularly useful adjunct to forehead
rejuvenation when a concomitant procedure provides suitable donor
tissue. A combination of facial rhytidectomy and fat graft to the frown
lines is a notable example. The surgeon may use fat alone or dermis
and fat in combination; however, when addition of a dermal compo-
nent may increase the risk of cyst formation.
Operative technique
● Because fat grafting is seldom performed as an isolated operation,
the patient will have received intravenous sedation for the concur-
rent procedures.
● The glabellar area is infi ltrated with lidocaine hydrochloride con-
taining 1 : 100 000 epinephrine with 3-units/mL of hyaluronidase.
● A stab incision is made in the most cephalic portion of the frown line.
● A pair of fi ne scissors is used to develop a pocket by undermining
the furrows.
● The fat is fashioned proportionately into a single strip and intro-
duced into the subcutaneous pocket.
● Overcorrection is unnecessary because the success rate is close
to 100%.
● The small stab incision is closed using 6-0 plain, fast-absorbing
catgut sutures.
● The graft may be gently molded after cutaneous repair.
● The wound usually heals well to leave an indiscernible scar.
Alternatively, the fat can be prepared in strips of 1–2-mm width and an
18-guage needle is used to release subcutaneous fi brous bands. The
sharp end of the needle is then used to deliver the grafts into the pocket.
Dermis fat is easier to insert into the target area using this technique.
A
B
Fig. 7.2 Before and after fat injection. A, Before fat injection.
B, 7 years after two injections of fat into frown lines. (From
Michelow B, Guyuron B. Rejuvenation of the upper face. A logical
gamut of surgical options. Clin Plast Surg 1997; 24(2):199–212).

7
FOREHEAD REJUVENATION
70
COMPLICATIONS
Fat graft may result in irregularities, infection, or accumulation of a
small amount of blood around the graft, which may persist and cause
the patient concern. These undesirable outcomes are unlikely.
Irregular absorption is an unlikely disadvantage of this technique
because this type of graft seldom dissolves.
POSTOPERATIVE CARE
The advantages of fat grafting are its simplicity and avoidance of larger
scars (Fig. 7.3A&B).
TRANSPALPEBRAL CORRUGATOR
RESECTION
OPERATIVE APPROACH
A transpalpebral incision may be used to resect the corrugator
which usually results in disappearance of the frown lines (Fig.
7.4A–D).19,20 Transpalpebral corrugator resection may be performed
concurrently with an endoscopic procedure to facilitate removal of
the corrugator muscle. The advantages of this operation are its
simplicity with direct and full exposure of nerves and muscles. The
results are highly predictable and reproducible. When combined
with a blepharoplasty, fat is readily available for replacement of the
corrugator muscle.
Relevant surgical anatomy
Frontalis muscle
Deep to the frontalis muscle, the epicranial layer is separated from
muscle by loose connective tissue, which allows the scalp to glide short
distances over the underlying bony skull. Neither frontalis nor occip-
ital muscle has bony origins. The frontalis:
● arises from the skin and subcutaneous tissue in the region of the
eyebrows and root of the nose and inserts into the galea;
● medial fi bers are continuous with the procerus muscle at the
nasion;
● intermediate fi bers blend with the corrugator supercilii muscle;
● lateral fi bers blend with the orbicularis oculi muscle.
Deep to the frontalis muscle, a layer of loose connective tissue parti-
tions the epicranium from the underlying bone, so allowing the scalp
to glide short distances over the skull.
During animation, the frontalis muscle, which expresses attention,
elevates the eyebrows and causes transverse wrinkling of the fore-
head.21 Its contraction provides a constant, cranially directed force
vector on the eyebrows.
Orbicularis oculi muscle
The cranial vector of frontalis muscle contraction is counteracted by
muscular and periosteal anchors. The orbicularis is one such muscle,
and is divided into orbital and palpebral portions:
● the orbital portion spans the superciliary arch and acts to depress
the eyebrow;
● the palpebral portion contains the preseptal segment (which is
found between the inferior border of the eyebrow and upper margin
of the tarsal plate) and the pretarsal segment (which covers the
tarsus).
The medial and superior portions of the orbicularis overlie another
muscle, the depressor supercilii, which is a forceful depressor of the
head of the brow.
Temporal and zygomatic branches of the facial nerve22 innervate
the cephalic portion of the orbicularis oculi.
Corrugator supercilii muscle
Corrugator supercilii muscle is a small, pyramidal muscle located at
the medial end of the eyebrow, deep to the frontalis and orbicularis
muscles. Its fi bers:
● originate from the medial portion of the supraciliary arch;
● span superolaterally and pass between the fi bers of the orbicularis
muscle to insert into the deep surface of the forehead skin.23
Corrugator supercilii is innervated primarily by temporal branches of
the facial nerve (CN VII). It often extends to the junction of the lateral
one-third and medial two-thirds of the supraorbital rim where it is
innervated by the frontal and zygomatic branches of CN VII, though
buccal branches of CN VII also make a contribution.
Removal of corrugator supercilii during forehead rejuvenation
eliminates the inferomedially directed vector, allowing separation and
elevation of the medial eyebrows.
Procerus muscle
Procerus is a pyramidal, fasciculate muscle with tendinous fi bers
originating at the inferior portion of the nasal bones and inserting into
the dermis between the eyebrows. It is:
A
B
Fig. 7.3 Before and after fat graft. A, Before fat graft. B, After
placement of fat graft in glabellar line. (From Michelow B, Guyuron
B. Rejuvenation of the upper face. A logical gamut of surgical
options. Clin Plast Surg 1997; 24(2):199–212).
A
B
C
D
Fig. 7.4 Before and after transpalpebral corrugator resection.
A, In repose before transpalpebral corrugator resection. B, In repose
approximately 1 year after transpalpebral resection of corrugator
supercilii, C, Animated expression before transpalpebral corrugator
resection. D, Animated expression approximately 1 year after
transpalpebral resection of corrugator supercilii.

Operative Approach
71
● innervated by the deep buccal branch of CN VII through the infra-
orbital plexus;
● responsible for expressions of aggression and pulls the glabella
caudally;
● attached to the periosteum of the nasal bones and this is a major
factor stabilizing the eyebrow.
Dividing the periosteum laterally and freeing the arcus marginalis is
necessary to free the lateral brow, enabling its elevation during endo-
scopic and/or open rejuvenation procedures.
Supraorbital and supratrochlear nerves
The supraorbital and supratrochlear nerves (see Fig. 7.1) are the
terminal branches of the ophthalmic division of the trigeminal nerve
(CN V) and provide sensory innervation to the forehead and scalp:
● the supraorbital nerve in the adult exits the supraorbital foramen
or notch 2.7 cm from the midline;
● the supratrochlear nerve is located 1.7 cm from the midline and
lies 0.8 cm anterior to the supraorbital nerve.24
Injury to the supraorbital and supratrochlear nerves may result in
intense forehead itching following surgical forehead rejuvenation
technique.
The thickest portion of the corrugator supercilii muscle is inter-
posed between these two sensory nerves.
Operative technique
● Transpalpebral corrugator resection is performed with the patient
under intravenous sedation using fentanyl, midazolam, or propofol.
● The upper eyelid and glabellar areas are generously infi ltrated
with lidocaine hydrochloride containing 1 : 100 000 epinephrine.
● If blepharoplasty is to be performed concurrently, eye shields are
placed fi rst, and the conventional upper blepharoplasty incision is
used. Otherwise, the incision is confi ned to the medial half of the
conventional blepharoplasty incision.
● After removal of the redundant skin if intended, the orbital
septum is retracted caudally and the orbicularis muscle is pulled
cephalically (Fig. 7.5).
● The easily identifi able plane between the orbital septum and orbi-
cularis muscle is easily entered, and dissection is continued toward
the superior orbital rim.
● While the orbicularis muscle is being retracted anteriorly, the
depressor and corrugator supercilii muscles are exposed immedi-
ately cephalad to the orbital rim (Fig. 7.6). A few branches of the
supratrochlear nerve may become visible at this point; if so, they
should be retracted and protected.
● As much as possible of the depressor and corrugator supercilii
muscles are exposed and removed. The supratrochlear and supra-
orbital nerves are identifi ed and preserved. The muscles are
removed using the coagulation power of the electrocautery (Fig.
7.7). Occasionally gentle traction with a pair of multi-tooth forceps
may be suffi cient to avulse the muscle.
Inadequate removal of the muscle will result in irregularities and
fl aws during the forehead rejuvenation.
● A pair of baby Metzenbaum scissors is used to separate the skin
overlying the glabellar area from the underlying tissues and the
procerus muscle fi bers are removed if indicated.
Complete or almost complete removal of the procerus muscle can
cause excessive elevation of the medial eyebrows.
Fig. 7.5 Transpalpebral corrugator resection 1. After incision and
removal of excess skin, if intended, the orbicularis muscle is
retracted cephalically, the orbital septum is pulled caudally and the
dissection is directed toward orbital rim. (From Michelow
B, Guyuron B. Rejuvenation of the upper face. A logical gamut
of surgical options. Clin Plast Surg 1997; 24(2):199–212).
Fig. 7.6 Transpalpebral corrugator resection 2. The corrugator
muscle is exposed as widely as possible while orbicularis muscle is
retracted anteriorly. (From Michelow B, Guyuron B. Rejuvenation of
the upper face. A logical gamut of surgical options. Clin Plast Surg
1997; 24(2):199–212).

7
FOREHEAD REJUVENATION
72
● At this point pieces of fat that have been harvested from the medial
portion of the upper eyelids are placed into the space created by
the resection of the corrugator muscles (Fig. 7.8). Use of this fat
offers several distinct advantages: it fi lls in the depression that may
result from a thorough resection of the corrugator muscle; it shields
residual corrugator fi bers so even if the corrugator resection is not
complete or if muscle fi bers regenerate, they will be deprived of
bony insertion and muscle that does not have bony fi xation is not
as potent; as part of the senescence, the glabellar area becomes
fl atter, so rejuvenation of the forehead should include replacement
of the lost volume in this region. The fat graft is fi xed to the under-
lying periosteum using 6-0 Vicryl or Monocryl to prevent postop-
erative dislodgement.
● The eyelid skin is repaired using 6-0 plain catgut.
● The incisions are treated with antibiotic ointment.
Optimizing outcomes
●
The depressor supercilii muscle is commonly mistaken for the
corrugator muscle. The latter is darker, more pliable, located
deeper and more medial to the former.
●
Some patients with longstanding frown lines may require laser
resurfacing to obtain optimal results.
COMPLICATIONS
The major disadvantage of transpalpebral corrugator resection is that
it does not signifi cantly correct eyebrow ptosis. Release of the corruga-
tor and depressor supercilii muscles primarily results in elevation of
the medial, and to a lesser degree, the lateral portions of the eyebrows.
This procedure will not be suffi ciently effi cacious for patients who
demonstrate more profound signs of forehead aging.
Transpalpebral resection of the corrugator may result in induration
around the fat graft or asymmetric corrugator function and permanent
numbness, though these complications are highly unlikely.
Eyelid incisional scar hypertrophy, specifi cally medially, or webbing
that results in the development of epicanthus, are observed in rare
situations. An injection of a small amount of triamcinolone 40 mg/ml
will improve the scars.
ENDOSCOPIC REJUVENATION
OPERATIVE APPROACH
The endoscopic procedure has revolutionized forehead rejuvenation
for many surgeons. It is performed almost exclusively on an outpatient
basis.
The most signifi cant advantage of endoscopic forehead rejuvena-
tion is the avoidance of the large incisional scars that are inherent to
the open techniques. Many patients who decline forehead rejuvenation
because of concerns about the incisional scars are willing to proceed
with an endoscopic procedure when they learn about the alternatives.
Other advantages are the reduced chance of forehead elongation
(which is commonly observed after a coronal incision) and a dimin-
ished chance of surgery-related alopecia, primarily because the inci-
sions have been minimized. Even if some hair is lost around the
incision, this is temporary and the hair follicles usually recover. The
magnifi cation is another positive aspect of endoscopic surgery.
Relevant surgical anatomy
See above for fat injection and transpalpebral corrugator resection.
Operative technique
● Intravenous sedation is preferred unless the procedure is con-
ducted in conjunction with other procedures that necessitate
induction of general anesthesia.
● Prior to sedation, the midline incision site is marked approximately
0.5 cm behind the hairline at the widow’s peak.
● Next, two incisions are marked in the temple area, the fi rst approx-
imately 7 cm and the second 10 cm from the midline and 1.5–2 cm
behind the hairline. These radial incisions are 1.2–1.5 cm in length,
depending on the thickness of the skin and subcutaneous tissue. A
longer incision is used when the scalp is thick. The hair between
these markings is braided by the assistants to avoid transfer of hair
into the wounds (Fig. 7.9).
● The entire non-hairbearing forehead area is injected with lido-
caine hydrochloride containing 1 : 100 000 epinephrine, and the
Fig. 7.7 Transpalpebral corrugator resection 3. As much of the
corrugator muscle as possible is removed using coagulation power
of electrocautery, while protecting the supratrochlear and
supraorbital nerves. (From Michelow B, Guyuron B. Rejuvenation of
the upper face. A logical gamut of surgical options. Clin Plast Surg
1997; 24(2):199–212).
Fig. 7.8 Transpalpebral corrugator resection 4. A matching size fat
graft is used to replace the resected corrugator muscle and, if
necessary, to contour the glabellar area. (From Michelow B, Guyuron
B. Rejuvenation of the upper face. A logical gamut of surgical
options. Clin Plast Surg 1997; 24(2):199–212).

Operative Approach
73
hairbearing scalp up to approximately 7.5 cm behind the incision
is injected with lidocaine containing 1 : 200 000 epinephrine to
minimize the potential for any hair loss.
● The most lateral incision is made in the right temple area. This
incision is taken through the superfi cial temporal fascia down to
the deep temporal fascia. Using a pair of baby Metzenbaum
scissors and spreading technique, the deep temporal fascia is
exposed.
● Using the Obwegeser periosteal elevator, enough space is created
above the deep and superfi cial temporal fascia to allow insertion
of the Endoscopic Access Device (Fig. 7.10). To insert the EAD the
inner shield is folded using a pair of large multi-tooth Adson
forceps and while the skin hooks are separating the wound margins,
the surgeon introduces the inner shield into the wound step-by-step
(Fig. 7.11). Any resultant folds inside the lumen are easily elimi-
nated by inserting the forceps into the central cannula and running
them around the lumen.
● The periosteal elevator is passed into the fi rst incision and
advanced in different directions to dissect the tissues at the plane
immediately superfi cial to the deep temporal fascia plane sur-
rounding the second incision. Almost invariably the second inci-
sion falls over the periosteum rather than the temporalis fascia and
near the temporal ridge. Skin hooks are now placed under the
periosteum through the second incision, and the wound edges are
retracted. The second EAD is then introduced.
● The dissection proceeds medially under the midline incision. At
this point a third incision is made in the midline, and the EAD is
again inserted. The procedure is then continued on the right side,
starting laterally and advancing medially. The dissected areas are
then connected with a periosteal elevator.
● At this point the surgeon’s attention returns to the right side. The
Obwegeser periosteal elevator is used to dissect posterior to the
incisions. This part of the procedure is done without the use of the
endoscope.
● The dissection is repeated in the subperiosteal plane in the central
forehead area, superfi cial to the deep temporalis fascia in the
temple region. At this point, the 30º 4-mm scope is introduced
through the EAD.
● The dissection is continued toward the supraorbital rim using the
endoscope (Fig. 7.12). The arcus marginalis and the periorbita are
released along the entire supraorbital rim using a longer periosteal
elevator (Fig. 7.13).
● The fi brous bands are separated and elevated until the orbital
septum, which has a glistening, grayish appearance, becomes
visible. The periosteum along the lateral orbital rim is also released
along the lateral orbital wall. A complete release of the periorbita
and adequate removal of the muscles is far more important than
fi xation techniques. A sweep of the periosteal elevator across the
temple area should not encounter any resistance.
● As the dissection is advanced medially, the supraorbital nerve and
vessels are identifi ed, as is the supratrochlear nerve. The supra-
orbital nerve is closer to the fi eld of dissection and therefore more
easily identifi ed.
● The corrugator muscle lies superfi cial to a communicating vein
between the supratrochlear and supraorbital veins. This vein is
cauterized and the corrugator muscle is removed as radically as
possible using the Daniel grasper or punch biopsy (Fig. 7.14). If
necessary, the nerves are retracted with a nerve hook. The perios-
teum over the glabellar area is elevated but not transected in most
patients, unless there is a signifi cant medial eyebrow ptosis with
skin folding over the radix.
Fig. 7.9 Endoscopic forehead rejuvenation 1. Design of fi ve radial
incisions, and demonstration of control of the hair with braiding.
Fig. 7.10 Endoscopic forehead rejuvenation 2. Photograph of the
endoscopic access device (EAD). This device has two shields – one
smaller internal and one larger external – connected by an obliquely
oriented cannula to properly guide the endoscopic instruments in
the targeted fi eld.
Fig. 7.11 Endoscopic forehead rejuvenation 3. Insertion of the
endoscopic access device (EAD) is initiated by folding the inner
shield and introducing it into the wound step-by-step using a pair of
multi-tooth Adson forceps.

7
FOREHEAD REJUVENATION
74
● The dissection is repeated on the opposite side, and the corrugator
supercilii muscle is removed.
● Hemostasis is secured step-by-step.
● The corrugator muscle site is then replaced with fat, which is often
harvested from another site if an additional procedure is done in
conjunction with the forehead rejuvenation. If no other procedure
is being performed, fat is harvested from the area immediately
under the deep temporal fascia above the zygomatic arch medially
(Fig. 7.15).25 The harvested fat is then delivered to the corrugator
supercilii site with a periosteal elevator. If there is fl attening or a
depression in the middle of the glabellar area, it is augmented with
fat grafts as well.
● In most patients, one fascia suspension suture on each side achieves
the aesthetic goal.26 At no point is a medial suspension performed.
To achieve proper fi xation, two single skin hooks are placed at
the junction of the anterio-caudal one-third and the posterio-
cephalad two-thirds of the incision, and the wound edges are
retracted. With the surgeon’s index fi nger of the nondominant hand
everting the caudal portion of the incision, a 3-0 polydioxanone
(PDS) suture is passed in and out, taking a substantial bite of the
superfi cial temporal fascia, which is then passed out-in through the
opposite side of the same incision (Fig. 7.16).
● Next, the skin hooks are placed at the cephalic or posterior one-
third of the incision and are used to retract the scalp as far pos-
teriorly as possible in the direction of the desired vector. This
vector is predominantly directed laterally and slightly cephalad.
The suture that has been passed through the anterior portion of
the incision is then passed through the temporalis fascia (Fig.
7.17). This suture is tied incrementally as the surgeon watches
the eyebrow being repositioned to the level deemed aesthetically
pleasing.
● A similar suture is then passed through the caudal portion of the
second incision only if additional fi xation is considered necessary
for further repositioning of the eyebrow or correction of eyebrow
asymmetry. Cephaloposteriorly, this suture will be passed through
a bone tunnel. To do this, the surgeon places the skin hooks in the
cranial half of the incision and pulls the scalp laterally and cephal-
ically along the intended vector. A malleable retractor is also
placed at the posterior edge of the wound to protect the soft tissue.
A 1.1 mm hole burr, with a safety guard providing maximum
effective length of 5 mm, is then connected to a power tool such as
an offi ce dermabrader or a Zimmer-Hall drill. Two burr holes,
opposing each other at a 45º angle and approximately 3–4 mm
apart, are made to meet at a depth of 3–4 mm (Fig. 7.18). The bone
is irrigated with saline containing antibiotic solution to avoid
thermal damage during creation of the bone tunnel.
Pre-existing eyebrow asymmetry will persist and be a source of
patient discontent postoperatively if not corrected with differential
eyebrow elevation.
● The free end of the previously placed PDS suture is bent using a
pair of fi ne hemostats, passed through the tunnel (Fig. 7.19) and
tied incrementally, while closely watching the eyebrow. A similar
suture is placed on the opposite side if necessary. The distance
from the cranial border of the eyebrow to the eyelash is measured
bilaterally while the eyes are closed. Generally, this distance
should be about 25 mm.
● Screws or absorbable fi xation devices such as the Endotine Fore-
head Device can be used for the fi xation. If a screw is used the site
Fig. 7.13 Endoscopic forehead rejuvenation 5. Release of arcus
marginalis and fi brous attachment of eyebrow.
Fig. 7.14 Endoscopic forehead rejuvenation 6. Exposure and removal
of the corrugator muscle using grasper.
Fig. 7.15 Endoscopic forehead rejuvenation 7. The fat graft can be
harvested by making a small rent in the deep temporal fascia
immediately cephalad to the most medial portion of the zygomatic
arch.
Fig. 7.12 Endoscopic forehead rejuvenation 4. The Obwegeser
periosteal elevator is used to raise the periosteum and to dissect the
plane superfi cial to deep temporal fascia.

Complications
75
for it is determined while the skin is being retracted, and the screw
is placed in the skull and the incision is repaired. Alternatively,
the screw is placed while the repaired incision is being pulled
cephalically. These screws have a short effective length and will not
likely penetrate the skull. The disadvantages of screw fi xation are
the need for extraction of the screw, cost of the screw, short fi xation
duration and potential for alopecia around the screw site.
● Following completion of fi xation, a TLS suction drain is passed
through the most lateral incision, into the adjacent incision, and
continued step-by-step until it is delivered through the last incision,
into the opposite temporal area and fi xed in position using a 5-0
plain catgut suture.
● The periosteum and the galea are repaired with 5-0 Monocryl, and
the skin is repaired using 5-0 plain catgut.
● After the soft tissue is repaired and while the skin is being draped
posteriorly, the drain is connected to the vacuum tube.
● Before the patient is transferred to the recovery room, the forehead
area, particularly the area of the supratrochlear and supraorbital
nerves, is injected with generous amounts of bupivacaine or ropi-
vacaine to minimize postoperative discomfort.
Optimizing outcomes
●
Preservation of the central portion of the periosteum and the
fascia during the endoscopic forehead lift is crucial to reducing
the medial eyebrow elevation.
POSTOPERATIVE CARE
The drain is removed in 2 days and the sutures usually dissolve in
approximately 7–10 days. With proper care, most patients are very
pleased with the results (Fig. 7.20A–D).
COMPLICATIONS
Although the corrugator muscle can be resected more thoroughly, the
deep horizontal lines on the forehead are not as effectively addressed
with endoscopic forehead rejuvenation as they are with the open tech-
nique, particularly with the subcutaneous forehead lift. This defi ciency
can be overcome to some degree, however, by combining endoscopic
forehead rejuvenation and laser resurfacing. The endoscope approach
is not an optimal choice for those who have an elongated forehead.
Fig. 7.16 Endoscopic forehead rejuvenation 8. A 3-0 PDS suture is
being passed through the anterocaudal portion of the most lateral
incision.
Fig. 7.17 Endoscopic forehead rejuvenation 9. While the skin is
pulled as far posterolaterally as possible, the suture that has been
passed through the anterior portion of the incision is passed
through the deep temporal fascia.
Fig. 7.18 Endoscopic forehead rejuvenation 10. Two burr holes are
made approximately 3–4 mm apart at a 45° angle to each other to
meet at a depth of 3–4 mm.
Fig. 7.19 Endoscopic forehead rejuvenation 11. The free end of the
suture is bent to facilitate passing it through the tunnel.

7
FOREHEAD REJUVENATION
76
An endoscopic forehead rejuvenation may result in inadequate or
excessive elevation of the eyebrows, asymmetry, dimpling upon anima-
tion, undercorrection, overcorrection, or persistent paresthesia.27 A
suboptimal endoscopic forehead rejuvenation result is often the con-
sequence of under, or uneven, resection of the muscle. Uneven resec-
tion of the muscle may also cause dimpling of the forehead skin.
Over-elevation of the eyebrows, most often medially due to aggressive
medial soft tissue release, is the consequence of zealous dissection and
aggressive repositioning of the eyebrows.27
Alopecia around the incision is unlikely and, if it occurs, is often
transient. However, using screws for fi xation, compared to bone tun-
neling, may result in a higher incidence of localized alopecia as a result
of undue tension on the skin level.
Damage to the temporal branch of the facial nerve may result in
paralysis of the frontalis muscle. If this occurs, it is often ephemeral;
however, permanent injury to this nerve is also possible.
Persistent and intense itching of the forehead may be experienced
after an endoscopic or coronal forehead lift. There is no universally
accepted treatment for this complication, but use of antiserotonin-type
compounds, such as cyproheptadine, may result in some relief. Use of
antihistamines may have a benefi cial effect.
Infection and hematoma are also complications of this surgery.
The disadvantages of endoscopic rejuvenation include the need for
specialized instruments and a training process, which is absolutely
vital. Performing an operation using an endoscope while watching
a monitor, rather than directly inspecting the surgical site, is a differ-
ent experience for many surgeons, and proper training and educa-
tion are essential. The chance of sensory nerve damage is initially
slightly higher because this dissection is conducted through a two-
dimensional view, whereas a safe nerve dissection mandates three-
dimensional observation.
CORONAL FOREHEAD LIFT
OPERATIVE APPROACH
Because of the increasing popularity of endoscopic forehead rejuvena-
tion, the coronal forehead lift has lost some of its popularity.
Its advantages include speed of surgery and a bloodless plane of
dissection.
Every student of aesthetic plastic surgery should be familiar with
this technique and perhaps begin learning the forehead rejuvenation
with an open technique provided the patient is willing to accept the
incisional scar. This offers an opportunity for the novice surgeon
to become more knowledgeable about the forehead anatomy and
pathology.
Operative technique
● Before sedation, the coronal incision is marked approximately
5 cm behind the hairline, extending from one temple to the other,
directly above the ear. Generally it is not necessary to shave the
hair; however, some means of controlling the hair, such as the use
of Surgilube, may prevent the hair from becoming a nuisance
during surgery. A curvilinear incision is preferred to minimize the
scar’s visibility. Braiding, especially anterior to the incision, is the
best means of controlling the hair. Care must be taken to avoid
tight braiding because it reduces the fl exibility of the skin.
● Like the other forehead rejuvenation techniques, the coronal
forehead rejuvenation is performed while the patient is under
intravenous sedation.
● After infi ltration of the non-hairbearing forehead with xylocaine
containing 1 : 100 000, and the hairbearing scalp using lidocaine
hydrochloride containing 1 : 200 000 epinephrine, an anteriorly
beveled incision is made and taken down to the subgaleal plane4,28
(Fig. 7.21). Adding curves to this incision may reduce the scar
visibly.
● Laterally the dissection is conducted superfi cial to the deep
temporal fascia.
● Medial to the temporalis muscle, the dissection is extended supra-
periosteally or above the periosteum to the supraorbital rims.
● The arcus marginalis and fi brous bands along the lateral supra-
orbital rim and the lateral orbital wall are released, allowing the
eyebrows to be moved to the intended level.
● The dissection is continued medially until the corrugator muscles
are exposed.
● The supraorbital and supratrochlear nerves are carefully dissected
and preserved.
● The corrugator and the depressor supercilii muscles are removed
as radically as possible (Fig. 7.22). If necessary, the procerus
muscle is also released, but no attempt is made to remove the
procerus muscle completely.
● The resected corrugator site is contoured using fat grafts, including
the glabellar area if indicated (Fig. 7.23).
● The area is irrigated copiously and the skin is draped back.
● Centrally, removal of the skin should be conservative to produce a
pleasing outcome (Fig. 7.24A&B). At no point should the forehead
be pulled tightly centrally.
● Placement of a drain may minimize postoperative bruising and
swelling.
● The incision should be repaired in two layers, approximating the
galea in a separate layer using 5-0 Monocryl and the epidermal
layer using 5-0 catgut.
COMPLICATIONS
● The most common mistake in a coronal forehead lift is aggressive
elevation of the eyebrows, especially medially, which creates an
A
B
C
D
Fig. 7.20 Before and after endoscopic forehead rejuvenation. A, In
repose before endoscopic forehead rejuvenation. B, In repose 1 year
after endoscopic forehead rejuvenation. C, While frowning before
endoscopic forehead rejuvenation. D, While frowning 1 year after
endoscopic forehead rejuvenation.

Complications
77
unnatural appearance. The most signifi cant disadvantages of this
procedure are long incisions and elongation of the forehead.
The most serious complication of coronal forehead rejuvenation is
hair loss. This type of alopecia is unlikely unless undue tension has
been exerted on the scalp fl ap or the patient smokes cigarettes.
A coronal forehead lift may also produce suboptimal results such
as undercorrection, or more commonly, overcorrection.
Patients may experience some paresthesia or permanent anesthesia
in the forehead area after this operation. Infection and hematoma are
also very rare.
Because of the need for further lateral dissection, the frontal branch
of the facial nerves can be injured.24 Other possible complications
include wide or depressed scars, recurrent brow ptosis, poor brow
elevation, and intense itching of the scalp.29 The ear-to-ear coronal
incision, which may result in alopecia, is the major drawback of this
technique.30 Connell et al.10 warn their patients that unusual scalp
sensations and intense itching may occur 3–6 months after surgery.
The symptoms usually disappear after 6–9 months. Occasionally the
patient may feel forehead tightness persisting for 12–18 months;
regenerating sensory nerves are probably the cause of this sensation.
Adamson et al.1 noted that of the 40 patients who underwent
coronal forehead lifts in his study, transient paresthesia (resolving
within 6 months) occurred in 17%, a widened scar in 12%, transient
frontal nerve paresis (lasting 3 weeks to 3 months) in 12%, and dys-
esthesia in 10%. Two patients experienced localized alopecia, and two
sustained transient episodes of depression.
Fig. 7.21 Coronal forehead lift 1. Marking of the incision for coronal
forehead rejuvenation.
Fig. 7.22 Coronal forehead lift 2. The defect following removal of the
corrugator and depressor supercilii muscle.
Fig. 7.23 Coronal forehead lift 3. Fat graft is placed in the corrugator
sites.
A
B
Fig. 7.24 Before and after coronal forehead lift. A, Before coronal
forehead lift. B, After coronal forehead lift.

7
FOREHEAD REJUVENATION
78
POSTOPERATIVE CARE
The sutures are allowed to dissolve. No particular postoperative care
is necessary, except for application of antibiotic ointment directly on
the incision and the drain site, which is continued for a period of 5–7
days. The drain is removed in 2 days and patients are allowed to wash
their hair with shampoo and warm water on the third postoperative
day.
Use of hair dryers and curling irons should be avoided for at least
2 weeks and with extreme care thereafter because the scalp may be
hypoesthetic, and thermal damage could occur without patient dis-
comfort. In addition, the patient should not color the hair for 2–3
weeks.
FOREHEAD RHYTIDECTOMY WITH
PRETRICHIAL INCISION
Forehead
rhytidectomy
with
pretrichial
incision
has
many
advantages:
● it effectively eliminates crow’s feet and forehead wrinkles;
● postoperative hair loss is avoided;
● scalp sensation is preserved with the subcutaneous dissection;
● long foreheads can be shortened (Fig. 7.25A&B);
● the surgeon is afforded outstanding exposure to the depressor
supercilii, procerus, and corrugator muscle groups.
OPERATIVE APPROACH
Operative technique
● Pretrichial forehead rejuvenation is conducted under intravenous
sedation.
● The incision design is critical and will determine the visibility of
the scars in most patients. If the patient is endowed with an exag-
gerated widow’s peak, the incision will be started approximately
1 cm behind this anatomic landmark, continued along the hairline
to the temple area, and taken behind the hairline toward the side-
burns. The incision should be designed in a curvilinear fashion to
further minimize its visibility (Fig. 7.25). Centrally, because the
amount of skin removed is somewhat minimal, a portion of the
widow’s peak could be preserved. The amount of skin to be removed
laterally is signifi cant; however, the hair in this area is sparse and
fi ne, so what is removed is not often consequential. This type of
incision often allows a portion of the incision to fall behind the
hairline.
Straight pretrichial incision may result in scar visibility, reducing
patient satisfaction.
● After completion of the marking, the hair is shaved anterior to and
a few millimeters behind the incision.
● Next, the face is prepped and draped, and the forehead is infi ltrated
with lidocaine hydrochloride containing 1 : 100 000 epinephrine
and a beveled incision is made (Fig. 7.27).
● In spite of vasoconstriction produced by injection of epinephrine,
some bleeding will be encountered. The dissection is carefully
conducted in a caudal direction at the interface between the sub-
Fig. 7.25 Forehead rhytidectomy with pretrichial incision 1. Design
of the curvilinear forehead incision for pretrichial forehead
rejuvenation.
Fig. 7.26 Forehead rhytidectomy with pretrichial incision 2. The
incision is made in a beveled fi ssure to provide an opportunity for
hair growth into the incisional scar.
Fig. 7.27 Forehead rhytidectomy with pretrichial incision 3. The
dissection will be conducted in the subperiosteal plane.

Operative Approach
79
cutaneous plane and the frontalis muscle, or in the subperiosteal
plane (Fig. 7.28). If there is no extensive wrinkling on the forehead
area, the dissection could be conducted in the submuscular or
subperiosteal level. The dissection in this plane is terminated
caudal to the most caudal horizontal line in the central forehead
area and down to the eyebrow level laterally. Every effort should
be made to avoid raising a thin skin fl ap especially on patients who
smoke or are previous smokers.
● After the fi nal caudal horizontal crease is released, the medial
borders of the frontalis muscle are elevated and the submuscular
dissection is continued medially until the corrugator and depressor
supercilii muscles are exposed. These muscles are then removed
with careful dissection and meticulous hemostasis.
● Fat graft is used to replace the resected corrugator muscle (see
above for endoscopic forehead rejuvenation).
● The procerus muscles are removed conservatively.
● Laterally the skin fl ap is dissected down to the lateral orbital
wall.
● As the skin is then re-draped, a great deal of excessive skin overlaps
the incision (Fig. 7.29). The redundant skin is excised and repaired
tension-free using 6-0 Monocryl and 6-0 fast absorbable catgut.
The aesthetic goals are achieved predictably (Fig. 7.30).
For patients who do not demonstrate deep horizontal lines or for
those who smoke, dissection may be subperiosteal or submuscular
without any subcutaneous component.
Dissection in the submuscular plane
● The skin incision is carried through the frontalis muscle and dis-
section is continued caudally in the plane between the muscle and
the periosteum (this technique is similar to the coronal forehead
rejuvenation, the only difference being that the incision site is at
the hairline rather than 5 cm behind the hairline and is curvilinear
rather than straight).
● The arcus marginalis is released.
● The dissection is continued laterally in the plane immediately
above the deep temporal fascia and the periosteum is released
above the orbital rim.
● The corrugator and depressor supercilii muscles are identifi ed and
resected and replaced with a fat graft.
Fig. 7.28 Forehead rhytidectomy with pretrichial incision 4. The
corrugator muscles are exposed by incising the periosteum.
Fig. 7.29 Forehead rhytidectomy with pretrichial incision 5. The
forehead fl ap is draped back and excess skin is excised without any
tension.
A
B
Fig. 7.30 Before and after forehead rhytidectomy with pretrichial
incision. A, Elongated and senescent forehead before surgery.
B, After pretrichial subcutaneous forehead rejuvenation technique.

7
FOREHEAD REJUVENATION
80
● If indicated, the procerus muscle is removed conservatively.
● Excess skin is trimmed following the outline of the underlying inci-
sion sequentially (some tension is necessary when the dissection is
conducted in a deeper plane compared with the subcutaneous
approach).
● A suction drain is placed in position if submuscular dissection is
being performed as an isolated procedure (if a subcutaneous fore-
head rejuvenation is combined with a facial rhytidectomy, there is
no need for a drain because any drainage in the subcutaneous
plane will fl ow to the facelift area).
● A combination of 6-0 Monocryl subcutaneous and 6-0 plain fast-
absorbable catgut skin sutures are used meticulously for a precise
repair of the incision.
● The incision line is treated with one pass of the CO2 laser set at
60 watts. The laser treated area is then covered with the Laser-Seal
dressing.
Optimizing outcomes
●
The amount of skin that is excised medially during open
forehead rejuvenation should be minimal to avoid excessive
elevation of the medial eyebrow.
●
Avoiding injection of a solution containing 1 : 100 000
epinephrine in hairbearing skin may reduce the incidence of
alopecia after forehead rejuvenation, especially if the patient is
a current or previous smoker.
COMPLICATIONS
If a subcutaneous dissection is used on a patient who currently smokes
or smoked heavily in the past or if the skin is pulled too vigorously,
skin necrosis may result. For this reason, the submuscular dissection
is a safer choice for the patient who is a current or past smoker.
Although permanent paresthesia of the scalp is an unlikely result of a
subcutaneous forehead lift, it becomes more likely when the dissection
has been submuscular. Asymmetry and damage to the facial nerve are
specifi c complications of submuscular dissection.
In a study of 30 patients with anterior incision forehead rejuvena-
tion13 only two patients (who were smokers) experienced small areas
of necrosis requiring revisions.
In another study by Vogel and Hoopes31, complications of subcu-
taneous forehead rhytidectomy included one small hematoma, tempo-
rary or clinically unnoticeable hypesthesia (66%), altered scalp
sensibility (33%), persistent forehead hypesthesia or paresthesia (33%),
and temporary (12%) or permanent (12%) alopecia.
To determine whether beveled or perpendicular incisions should
be used when areas containing hair follicles are incised during brow
elevation or facial rejuvenation, Camirand and Doucet4 studied 30
patients. For each patient, one half of the incision was beveled and the
opposite half was perpendicular. Neither the patients nor the examin-
ers were aware of the type of incision used for each side. The resulting
scars were examined for visibility, nonlinearity, absence of hypopig-
mentation, and presence of hair in and in front of the scar. In 95% of
the patients the scar on the side that was incised in a beveled fashion
was judged to be more desirable.
The disadvantages of forehead rhytidectomy with pretrichial inci-
sion are the additional time required for dissection and detailed repair,
and the potential for a visible scar at the hair junction on the frontal
area.13
Fig. 7.31 Shortening of the elongated forehead 1. If the intention is
to shorten the forehead signifi cantly, the subgaleal dissection of the
scalp is continued to the occiput area in the subgaleal level.
SHORTENING OF
THE ELONGATED FOREHEAD
The main advantage of this technique is that it is very effi cacious and
produces gratifying results (Fig. 7.31A&B); however, it is tedious and
time consuming to perform.
OPERATIVE APPROACH
The forehead may become elongated as a consequence of senescence
or genetic predisposition. It can also be the consequence of hair loss
or may result from a coronal forehead lift. Slight or moderate elonga-
tion of the forehead can be corrected by the pretrichial incision
described above. For a patient who exhibits signifi cant forehead elon-
gation, exceeding 1.5–2 cm beyond what is considered aesthetically
pleasing, a scalp advancement is performed.32 This procedure can be
combined with a forehead lift or can be utilized merely to shorten the
forehead on a patient who has previously undergone an open forehead
rejuvenation that has elongated the forehead.
Operative technique
● Shortening of the elongated forehead is done under intravenous
sedation.
● Before the incision is made, the existing incision is marked in a
curvilinear fashion, a few millimeters behind the current hairline,
to ensure the presence of denser hair at the beginning of the inci-
sion. The positions of the current and the planned hairlines are
registered in the underlying bone using brilliant green and a 25-
gauge needle. A curvilinear, beveled incision is used to allow hair
growth in the incisional scar.
● The incision is then deepened through the galea and extended to
the periosteum.
● The dissection is continued posteriorly in the supraperiosteal
plane, and the entire scalp is elevated to the level of the occipital
notch posteriorly and the ear laterally (Fig. 7.31).
● Depending on the amount of skin advancement necessary, one to
three relaxation incisions are made in the galea, approximately
4 cm apart (Fig. 7.32). Corresponding to the advanced level of

Conclusion
81
Fig. 7.32 Shortening of the elongated forehead 2. One to three
relaxing incisions are made in the galeal fascia, depending on the
extent of necessary forehead advancement.
Fig. 7.33 Shortening of the elongated forehead 3. Galeal fascia is
advanced and suspended using a bone tunneling technique.
Fig. 7.34 Shortening of the elongated forehead 4. The non-
hairbearing skin of the scalp is excised incrementally to achieve
shortening of the forehead.
these relaxation incisions, bone tunnels are created using a burr
with safety guard at 5 mm. Two holes 3–4 mm apart at 45º angles
are placed to meet at a depth of approximately 3–4 mm.
● Next, a 3-0 PDS suture is passed through the galeal fascia anterior
to the relaxation incision. The free end of the suture is then bent
using a fi ne pair of hemostats and passed through the bone tunnel.
● The galeal fascia is advanced and fi xed to the bone in three sites
on each row (Fig. 7.33). As indicated earlier, the number of rows
is dictated by the suppleness of the skin and the amount of advance-
ment necessary. Each relaxation incision will yield 1.0–1.5 cm of
advancement depending on the elasticity of the scalp. For a patient
who needs a full 2–4 cm of advancement, three rows of relaxation
incisions and bone tunnels may be necessary. A fi nal row of sutures
is placed to fi x the posterior fl ap margin to the underlying bone at
the hairline level, using the markings described earlier, to avoid
unplanned elevation of the eyebrows.
● After advancement of the scalp to the proper position and forehead
lift, if it is part of the aesthetic plan, the surplus non-hairbearing
skin of the forehead is trimmed (Fig. 7.34).
● The scalp is repaired using 5-0 Monocryl and 6-0 plain catgut
sutures with minimal tension laterally only.
● The incision is treated with one pass of a CO2 laser with energy
levels of 60 watts and density of 5 (100 mg on new CO2 machines
and 300 mg with the former CO2 laser machine) and covered with
Laser-Seal dressing.
● Because of elimination of dead space, there is no need for a drain;
however, if the forehead is elevated in addition to being shortened,
use of a drain becomes advisable.
COMPLICATIONS
The most signifi cant complication of forehead shortening is patchy
alopecia. If it occurs, this problem is rarely permanent. Infection and
hematomas are unlikely. Asymmetry may develop. The scars may also
become visible and cause patient dissatisfaction.
Occasionally the procedure results in temporary (or rarely, perma-
nent) sensory loss.
POSTOPERATIVE CARE
If a drain is placed it is removed 2 days postoperatively. The Laser-Seal
dressing is removed after 5 days. The results are usually very gratifying
(Fig. 7.35).
CONCLUSION
Multiple techniques are available for forehead rejuvenation (Table 7.1).
For patients who seek temporary improvement of forehead wrinkles,
injectable material is the optimal treatment. More lasting results may
be obtained from the injection of fat or fat grafting.
Patients who have deep frown lines and optimal, or near optimal
eyebrow position are best served by transpalpebral corrugator resection,
whereas those who exhibit eyebrow ptosis and deep frown lines with
normal or near normal forehead lengths without deep horizontal
creases benefi t most from an endoscopic forehead lift.
Patients with borderline or mildly elongated forehead length are
suitable candidates for a pretrichial, subcutaneous or submuscular
forehead lift, and those with moderate to severe forehead elongation
may be best treated with a forehead shortening technique.

7
FOREHEAD REJUVENATION
82
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13. Guyuron B, Davies B. Subcutaneous anterior hairline forehead
rhytidectomy. Aesthetic Plast Surg 1988; 12:77–83.
14. Hinderer UT, Urriolagoitia F, Vildosola R. The blepharoperiorbitoplasty:
anatomical basis. Ann Plast Surg 1987; 18:437–453.
15. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg
1997; 24:347–367.
16. Michelow B, Guyuron B. Rejuvenation of the upper face: a logical
gamut of surgical options. Clin Plast Surg 1997; 24:199–212.
17. Guyuron B, Majzoub MD. Facial augmentation with core fat graft:
a preliminary report. Plast Reconstr Surg 2007; 120(1):295–302.
18. Neuber G. Fat transplantation. Verl Dtsh Ges Chir 1893; 22:66.
19. Guyron B, Michelow B, Thomas T. Corrugator supercilii muscle
resection through blepharoplasty incision. Plast Reconstr Surg 1995;
95:691–696.
20. Knize DM. Transpalpebral approach to the corrugator supercilii and
procerus muscles. Plast Reconstr Surg 1995; 95:52–62.
Table 7.1 Summary of the armamentarium for forehead rejuvenation.
Procedure
Indications
Advantages
Disadvantages
Poor indicators
Transpalpebral
corrugator resection
No eyebrow ptosis;
minimal frown lines
Simplicity
Minimal medial eyebrow
elevation and no lateral
eyebrow elevation
Signifi cant eyebrow ptosis
Endoscopic
Optimal or borderline
long forehead
Minimal scars; high
patient acceptance
Need for special tools
(scope/monitor); slow
learning curve
Long forehead
Open forehead
(coronal)
Short forehead
Effective; short
duration of surgery
Elongation of forehead;
length of incision
Long forehead
Open forehead
(pretrichial)
Slight elongation,
many deep wrinkles
Forehead shortening;
effective
Scar visibility; tedious
procedure
Propensity to form hypertrophic
scar; short forehead
Open forehead
(shortening)
Moderate to severe
elongation
Forehead shortening
Lengthy and tedious
procedure
Poor healers
A
B
Fig. 7.35 Before and after shortening of the elongated forehead. A, Before forehead shortening and lift. B, After forehead shortening and lift.

83
References
21. McGregor L. A synopsis of surgical anatomy. 4th edn. Bristol: John
Wright & Sons; 1942:1–4.
22. Isse N, Fodor PB. Forehead rejuvenation. In: Isse N, Fodor PB, eds.
Endoscopically assisted plastic surgery. St Louis: Mosby; 1996.
23. Gross CM, ed. Gray’s anatomy of the human body. 28th edn.
Philadelphia: Lea & Febiger; 1968:382–385.
24. Lorenc ZP, Ivy E, Aston SJ. Neurosensory preservation in endoscopic
forehead plasty. Aesthetic Plast Surg 1995; 19:411–413.
25. Guyuron B, Rose K. Harvesting fat from the infra temporal fossa. Plast
Reconstr Surg 2004; 114:245–247.
26. Guyuron B, Kopal C, Michelow PJ. Stability after endoscopic forehead
surgery using single-point fascia fi xation. Plast Reconstr Surg 2004;
116:1988–1994.
27. Guyuron B. Endoscopic forehead rejuvenation. I. Limitations, fl aws, and
rewards [reply]. Plast Reconstr Surg 2007; 119:1116–1119.
28. Camirand A. Hairline incisions. Plast Reconstr Surg 1999;
103:736–737.
29. Ramirez OM. The anchor subperiosteal forehead lift. Plast Reconstr
Surg 1995; 95:993–1003.
30. Vasconez LO, Core GB, Gamoa-Bobadilla M, et al. Endoscopic
techniques in coronal brow lifting. Plast Reconstr Surg 1994; 94:788–
793.
31. Vogel JE, Hoopes JE. The subcutaneous forehead lift with an anterior
hairline incision. Ann Plast Surg 1992; 28:257–265.
32. Guyuron B, Behmand RA, Green R. Shortening of the forehead. Plast
Reconstr Surg 1999; 103:218–223.

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85
CHAPTER 8
Periorbital Rejuvenation
Bahman Guyuron and Donald Hudak
Senescent changes in the periocular area are common aging stigmata.
These changes include brow ptosis, development of excess skin in the
upper eyelid and protrusion of orbital fat in both the upper and lower eyelid
due to weakening of the orbital septum. Involutional eyelid ptosis may
also affect most patients over the age of 60. Aponeurotic or involutional
ptosis and congenital ptosis are the two most common types of ptosis.
Ernst Fuchs coined the term blepharochalasia in 1896.1 The term
is used now for idiopathic recurrent swelling, although Fox fi rst used
the term dermatochalasis over 50 years later. In the 19th century, the
correction of ptosis was performed by resecting skin. William Bowman
fi rst described both anterior and posterior approaches.2 The fi rst cos-
metic surgery article was written by Charles Conrad Miller on the
excision of ‘bag like folds of skin of the eyelid’.3 He went on to describe
a subciliary incision as well as a supratarsal fold incision. The fi rst
cosmetic surgery text was published in 1907 by the same author.4 This
new area of modern medicine was not as well accepted as the second
book of cosmetic surgery by Frederick Strange Kolle.5 Kolle described
the importance of marking the amount of skin to be excised preop-
eratively. A transconjunctival approach was fi rst described by Julien
Bourget along with the fi rst pre- and postoperative photographs.6 The
transconjunctival approach lost favor but regained popularity when
Tessier used the same approach for access to the orbital fl oor.7 The
retroseptal approach was introduced by Baylis and Sutcliffe in 1983.
The distinct fat compartments of the upper lid were fi rst described
by Bourget, but Salvadore Castanares described their relation to each
other as well as the lower-lid fat pads.8 The importance of lacrimal
gland prolapse was noted by Smith and Petrelli.9 Naugle realized the
importance of lower-lid tightening in blepharoplasty.10 Multiple authors,
including Rees, Flowers, Furnas, Aston, Skoog, and Sheen, have further
advanced the art of blepharoplasty surgery. Hamra noted that correc-
tion of the periocular area extends to the lower face and includes re-
draping of the orbital fat with elevation of the SOOF and midface.11
Indications and contraindications
Indications:
●
Excess skin of the upper or lower eyelids
●
Steatoblepharon or fat protrusion in the upper or lower eyelids
●
Ptosis or drooping of the upper eyelids.
●
Eyelid hyperpigmentation.
Contraindications:
●
Severe dry eye
●
Facial palsy – if excision of the eyelid is part of the aesthetic goal
●
Lagophthalmos – exception is removal or repositioning of the
fat at time of correction of lagophthalmos
●
Corneal disease, such as neurotrophic keratopathy, that could
be exacerbated by blepharoplasty. Presence of any infection or
infl ammatory conditions in the periorbital region.
Summary
1. Periorbital anatomy is complex and surgery in this region can
result in some of the most troubling and possibly, though
rarely, serious complications without suffi cient knowledge of
the anatomy and proper patient preparation.
2. One has to determine the exact desires and expectations of
the patient. This will govern how one will correct the various
pathologic problems.
3. A consultation with an ophthalmologist within 1 year of
surgery is important to assess for dry eye, unrecognized
corneal disorders, visual defects, or glaucoma.
4. Strict control of hypertension and avoidance of medications
with potential adverse effects on coagulation, including herbal
supplements, over-the-counter non-steroidal anti-infl ammatory
compounds (NSAIDS) and/or aspirin will help to reduce
hemorrhagic complications.
5. It is crucial to evaluate the patient for signifi cant frontalis
muscle recruitment, as this may mask eyelid ptosis and cause
asymmetric eyebrow position.
6. The margin refl ex distance (MRD) as measured from the light
refl ex point on the cornea to the upper lid margin is optimally
about 4–5 mm.
7. Lower eyelid laxity is exceedingly common and either canthopexy
or canthoplasty should be considered in most patients.
8. Fat excision should be conservative and should not exceed
posterior to the level of the orbital rims. Repositioning of some,
or most, of the protruding fat should be considered on the
majority of patients.
9. A negative vector, where the most prominent portion of the
globe on the profi le view is more anterior to the most
prominant portion of the malar soft tissues, is associated with
a higher incidence of dry eye syndrome postoperatively.
10. A minor, temporary post-blepharoplasty lagophthalmos is
common. This is even more common after using the levator
approach to ptosis surgery. It initially should be treated with
frequent lubrication and ophthalmic ointment and lid exercises.
11. Most patients have a symmetric eyelid and globe position
which should be brought to the patients attention.
INTRODUCTION
Of all the plastic surgical procedures, blepharoplasty is second only to
rhinoplasty in complexity and demand for technical precision. Further-
more, it carries a potential risk of blindness, the most morbid compli-
cation of any cosmetic procedure other than death. Therefore, detailed
preoperative planning and meticulous execution of the surgical objec-
tives are essential for a successful outcome.