Aesthetic Plastic Surgery Video Atlas E Book
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Aesthetic Plastic Surgery Video Atlas E Book

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625 pages
English

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Description

Aesthetic Plastic Surgery Video Atlas - edited by Dr. Bahman Guyuron et al. - brings you the detailed visual guidance and unmatched expertise you need to master the most popular cosmetic surgery procedures and achieve breathtaking results. Full-color photographs and narrated procedural videos lead you step-by-step through techniques such as breast augmentation, non-surgical facial rejuvenation with fillers, periorbital rejuvenation, primary rhinoplasty, and more. Tips and tricks from a veritable "who’s who" in plastic surgery equip you to successfully deliver the results your patients expect. At www.expertconsult.com you can reference the complete text, download the images, and watch the videos anytime, anywhere from any computer.

  • Visualize how to proceed through a highly visual format that employs full-color art and video clips to demonstrate breast augmentation, non-surgical facial rejuvenation with fillers, periorbital rejuvenation, primary rhinoplasty, and more.
  • Avoid pitfalls and achieve the best outcomes thanks to a step-by-step approach to each procedure, complete with tips and tricks of the trade from leading experts in aesthetic plastic surgery.
  • See how the masters do it! Watch video clips of 16 key procedures (two hours running time) being performed by experts, complete with narration explaining each step.
  • Stay current with the latest techniques and findings about cohesive gel breast implants, the use of minimally invasive techniques, and other hot topics.
  • Take it with you anywhere! Access the full text, downloadable image library, video clips, and more at www.expertconsult.com.

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Informations

Publié par
Date de parution 09 septembre 2011
Nombre de lectures 4
EAN13 9781455739899
Langue English
Poids de l'ouvrage 4 Mo

Informations légales : prix de location à la page 0,0496€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.

Exrait

  • Visualize how to proceed through a highly visual format that employs full-color art and video clips to demonstrate breast augmentation, non-surgical facial rejuvenation with fillers, periorbital rejuvenation, primary rhinoplasty, and more.
  • Avoid pitfalls and achieve the best outcomes thanks to a step-by-step approach to each procedure, complete with tips and tricks of the trade from leading experts in aesthetic plastic surgery.
  • See how the masters do it! Watch video clips of 16 key procedures (two hours running time) being performed by experts, complete with narration explaining each step.
  • Stay current with the latest techniques and findings about cohesive gel breast implants, the use of minimally invasive techniques, and other hot topics.
  • Take it with you anywhere! Access the full text, downloadable image library, video clips, and more at www.expertconsult.com.

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Aesthetic Plastic Surgery Video Atlas

Bahman Guyuron, MD, FACS, Kiehn-DesPrez Professor and Chair
Department of Plastic Surgery, Case Western Reserve University/University Hospitals Case Medical Center, Cleveland, Ohio, USA

Brian M. Kinney, MD, FACS, MSME, Clinical Assistant Professor of Plastic Surgery
University of Southern California, Private Practice, Plastic and Reconstructive Surgery, Los Angeles, CA, USA
Saunders
Copyright

SAUNDERS is an imprint of Elsevier Inc.
© 2012, Elsevier Inc. All rights reserved.
DVD footage for chapter 123 Thigh and buttock lift, and post-bariatric surgery skin tightening Copyright © 2007 Covidien. All rights reserved. Reprinted with the Permission of Covidien
First published 2009
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: healthpermissions@elsevier.com . You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions .
Saunders
British Library Cataloguing in Publication Data
Aesthetic plastic surgery video atlas .
1. Surgery, Plastic-Atlases.
I. Guyuron, Bahman .
617.9’52-dc22
9781455711833
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress.

Notice
Medical knowledge is constantly changing. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the Publisher nor the author assume any liability for any injury and/or damage to persons or property arising from this publication.
The Publisher

Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
User Guide
Aesthetic Plastic Surgery Video Atlas
The supporting website for the book, which includes all of the book’s content, including the video and image downloads, can be found at www.expertconsult.com
Preface

Bahman Guyuron, MD
Implementing the knowledge attained from a book chapter in the operating room, regardless of how detailed the description of the procedure is in the text, often presents an enormous challenge since some of the nuances would be commonly omitted. A combination of proper description of the surgical technique and precise artistic renderings along with clear videos provides the optimum source of information for surgery, and overcomes this difficulty in execution in most instances. With that in mind, we have prepared this book to give the readers a practical tool that can be used to augment the safety of the contemplated procedures. This atlas with accompanying videos will not only serve residents and new graduates, who can read the text, review the illustrations and observe the video prior to the surgery, it will also help seasoned surgeons who may wish to refine their technique. Especially for the latter group who has experience with these techniques, some of the points that are demonstrated by the experts in the videos may serve to facilitate the surgery, add to the safety and improve the outcomes. We have asked highly respected authors in the field to share their techniques with the readers using as much detail as possible. The videos have been edited by our well-regarded colleague Dr. Brian M. Kinney, who is highly recognized for his quintessential talent in this area, and we are utterly grateful to him for his contribution to this volume. We are very much hopeful that the readers are going to enjoy the content, the illustrations and the videos. Finally, we would like to acknowledge and thank the other editors of Plastic Surgery, Indications and Practice for their unselfish and persevering work, expertise and wisdom which made this spin off possible.
List of Contributors

Al S. Aly, MD
Assistant Professor of Surgery, University of Iowa College of Medicine, Coralville, IA, USA
Chapter 20 Abdominoplasty
Clip 122.1 Abdominoplasty

Marcus Vinicius Jardini Barbosa, MD PhD
Collaborator Professor, Department of Surgery, Division of Plastic Surgery, Federal University of Sâo Paulo, Sâo Paolo, SP, Brazil
Chapter 121 Liposculpture

Devra B. Becker, MD
Assistant Professor, Department of Plastic Surgery, Case Western Reserve University/University Hospitals, Cleveland, OH, USA
Chapter 22 Surgical Management of Migraine Headaches

Sydney R. Coleman, MD
Assistant Clinical Professor NYU School of Medicine, Tribeca Plastic Surgery, New York, NY, USA
Chapter 15 Augmentation of Facial Structures with Autologous Fat

Albert E. Cram, MD FACS
Iowa City Plastic Surgery, Coralville, IA, USA
Chapter 20 Abdominoplasty

Zoe Diana Draelos, MD
Primary Investigator, Dermatology Consulting Services, High Point, NC, USA
Chapter 2 Skin Care Including Chemical Peeling

Lydia Masako Ferreira, MD
Full Professor and Chairwoman, Plastic Surgery Division, Federal University of Säo Paulo, Säo Paulo, Brazil
Chapter 121 Liposculpture

Jack Fisher, MD
Associate Clinical Professor, Department of Plastic Surgery, Vanderbilt University, Nashville, TN, USA
Chapter 6 Management of Alopecia

Richard O. Gregory, MD
Director, Institute of Aesthetic Surgery Celebration, FL, USA
Chapter 5 Laser Facial Resurfacing and Dermabrasion

Jeffrey Gusenoff, MD
Director, Life After Weight Loss, Division of Plastic and Reconstructive Surgery, University of Rochester, Rochester, NY, USA
Chapter 21 Bodylifts and Post-massive Weight Loss Body Contouring
Clip 21.1 Post Bariatric Skin Tightening

Bahman Guyuron, MD FACS
Kiehn-DesPrez Professor and Chair, Department of Plastic Surgery, Case Western Reserve University/University Hospitals Case Medical Center, Lyndhurst, OH, USA
Chapter 1 Patient Assessment
Chapter 7 Forehead Rejuvenation
Chapter 8 Periorbital Rejuvenation
Chapter 12 Secondary Rhinoplasty
Chapter 13 Genioplasty
Chapter 22 Surgical Management of Migraine Headaches
Clip 4.1 Botulinum toxin
Clip 7.1 Forehead Rejuvenation
Clip 8.1 Periorbital Rejuvenation
Clip 10.1 Neck Rejuvenation
Clip 13.1 Genioplasty

Elizabeth J. Hall-Findlay, MD FRCSC , Private Practice, Mineral Springs Hospital, Banff, AB, Canada
Chapter 17 Breast Reduction
Clip 17.1 Breast Reduction
Clip 18.1 Mastopexy

Per Hedén, MD PhD
Associate Professor in Plastic Surgery, Akademikliniken, Stockholm, Sweden
Chapter 16 Breast Augmentation
Clip 16.1 Breast Augmentation

Ronald E. Hoxworth, MD
Assistant Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
Chapter 11 Rhinoplasty
Clip 11.1 Primary Rhinoplasty

Erik A. Hoy, MD
Resident, Department of Plastic Surgery, Brown University - Rhode Island Hospital, Providence, RI, USA
Chapter 10 Neck Rejuvenation

Donald T. Hudak, MD
Assistant Professor of Plastic Surgery and Ophthalmology, Case Medical Center, Cleveland, Assistant Professor of Ophthalmology, University of Cincinnati, Cincinnati Eye Institute, Cincinnati, OH, USA
Chapter 8 Periorbital Rejuvenation

Michael A.C. Kane, MD
Attending Surgeon, Manhattan Eye, Ear and Throat Hospital, New York, NY, USA
Chapter 4 Botulinum Toxin

Brian M. Kinney, MD FACS MSME
Clinical Assistant Professor of Plastic Surgery, University of Southern California Private Practice, Plastic and Reconstructive Surgery, Los Angeles, CA, USA
Chapter 3 Non-surgical Facial Rejuvenation with Fillers
Clip 3.1 Non-surgical Facial Rejuvenation with Fillers
Clip 9.1 High SMAS Face and Midface Lift

Timothy J. Marten, MD
Founder and Director, Marten Clinic of Plastic Surgery, San Francisco, CA, USA
Chapter 9 Facelift with SMAS Flaps

G. Patrick Maxwell, MD FACS
Maxwell Aesthetics, Nashville, TN, USA
Chapter 18 Mastopexy

Fabio X. Nahas, MD PhD
Associate Professor, Division of Plastic Surgery, Federal University of Säo Paulo, Säo Paulo, Brazil
Chapter 19 Liposculpture
Clip 19.1 Liposculpture

Thomas E. Rohrer, MD
Director, Mohs Surgery, SkinCare Physicians of Chestnut Hill, Clinical Associate Professor, Department of Dermatology, Boston University, Boston, MA, USA
Clip 5.1 Laser Resurfacing and Dermabrasion

Rod J. Rohrich, MD
Professor and Chairman, Crystal Charity Ball Distinguished Chair in Plastic Surgery, Betty and Warren Woodward Chair in Plastic and Reconstructive Surgery, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
Chapter 11 Rhinoplasty
Clip 11.1 Primary Rhinoplasty

Silvia Cristina Meneghetti Rotemberg, MD
Associate Staff, Plastic Surgery, The Cleveland Clinic, Cleveland, OH, USA
Chapter 20 Abdominoplasty

David J. Rowe, MD
Assistant Professor, Plastic Surgery, Department of Plastic Surgery, University Hospitals Case Medical Center, Lyndhurst, OH, USA
Chapter 3 Non-surgical Facial Rejuvenation with Fillerss

J. Peter Rubin, MD
Director of Body Contouring Program, Associate Professor of Surgery, Division of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Chapter 21 Bodylifts and Post-Massive Weight Loss Body Contouring
Clip 21.1 Post Bariatric Skin Tightening

Alesia P. Saboeiro, MD , Private Practice, Tribeca Plastic Surgery, New York, NY, USA
Chapter 15 Augmentation of Facial Structures with Autologous Fat

David Stepnick, MD FACS
Associate Professor, Facial Plastic Surgery, Department of Plastic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, Lyndhurst, OH, USA
Chapter 3 Non-surgical Facial Rejuvenation with Fillers
Chapter 12 Secondary Rhinoplasty

Stephanie Stover, MD
Associate to Dr Maxwell, Nashville Plastic Surgery, Nashville, TN, USA
Chapter 18 Mastopexy

Patrick K. Sullivan, MD
Associate Professor, Plastic Surgery, Brown University, Providence, RI, USA
Chapter 10 Neck Rejuvenation

Robin Unger, MD
Assistant Clinical Professor, Department of Dermatology, Mount Sinai Medical School, New York City, NY, USA
Clip 6.1 Hair Transplantation

Walter Unger, MD
Clinical Professor, Department of Dermatology, Mount Sinai School of Medicine, New York, NY, USA
Clip 6.1 Hair Transplantation

Jeremy Waldman, MD
Plastic Surgeon, Private Practice, Plastic and Reconstructive Surgery, Waldman Plastic Surgery and Dermatology, PLLC, Nashua, NH, USA
Chapter 18 Mastopexy

Adam Bryce Weinfeld, MD
Attending Plastic Surgeon, University Medical Center, Brackenridge and Dell Children’s Medical Center of Central Texas, Austin, TX, USA
Chapter 13 Genioplasty

Michael J. Yaremchuk, MD
Clinical Professor of Surgery, Harvard Medical School, Chief of Craniofacial Surgery, Massachusetts General Hospital, Boston, MA, USA
Chapter 14 Aesthetic Contouring of the Craniofacial Skeleton
Clip 14.1 Chin Augmentation with Porous Implants
Clip 14.2 Mandible Augmentation with Porous Implants
Dedication
To Bruce Achauer.
Acknowledgements
We would like to thank our families whose sacrifices and unselfish reduction of demand on our family time makes our participation in endeavors like editing this book possible for us.
Bahman Guyuron: To Lora, Glen, Greg, and Grant
Brian M. Kinney: To my Mother and Father, and Pearl
Table of Contents
Instructions for online access
Cover
Copyright
User Guide
Preface
List of Contributors
Dedication
Acknowledgements
Chapter 1: Patient Assessment
Chapter 2: Skin Care Including Chemical Peeling
Chapter 3: Non-surgical Facial Rejuventation with Fillers
Chapter 4: Botulinum Toxin
Chapter 5: Laser Facial Resurfacing and Dermabrasion
Chapter 6: Management of Alopecia
Chapter 7: Forehead Rejuvenation
Chapter 8: Periorbital Rejuvenation
Chapter 9: Facelift with SMAS Flaps
Chapter 10: Neck Rejuvenation
Chapter 11: Primary Rhinoplasty
Chapter 12: Secondary Rhinoplasty
Chapter 13: Genioplasty
Chapter 14: Aesthetic Contouring of the Craniofacial Skeleton
Chapter 15: Augmentation of Facial Structures with Autologous Fat
Chapter 16: Breast Augmentation
Chapter 17: Breast Reduction
Chapter 18: Mastopexy
Chapter 19: Liposculpture
Chapter 20: Abdominoplasty
Chapter 21: Bodylifts and Post Massive Weight Loss Body Contouring
Chapter 22: Surgical Management of Migraine Headaches
Index
Chapter 1 Patient Assessment

Bahman Guyuron
A cosmetic surgery patient requires a different evaluation from the patient who is seeking a reconstructive procedure. Since the former is an elective surgery, decisions regarding the patient’s medical suitability to undergo surgery, patient preparation and selection of a procedure that will successfully fulfill the aesthetic objectives must be approached with more scrutiny every step of the way.



Summary

1. The first step in achieving a successful surgery outcome is to establish a clear understanding of the patient’s objectives and to ensure that they match those of the surgeon’s.
2. Hypertension, diabetes, smoking, cold intolerance, consumption of anti-inflammatory medication and some of the herbal medications, such as gingko biloba, may increase the risk of aesthetic surgery or prolong the recovery.
3. Patients who have a history of multiple previous aesthetic procedures and continue to be dissatisfied may be suffering from body dysmorphic disorder (BDD) and should be assessed with more scrutiny.
4. While patients with thin, light skin (Fitzpatrick I or II) may demonstrate aging faster with fine lines, they respond to chemical peel and laser resurfacing more favorably. On the contrary, patients with thick and dark skin (Fitzpatrick V or VI) are not ideal candidates for resurfacing.
5. Deep horizontal forehead lines are often the consequence of blepharodermachalasia or blepharoptosis and compensation by frontalis muscle. Steps should be taken to relax the frontalis muscle prior to a final judgment as to the position of the eyebrow.
6. On a face with optimal balance, distance from the cephalic border of the eyebrow to the mid point of the pupil on a straight gaze is 2.5 cm.
7. Pre-existing lower lid lag, loss of lower lid tone or presence of a negative vector where the malar soft tissue prominence is positioned behind the cornea on profile, and symptoms of dry eyes mandate conservative surgery and canthopexy or canthoplasty.
8. The intercanthal distance is about 31-33 mm wide and matches the distance from the medial to the lateral canthus {orbital fissure}. The orbital fissures should be more cephalad laterally by 2°.
9. The upper incisor should be visible 2 mm caudal to the upper lip with the lips gently parted on repose, with minimal or no gingiva exposed on smiling.
10. An obtuse neck angle could be the consequence of varying combinations of excess skin, excess supra-platysma fat, excess sub-plastysma fat, prominent platysma bands, hypertrophic anterior belly of the digastric muscles or submaxillary gland and ptotic submaxillary gland.

Introduction
A cosmetic surgery patient requires a different evaluation from the patient who is seeking a reconstructive procedure. Since the former is an elective surgery, decisions regarding the patient’s medical suitability to undergo surgery, patient preparation and selection of a procedure that will successfully fulfill the aesthetic objectives must be approached with more scrutiny every step of the way.
The individual’s perception of the nature of the aesthetic disharmony and his or her motivation for consultation may differ from those of the surgeon. For this reason, the cardinal aim in the assessment of a patient seeking aesthetic surgery is to delineate the patient’s perception of the existing problems. A circumspect facial analysis then guides the surgeon in choosing the proper candidate and the optimal procedure. Current, or previous, cigarette smoking may increase the risk of complications from surgeries of any type, especially those requiring elevation of skin flaps. Cessation of smoking does not necessarily eliminate this risk; it may only reduce the extent of complications. Thus, in most incidences, those who have smoked cigarettes heavily for a long period pose higher risk than non-smokers, due to compromised skin circulation. Additionally, patients with cold intolerance, in all likelihood, suffer from reduced skin circulation and any surgery involving skin flaps on this group of patients may ensue with delayed healing or loss of a portion of the skin flap.
Careful listening to the patients’ statements, exploration of their reasons for surgery and their expectations from the surgery, may lead the surgeon to suspect that a patient may have, at least, unrealistic expectations from the surgery or even perhaps body dysmorphic disorder (BDD). Visits to numerous plastic surgeons’ offices, having undergone multiple surgeries with resultant dissatisfaction and/or disparaging remarks about the previous surgeon should alert the examining surgeon to the need for exercising more caution, analyzing the patient’s emotional stability more in depth and, if deemed necessary, seeking consultation from a psychiatrist or a psychologist, especially when a depressive or dysmorphic type disorder is suspected. A morose, tearful patient who sees only the negative aspect likely suffers from a depression, while the patient with BDD either sees a deformity that does not exist or sees a great deal more than is present ( Table 1.1 ).
Table 1.1 Alarming clues suggestive of further patient assessment or avoidance of surgery You have an uncomfortable feeling about the patient Patient exhibits clinical signs of emotional instability Patient’s expectations seem unrealistic Patient’s objectives are in conflict with your aesthetic judgment Patient provides you with deceitful information Patient demands guarantees Patient makes disparaging remarks about the previous surgeon Patient asks you to take part in keeping the truth about surgery from the spouse Patient treats you or your staff disrespectfully Patient appears to have difficulty comprehending the recommended course
The mean age of BDD onset is 16.4 ± 7 years, although most patients don’t seek treatment until their late thirties. 1, 2 The course of the disorder tends to be continuous rather than episodic and complete remission of symptoms appears to be rare, even after treatment. The disorder appears to affect men and women with equal frequency. 2, 3 Male patients may be more likely to be unmarried.
Clinical features of BDD include varying degrees of preoccupation with perceived defects. Men may become preoccupied with their genitals, height, hair and body build, whereas women typically report concerns with their weight, hips, legs and breasts. Some patients may present with highly specific concerns (e.g. perceived asymmetry of a body part), whereas others may have vague complaints (e.g. concern that a body part just does not look right). Rhinoplasty, liposuction and breast augmentation are among the most frequently sought surgical procedures by the patients afflicted with BDD. 4, 5 Seven to fifteen percent of cosmetic surgery patients meet criteria for BDD.

Medical History
Consumption of prescription, over-the-counter or herbal medications should be investigated carefully ( Table 1.2 ). These may have deleterious effects on surgery and recovery by causing intraoperative bleeding, subsequent hematomas and delayed healing.

Table 1.2 Medications and food products that have deleterious effects on surgery
The condition and color of the skin is relevant to the successful outcome of the final surgery in pivotal ways. The patients with lighter skin (Fitzpatrick I or II) generally heal better and are more suitable candidates for laser resurfacing or chemical peel, although their dynamic lines, which appear on animation, would not respond favorably to resurfacing, while the static lines, which are present all the time, improve notably with resurfacing. However, those with light freckled skin and blue eyes, have a higher propensity to bleed excessively and develop hypertrophic scars after surgery. The patients who possess darker skin (Fitzpatrick V or VI) are not ideal candidates for resurfacing and any resurfacing on this group of patients will require additional consideration. This group of patients, on the other hand, usually does not exhibit deep dynamic lines.
Patients in the age group of 50 years or older, and those with known medical conditions that could potentially increase the risk of surgery, should undergo a full medical check up, or an ophthalmology examination within 1 year of surgery if eyelid surgery is being considered.
Completion of a comprehensive health form is the most effective way to record information regarding a patient’s medical history. Most seasoned surgeons have designed their own questionnaires to lead patients in disclosing medical problems that may have an adverse effect on the surgical outcome.
The most common medical condition that may have deleterious influence on an aesthetic surgery outcome is hypertension. Undoubtedly, controlling the hypertension plays a prodigious role in reducing the risk of postoperative hematoma development. The patient’s blood pressure must be normalized during the several weeks before surgery. If the patient is consuming medications that may contract the blood volume, the surgeon must exercise caution for any developing intraoperative hypotension and, if it occurs, it should be corrected before the incisions are closed. Otherwise, hypotension prevents visualization of the transected blood vessels since they do not bleed, which can start bleeding when the blood pressure rises to the normal level post operatively. In other words, it is the relative hypertension that may cause postoperative hematomas. 6
Diabetes is another condition that may lead to postoperative complications. 7 Patients with a positive family history of diabetes may have a weakened immune system without clinical or laboratory evidence of diabetes, causing infectious complications that would not otherwise occur under ordinary circumstances. A history of recurrent infection or poor healing on a patient with a family history of this condition, may aid in diagnosing previously undetected diabetes. 7 When diabetes is suspected and the fasting blood glucose levels are normal, a simple glucose tolerance test can help uncover an unrecognized diabetes. History of easy bruising or prolonged bleeding, if no pharmaceutical products which can cause bleeding have been consumed, should raise the suspicion of some type of coagulopathy, such as Von Willebrand’s disease. 7a

Facial Analysis
In this chapter we will focus on facial analysis in detail. Analysis of the other parts will be incorporated within the related chapters. To analyze the face in an organized manner, the face is arbitrarily divided into three anatomic zones by three imaginary horizontal lines. The upper line lies at the hairline; the second is at eyebrow level; and the lower line passes through the columella-labial junction ( Fig. 1.1 ). In a comely face these three horizontal lines divide the face into three equal sections. The components of these three zones are appraised individually from frontal and profile views, and likewise the relationships between these units are examined.

Fig. 1.1 Lines passing through eyebrows and subnasale divide face into three equal zones.

Front view of the upper zone
The harmony of the upper aesthetic unit can be marred by a highpositioned hairline, leading to an elongated forehead. This finding is of particular significance when planning the incision for forehead rejuvenation on a patient with a senescent forehead ( Fig. 1.2 ). When the forehead is long, the surgeon may forego a coronal incision or an endoscopic forehead rejuvenation and choose a pretracehial incision, using either the subcutaneous or subgaleal dissection to reduce the forehead height. 8, 9

Fig. 1.2 Frontal view of a patient with elongated forehead and eyebrow ptosis who would be a better candidate for forehead rejuvenation with pretrichial incision rather than endoscopic forehead rejuvenation or coronal incision.
Deep wrinkles in the forehead area are commonly the result of compensation of the frontalis muscle to minimize the effects of eyebrow or eyelid ptosis ( Fig. 1.3 ). Thus, it is critical for the surgeon to relax the forehead before selecting a forehead rejuvenation procedure. This can often be accomplished by asking the patient to smile. Usually a compensatory elevation of the eyebrow is eliminated while smiling. The second approach is to ask the patient to close the eyes tightly, and then gently start opening the eyes until the patient can see the viewer. The compensation will become evident as soon as the patient is asked to open the eyes at libre. Analyzing the type of existing wrinkles also aids in choosing a more effective forehead rhytidectomy procedure. In general, deep forehead wrinkles do not respond as favorably to a subgaleal forehead rhytidectomy or an endoscopic forehead rejuvenation. A subcutaneous approach may produce a more successful result in patients with pronounced forehead wrinkling. 10 A combination of endoscopic forehead rejuvenation and laser resurfacing is a logical choice for those who exhibit eyebrow ptosis and many fine wrinkles.

Fig. 1.3 Patient with iatrogenic receding temple hairline as a consequence of rhytidectomy incision being placed at temple hairline.
Because of the role they play in the selection of suitable corrective procedures, the function of the corrugator and procerus muscles and their effect on the overlying skin deserve attention. Visible vertical frown lines may require removal of the corrugator muscle and subcutaneous placement of fat. An overactive depressor supercilii muscle results in oblique lines medial to the eyebrows.

Profile view of the upper zone
Reviewing the lateral portion of the forehead helps the surgeon to determine the position of the temple hair in relation to the lateral canthus. If the hairline is receding at the temple area and the patient is considering a facial rhytidectomy ( Fig. 1.4 ), one may choose the anterior hairline temple incision 11, 12 over the incision placed within the hair-bearing temple.

Fig. 1.4 Patient with significant forehead wrinkles and eyelid ptosis; note eyebrow compensation.
The forehead profile contour should be smooth and pleasing. Any imperfections, such as frontal protrusion and recession, can be the result of a variety of pathologic conditions. Most commonly, the forehead contour abnormality results from bony protrusion caused by sinus hyperaeration (frontal bossing) ( Fig. 1.5 ) and, less commonly, it results from soft tissue excess. 13 Not only do these flaws reduce the desirability of the forehead contour; they may influence the outcome of other aesthetic procedures, such as rhinoplasty. A small ridge cranial to the eyebrow is an acceptable masculine characteristic. Presence of a ridge on a woman, or an exaggerated prominence on either gender, may require aesthetic contouring of the frontal bone. Additionally, as a consequence of aging, the round and slightly projected glabellar area may appear flat or even depressed to varying degrees. Correction of this flattening undoubtedly bestows a rejuvenated appearance to the forehead.

Fig. 1.5 Profile view of patient with frontal bossing caused by hyperaeration of frontal sinuses.

Front view of the middle zone
Most imbalances involve the middle and lower areas of the face. The upper border of the eyebrows should be located at least 2.5 cm above the mid pupil level on a straight gaze. 14 The medial end of a pleasing eyebrow is caudal to the lateral extreme, and the highest portion of the eyebrow arch is at the junction of the lateral third with the medial two-thirds of the eyebrow, corresponding to the lateral limits of the limbus in a straight gaze. Eyebrow ptosis results in crowding of the orbital region and must be differentiated from blepharodermachalasia. Any asymmetry in the level or the shape of the eyebrow arch may require differential eyebrow ptosis correction.
The distance between the medial canthi (intercanthal distance) that is normally approximately 31-33 mm, equals the distance between the medial and lateral canthi (orbital fissure width) ( Fig. 1.6 ). This relationship becomes particularly important when dealing with rhinoplasty candidates who would benefit from refinement of the nasal dorsum and adjustment of the alar bases. Adding to the radix creates an illusion of reduced intercanthal distance, which is detrimental to those patients who exhibit hypotelorism, whereas reduction of the nasal dorsal projection produces the opposite effect. 15 Even slight hypotelorism is undesirable and detracts significantly from the patient’s attractiveness. Narrowing the distance of the nasal bones spawns an illusion of decreased intercanthal distance. 8

Fig. 1.6 Width of upper face is 5 times that of palpebral fissure. Of five equal segments, two are occupied by eyes, one by nose and two by temples.
The individual with a slight increase in the intercanthal distance may still be considered attractive. Yet, when the distance extends beyond 36 mm, it leads to a grossly abnormal and displeasing appearance. Presence of hypertelorism or telecanthus is also consequential when planning rhinoplasty because widening the distance between the nasal bones literally or by virtue of an optical illusion, such as adding a wide dorsal graft, will result in the appearance of more severe hypertelorism or telecanthus. While the surgeon must be conservative when widening the nasal bridge of a patient with a wide intercanthal distance, a wider bridge may prove salutary for the patient who has a shorter intercanthal distance.
The upper portion of the midface can be divided into five equal segments, two are occupied by the eyes; one extends from one medial canthus to another, containing the root of the nose; and two extend from the lateral canthi to the lateral boundary of the ipsilateral temple area ( Fig. 1.6 ). Disharmony of this area has a significantly ruinous effect on the pulchritude of the face. Anteroposterior discrepancies of the eyes cannot be fully noticed on a frontal view, but are more perceptible on a basilar view. Detection of level and depth abnormalities of the eye is important so that the patient can be informed of structural abnormalities that may fail usual efforts at achieving balance in this part of the face.
Edema around the eyes in a blepharoplasty candidate may indicate abnormal thyroid dysfunction or renal failure ( Fig. 1.7 ). Bilateral or unilateral exophthalmus may be the consequence of hyperthyroidism ( Fig. 1.8 ). On patients who are contemplating blepharoplasty, vision and lacrimal function also should be assessed. A combination of slight proptosis and dry eyes or borderline tear production is inauspicious and can lead to a troublesome postoperative course.

Fig. 1.7 Patient presenting for blepharoplasty exhibits periorbital edema. Thyroid tests disclosed hypothyroidism.

Fig. 1.8 Patient seeking blepharoplasty to correct exophthalmus was discovered to have hyperthyroidism.
The optimal vertical opening of one eye is approximately 10 mm, placing the upper eyelid margin 1 mm below the upper limits of the limbus. In the aesthetic surgery patient population, mild-to-moderate upper eyelid ptosis is common, but can easily be missed. This condition is readily corrected using one of several available techniques. In a harmonious face the lateral canthus is generally 2° higher than the medial canthus, giving a slight slant to the eye fissure. The antipode of this relationship gives the patient a tired and sad appearance ( Fig. 1.9 ), typically seen in patients with craniofacial deformities, such as Treacher-Collins syndrome, and in patients with lateral lid lag following lower blepharoplasty ( Fig. 1.10 ).

Fig. 1.9 Patient with antimongoloid slant of orbital fissure, rendering sad and tired appearance.

Fig. 1.10 Patient with iatrogenic displacement of lateral portion of lower eyelid and lateral canthus.
As stated, unilateral or bilateral proptosis is an important finding that may present as only a slight asymmetry and excessive opening of one eye or both eyes, or as a significant prominence of the globes. Often this finding is an indication of a thyroid dysfunction and, therefore, it necessitates a careful medical evaluation before blepharoplasty. Generalized thickening of the upper and lower eyelids may be a reflection of hypothyroidism, which should be investigated thoroughly before any periorbital surgical endeavor. Occasionally the lacrimal glands are ptotic and present as an excessive bulk along the lateral portions of the upper eyelids. In this case, lacrimal gland suspension should be discussed with the patient. Neither this condition nor suspension of the gland is of functional significance. 16
Ideally, the supratarsal fold is visible about 3-4 mm above the lid margin on a straight gaze while this distance is about 10-11 mm when the eyelids are closed. A levator dehiscence is suspected when the tarsal show is increased in the cephalocaudal dimension with a more pronounced supratarsal crease. If eyelid ptosis is diagnosed, levator function must be checked because it is a crucial factor in the selection of a corrective approach. Presence of Bell’s phenomenon indicates a reduced risk of exposure keratitis if complications, such as lid lag, occur. To conduct the test for Bell’s phenomenon, the examiner asks the patient to force the eyes closed while the examiner attempts to open the eyelid by lifting the lid with a finger. With a positive Bell’s phenomenon, the globe rolls cephalad, protecting the cornea under the upper lid ( Fig. 1.11 ). A negative Bell’s phenomenon may be indicative of a potential for an increase in corneal exposure; hence, dryness and ulceration of the cornea should a lid lag ensue post eyelid surgery.

Fig. 1.11 A, Positive Bell’s phenomenon demonstrated by cephalad rotation of globe when examiner attempts to separate eyelids against patient’s resistance. B, Negative Bell’s phenomenon depicted by failure of globe to rotate cephalad when examiner tries to separate eyelid and patient attempts to keep them closed.
A pleasing lower eyelid is located at the caudal limits of the limbus or minimally overlaps it. An increased distance between the lower lid and the limbus, with excessive sclera visible through the lids, is an indication of a lower lid lag, which should be evaluated carefully. The lower lid support system weakness could be congenital. Whether it is congenital, iatrogenic or due to senescence, this condition should alert the aesthetic surgeon to undertake a conservative lower lid surgery or to incorporate a procedure that fortifies the lid support, such as canthoplasty or canthopexy. A lower lid lag should be differentiated from an ectropion. The latter is characterized by outwards rotation of the lid margin and the eyelashes. Checking the tone of the lower lid with a pinch and traction test may aid the examiner in differentiating a congenital caudal lower lid malposition from a weak lower lid support. Swift return of the lid to its previous position, after it is pulled caudally or pinched and released, indicates good muscle tone. Motility (cephalocaudal moveability) of the lateral canthus should be less than 7–8 mm and the maximum distance from the globe while the lid is pulled anteriorly should not exceed 7 mm.
The quality of the skin and the types of existing wrinkles guide the surgeon in deciding between skin/muscle flap, conjunctive blepharoplasty, a lower lid laser resurfacing procedure, a chemical peel, or a combination of these techniques. Generally, patients with thin skin and fine wrinkles do not experience long-lasting results from laser resurfacing, even though the initial improvement may be significant. On the other hand, patients with thicker skin usually experience a lesser degree of improvement that is of longer duration.
Any depression in the nasojugal area or cephalad to the infraorbital rim may necessitate soft tissue repositioning or fat grafting. Malar bone hypoplasia, although better judged in the profile view, may be detected in the frontal view as well. When evaluating the nose, the examiner must observe the width, direction and smoothness of the dorsal contour. The cephalocaudal nose length, defined as the distance from the nasion to the caudal border of the infra tip lobule, is twice the distance from the columella-labial junction (subnasale) to the junction of the lips (stomion) and equals the distance from the stomion to the menton (base of the chin) ( Fig. 1.12 ). The nasal dorsum and the tip should be in line with the midline of the other facial structures. Any abnormalities can be easily ascertained by drawing an imaginary vertical line starting from the glabella. The nose tip, the philtum dimple and the center of the chin should all fall on the same line.

Fig. 1.12 Proportions of the middle to lower facial areas.
The quality of the nasal skin is a significant factor in planning surgery and achieving the intended objectives. 10 Patients who have thicker skin usually are not optimal candidates for rhinoplasty because the tip would not be as well-defined post operatively. On the other hand, patients who have very thin skin tend to reveal every imperfection in the nasal frame. Both extreme cases require a change in the surgical planning, and the incidence of revisional surgery could be higher on these patients because of these adverse conditions. A thorough explanation of the reasons for potential revisional surgery may result in lesser postoperative dissatisfaction in these patients.
The nasal bones should line up symmetrically, allowing a graceful transition of shadow from the eyebrows to the nasal tip through a pair of smooth and pleasing dorsal lines. Any excess or deficiency of nasal bone width, unilateral or bilateral may distort these lines. 17
A portion of the nostril opening should be visible on the frontal view. Inadequate nostril show may be an indication of a long nose or caudally positioned ala, whereas excessive nostril show may denote a short nose or retracted alar rims. Most rhinoplasty candidates have wide and asymmetric nostrils. This becomes even more apparent when the individual smiles. This imperfection has significant surgical connotations and must be elicited by asking to the patient to smile. Tip overlap on the upper lip becomes more noticeable on animation. Furthermore, the form, symmetry and particularly the width of the lower lateral cartilages can be judged easily on the front view.
The distance between the alar bases, as measured from the lateral border of one alar base to its opposite counterparts, should be slightly wider than the intercanthal distance. An imaginary line drawn vertically from the medial canthi should pass 1-2 mm on the inside of the alar base, providing that the intercanthal distance is normal ( Fig. 1.13 ). If the intercanthal distance is abnormal, the alar base distance should be 2 mm wider than the orbital fissure width (from the medial to the lateral canthus). 18 The pleasing nasal tip has two highlights. The distance between these two points matches the width of optimal nasal dorsal lines.

Fig. 1.13 Width of alar base is slightly wider than intercanthal distance. Distance from eyelid to eyebrow and position of eyebrow arch in relation to iris are shown.

Profile view of the middle zone
On the frontal view, the lateral boundaries of the ears are visible with the helix slightly more projected lateral to the antihelix. The entire ear contour creates a parallel vertical line relative to the face. Excess ear projection results in greater visibility of the helix and disappearance of the antihelical fold. The length of the ear equals that of the nose. A horizontal line drawn from the subnasale touches the caudal border of the earlobes. The ears are more precisely assessed on the lateral view. The overall configuration, helix size, development of antihelical folds, earlobe size, and cephaloconchal angle are observed. The normal angle between the patient’s body and long ear is approximately 30°, with the cephalic portion of the ear tilting posteriorly.
On the profile view, the supraorbital rims are about 10-15 mm anterior to the globes. The nasion, the most depressed portion of the nasal dorsum, is located at the level of the upper lid margin on a straight gaze and is 4-6 mm deep in relation to the glabella. The nasal dorsum creates a 34° angle with the vertical facial plane on a woman and a 36° angle on a man. In both men and women there is a gentle and gradual curve of the dorsum extending from the nasion to the tip; the deepest portion is 0.5-1 mm for a man and 1-1.5 mm for a woman. The nasolabial angle measures 105-108° for a woman and 95-100° for a man. 19 A desirable tip definition includes a small supratip break on the profile view. The inferior border of the columella is approximately 4 mm caudal to the alar rim on the lateral view and the alar base is about 2 mm cephelad to the subnasale. 20
The malar soft tissue is projected anterior to the most prominent portion of the optical globe. Reversal of this relationship produces a negative lower lid vector, potentiating the chance of lid retraction and postoperative dry eye syndrome. 21

Front view of the lower zone
In the frontal view of the lower facial zone, the upper lip length, as measured from the base of the columella to the stomion, should be half the distance from the stomion to the horizontal line, passing through the most caudal portion of the chin. On a patient with a normal underlying maxillary and mandibular frame, dentitions and patent airway, the lips are sealed in repose. Lip incompetence, which is habitual failure to close lips in repose, often is seen on patients with a long face deformity on those who are mouth breathers due to nasal blockage, patients with an open bite, or patients with iatrogenic or muscular dystrophy related lower lip ptosis.
The upper lip is slightly thinner than the lower lip. The width of the oral commissure equals the distance from one medial limbus to the other side. On frontal view the lower jaw line is well defined in a symmetric fashion, with the superficial musculoaponeurotic system (SMAS) being tight and smooth. Ptosis of the SMAS and fat is an integral part of gravity effects and the aging process, which causes jowls to develop and the lower face to widen. A horizontal line connecting the oral commissures runs parallel to the lines connecting the canthi. The oral commissures are located horizontally on young patients, whereas senescent patients demonstrate claudal tilt of the oral commissures. The philtrum dimple is bordered with a well-defined cupid’s bow. Excess submental fat may obscure the chin definition and hide enlarged or ptotic submaxillary glands and they can only be detected by palpation.
A congruous tooth alignment is a material component of an attractive smile. When the lips are slightly apart, 2-3 mm of the upper incisors should be visible between the lips. Any excess incisor show may infer a long face deformity or a short upper lip. When the patient is asked to smile, there is usually minimal gum show. Excess gum show may indicate a long face deformity or a short upper lip. Normally the central incisors and canines are slightly longer than the lateral incisors. Crowding is an indication of discrepancy between the width and number of teeth and the size of the dental arch. Patients with this type of dental flaw may require orthodontic correction or combined orthodontic preparation and orthognathic surgery. Dental occlusion should be examined to ensure the presence of a normal relationship between the mandible and the maxilla. Abnormal jaw growth and speech difficulties can be the consequence of a large tongue, detection of which is an integral part of a thorough facial evaluation.

Profile view of the lower zone
On patients with a hypoplastic anterior maxillary region or a deficient nasal spine, cephalad portion of the upper lip is retruded on the profile view. Augmentation of the anterior maxilla, nasal spine and caudal septum improves this relationship noticeably. In a harmonious face either the upper and lower lips are lined up evenly in a vertical plane or the lower lip is slightly posterior to the upper lip. The lips are sealed in a relaxed position. Any substantial imbalance between the upper and lower lips often indicates a skeletal abnormality.
The labiomental groove is often well defined and approximately 4 mm deep. This is one of the most underestimated features of the face. An imaginary line touching the most projected portions of the upper and lower lips should touch the most anterior portion of the chin (Reidel’s plane) ( Fig. 1.14 ). 22 A deficient or excessive chin may be easily detected by this simple examination. Patients with receding chins who already exhibit a deep labiomental groove often have retrognathia and usually are not good candidates for genioplasty alone. Commonly, mandibular advancement, with or without a genioplasty, serves these patients best.

Fig. 1.14 Reidel’s plane of lip and chin line-up is straight line connecting most prominent portion of upper lip to lower lip. In pleasing profiles, line usually contacts most prominent portion of soft tissue chin.

The cervical region
Ellenbogen has described the attributes of an aesthetically pleasing neck whereby a 100 angle is created between the chin and the neck. 23 This angle can be altered by a variety of neck flaws. These could include: excess skin, presence of platysmal muscle bands, excess subplatysmal and supraplatysmal fat, a malpositioned hyoid bone ( Fig. 1.15 ), 24 a receding chin, or a varying combination thereof. A ptotic or enlarged submaxillary gland may also disturb the balance of the cervicomental region.

Fig. 1.15 Patient with poorly positioned hyoid bone. A, Patient profile exhibits undesirable cervicomental definition. B, Cephaloxerogram demonstrates low and anteriorly positioned hyoid bone.

The basilar view
Evaluation of the face on basilar view is crucial to a thorough facial assessment. In this view, any asymmetry of the forehead can be detected easily. More importantly, the anteroposterior eye globe position can be observed more precisely. The malar bones, their symmetry and the overlying soft tissue prominence also can be evaluated clearly in this view. The columella direction and nostril asymmetry also are more detectable in this view. Additionally, the chin position and its line-up with respect to the rest of the face are more clearly identified in this position. Also, the ear projection is assessed more readily with the head tilted back.

The overhead view
Finally, if the examiner stands behind the patient’s chair, tilts the patient’s head back and reviews the face from this perspective, several abnormalities may become discernible more clearly. Gradually moving from a standing to a sitting position, the examiner reviews the face from different cephalic angles. The imperfections of the forehead and eye position, enophthalmus and exophthalmus, malar asymmetry, direction of the nasal bridge, and chin asymmetry can be easily appraised in this particular type of examination.

Internal nose examination
Assessment of the nasal valves function is an integral part of the nasal evaluation. This is done by asking the patient to breathe in and out with, and without, a cotton tip or speculum lifting the ala and upper lateral cartilages. Also, observation of the internal nose for septal deviation, enlargement of the inferior turbinates, septal perforation, synechia and polyps is essential for a successful septorhinoplasty.

Visual Examination
In preparation for aesthetic surgery the importance of a simple vision test, using a vision chart cannot be overemphasized. Each eye must be examined separately. A Schirmer’s test also may be helpful if the patient has a history of dry eyes, although it is not a very reliable test.

References

1. Phillips K.A., Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis . 1997;185:570.
2. Phillips K.A., Menard W., Fay C., et al. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics . 2005;46:317.
3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn. Washington, DC: American Psychiatric Association, 2000.
4. Crerand C.E., Franklin M.E., Sarwer D.B. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg . 2006;118:167E-180E.
5. Crerand C.E., Phillips K.A., Menard W., et al. Non-psychiatric medical treatment of body dysmorphic disorder. Psychosomatics. 2006;46: 549.
6. Beckenstein M, Guyuron B. Postrhytidectomy hematomas and “relative” hypertension. 1994. Unpublished data
7. Guyuron B., Rasqewski R. Undetected diabetes and the plastic surgeon. Plast Reconstr Surg . 1990;86:471-474.
7a. Guyuron B., Zarandy S., Tirgan A. Von Willebrand’s disease and plastic surgery. Ann Plast Surg . 1994;32:351-355.
8. Connell B. Brow ptosis: local reactions. In Third International Symoseum on Plastic and Reconstructive Surgery of the Eye and Adnexa . Baltimore: Williams and Wilkins; 1982.
9. Guyuron B., Davies B. Subcutaneous anterior hairline forehead rhytidectomy. Aesthetic Plast Surg . 1988;12:77-83.
10. Guyuron B. Precision rhinoplasty. II. Prediction. Plast Reconstr Surg . 1988;81:500-505.
11. Guyuron B. Modified temple incision of facial rhytidectomy. Ann Plast Surg . 1988;21:439-443.
12. Lewis C.M. Preservation of the female sideburn. Aesthetic Plast Surg . 1984;8:91.
13. Guyuron B. Soft-tissue frontal bossing. Plast Reconstr Surg . 1987;80:296-297.
14. McKinney P., Mossie R.D., Zukowski M.L. Criteria for the forehead lift. Aesthetic Plast Surg . 1991;15:141-147.
15. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg . 1991;80:970-978.
16. Guyuron B., DeLuca L. Aesthetic and functional outcomes of dacryoadenopexy. Aesthetic Surgery Quarterly . 1996;16:138-141.
17. Sheen J. Aesthetic rhinoplasty, 2 nd edn, St Louis: Mosby, 1987. vol. 2
18. Guyuron B. Precision rhinoplasty. I. The role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg . 1988;81:489-499.
19. Guyuron B., Davies B. Experience with the modified Putterman procedure. Plast Reconstr Surg . 1980;82:775-780.
20. Powell N., Humphreys B. Preparation of the aesthetic face. New York: Theime, 1984.
21. Rees T.D., Jelks G.W. Blepharoplasty and the dry eye syndrome. guidelines for surgery? Plast Reconstr Surg . 1981;68:249-252.
22. Reidel R.A. An analysis of the dentofacial relationships. Am J Orthod Dentofacial Orthop . 1957;43:103.
23. Ellenbogen R., Karlin J.V. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg . 1980;80:823-837.
24. Guyuron B., Arons J. The chin, hyoid bone, and neck. World Plast . 1995;3:195-205.
Chapter 2 Skin Care Including Chemical Peeling

Zoe Diana Draelos
Skin is the defining boundary of our personal space, a self-renewing organ, the first line of defense against systemic infection, and an indicator to others of our chronologic age. It is a barrier that weathers with advancing age and the insults of ultraviolet (UV) radiation to become wrinkled, discolored, and uneven. Skin care includes cleansing, moisturizing, and photoprotection, while chemical peeling is a method for improving the appearance and function of aging skin.



Summary

1. Chemical peeling is the controlled removal of the stratum corneum, epidermis, and/or superficial dermis to improve skin texture and pigmentation.
2. Superficial chemical peeling with hydrophilic glycolic acid or lipophilic salicylic acid is intended to produce mild exfoliation of the stratum corneum.
3. Medium-depth chemical peeling with trichloroacetic acid preceded by a superficial chemical peel is useful in improving facial dyspigmentation.
4. Deep chemical peeling with phenol is useful in improving superficial facial rhytids, but inevitably produces skin lightening.
5. Chemical peel is contraindicated in patients who have been treated with systemic tretinoin within the previous 6 months and as a treatment of keloids.
6. The skin barrier can be visualized as a brick wall consisting of the protein-rich corneocytes functioning as the bricks held in place by intercellular lipids as the mortar.
7. Cleansers are designed to remove environmental dirt, sebum, bacteria, and fungal organisms from the face while leaving the intercellular lipids and stratum corneum barrier intact. Modern cleansers contain synthetic detergents (syndets), such as sodium cocoyl isethionate and sodium laureth sulfate, which maintain skin hygiene, but prevent damage to the intercellular lipids.
8. Moisturizers decrease transepidermal water loss, creating an environmental optimal for barrier repair. They create an occlusive barrier to evaporation (petrolatum, dimethicone, mineral oil) or functioning as a humectant to attract water from the dermis to the viable epidermis and stratum corneum (glycerin, propylene glycol, sorbitol).
9. Estrogen replacement therapy and oral contraceptives predispose the patient to hyperpigmentation following chemical peel.
10. Sunscreens can be added to moisturizers to prevent UVB- and UVA-induced photodamage and photocarcinogenesis.

Introduction
Skin is the defining boundary of our personal space, a self-renewing organ, the first line of defense against systemic infection, and an indicator to others of our chronologic age. It is a barrier that weathers with advancing age and the insults of ultraviolet (UV) radiation to become wrinkled, discolored, and uneven. Skin care includes cleansing, moisturizing, and photoprotection, while chemical peeling is a method for improving the appearance and function of aging skin.
The skin is composed of three layers: the stratum corneum, epidermis, and dermis.
The stratum corneum forms the skin barrier and is composed of two distinct anatomic units:
• protein rich cells (corneocytes);
• skin lipids that hold the corneocytes together ( Fig. 2.1 ).

Fig. 2.1 Stratum corneum. The stratum corneum is visually modeled as a brick wall with the bricks representing the corneocytes and the mortar representing the intercellular lipids.
Structural damage to the corneocytes or to the lipids results in a defective barrier. With the aid of an electron microscope, it is possible to see the covalently bound lipid layer between the corneocytes forming an organized watertight seal over the body ( Fig. 2.2 ).

Fig. 2.2 Intercellular lipids. The intercellular lipids that surround the corneocytes provide waterproof characteristics to the skin barrier.
Barrier damage occurs when:
• the intercellular lipids are removed, typically by the chemical insult of soaps;
• the corneocytes are physically removed, such as through aggressive scrubbing or the use of chemical peels.
The health of the skin is therefore ultimately dependent on the non-living stratum corneum. The underlying viable epidermis and dermis form the cellular renewable layers of the skin, accounting for its strength and distensible characteristics.
The most important role of the stratum corneum is to modulate the water content of the skin, which should be approximately 30%. Too much water creates maceration and too little water decreases the elastic properties of the skin and creates skin surface wrinkles of dehydration.
Equilibrium between the external climate and internal environment of the body occurs at about 70% humidity; however, the average humidity of a conditioned environment is 20–30%. Therefore, there is a constant net loss of water from the skin to the air (i.e. transepidermal water loss). If this water loss becomes excessive, the skin recognizes that a barrier defect has occurred, resulting in a rapid burst in the synthesis of intercellular lipids (ceramides, sterols, and fatty acids).
Deliberate wounding of the skin, such as the insult induced by chemical peeling, results in a profound, but controlled, damage to the skin structures, requiring the proper selection of skin care products to optimize the cosmetic result.

Indications



Fair complected patients:

• dyspigmentation
• poor skin texture

Relative contraindications

• Patients with dark skin (Fitzpatrick types IV and higher)
• History of consumption of oral retinoids within the past year
• Radiated skin.

Contraindications

• Hypersensitivity to chemical peels
• Keloid formation within 6 months after cessation of oral retinoids
• Evidence of poor healing.
Skin peeling is a controlled removal and renewal of the various layers of the skin, depending on the depth of the wound:
• superficial peels wound the stratum corneum and possibly the upper layers of the epidermis;
• medium-depth peels wound the stratum corneum, epidermis, and superficial dermis;
• deep chemical peels wound the stratum corneum, epidermis, and mid-dermis.
The depth of the peel is controlled by the strength of the acid applied to the skin surface and the length of time for which the acid is left in contact with the skin.
Chemical peels are a carefully controlled wounding of the skin and are designed to improve cosmetic appearance.
Any part of the body can be subjected to a chemical peel, but the face produces the most dramatic and reliable results. This is because the facial skin is thin and it heals with minimal scarring. The face is the only body site where a deep chemical peel is performed.
Superficial chemical peels produce little effect on any area other than the face where they are used to produce a mild exfoliation improving skin texture. This improved skin texture is appreciated by the patient as increased facial shine (sometimes referred to as radiance) and smoother facial cosmetic application.
Medium-depth chemical peels may be performed on the entire body, but are most frequently used on the neck, chest, and arms. Typically, higher concentration acids are used on the face with a reduced concentration applied to any other body area.
Chemical peels produce the best results in fair complected individuals (Fitzpatrick type I and II) with predominantly pigmentary photodamage. Darker skin types (Fitzpatrick type III and higher) are more challenging to treat with chemical peeling because the inflammation induced by the superficial or medium-depth peel may result in unsightly post-procedure hyperpigmentation. Darker skin types also more frequently exhibit hypertrophic scarring and keloid formation, predisposing to an undesirable outcome.
Deep chemical peels are never performed on darker skinned individuals because the acid may damage the melanocytes, resulting in permanent hypo- or depigmentation, unless hypopigmentation is part of the aesthetic goal.
A chemical peel can be performed for a variety of indications:
• superficial chemical peels can be used to enhance exfoliation, improve skin texture, and minimize comedonal acne;
• superficial peels damage the skin barrier and may be used to enhance the penetration of topical medications, such as hydroquinone skin lightening cream or tretinoin, and
• a superficial chemical peel is the first step in performing a medium-depth peel, allowing deeper penetration of the acid into the skin;
• medium-depth peels are used to improve defects in skin pigmentation (such as lentigenes and melasma), and fine lines around the eyes and upper cheeks;

The best indication for chemical peeling is to improve facial pigmentation.
A medium-depth peel will not improve deeper rhytids around the mouth and folds on the face, such as the nasolabial and melolabial folds. It is not possible to successfully improve facial folds with any type of chemical peel, but deeper rhytids around the mouth and on the lateral cheeks can be improved with a deep chemical peel, possibly combined with a facelift procedure or the use of injectable fillers.
In my opinion, the best indication for chemical peeling is in the improvement of facial pigmentation. The precise ability to control the depth of the peel by proper acid selection yields excellent pigment removal without further dyspigmentation or scarring. Although laser resurfacing is sometimes used for pigmentation improvement, the laser does not afford the control of chemical peeling. Chemical peeling is an art combining visual assessment of the peel depth produced by the different types and strengths of acid left on the skin for varying intervals. This allows clinicians to adapt the chemical peel to the varying degrees of pigmentation in the treated area.

Preoperative History and Considerations
A detailed history must be obtained prior to a chemical peeling procedure to ensure an optimal outcome and result longevity.
Individuals who have been treated with systemic retinoids should not undergo a chemical peeling procedure for at least 6 months to 1 year, depending on the depth of the chemical peel desired. This is because systemic retinoids such as isotretinoin reduce the activity of sebaceous glands and thereby increase susceptibility to hypertrophic scarring, which can be disastrous in the case of a chemical peel where the entire face is wounded.
A history of oral hormone supplementation is also important. Estrogen replacement therapy and oral contraceptives predispose the patient to facial hyperpigmentation. In some individuals, dyspigmentation may rapidly return following a facial peel if exogenous estrogen is consumed. Discontinuation of the estrogen for at least 3–6 months prior to the procedure and after the procedure is advantageous, but not always feasible. Women who are not able to discontinue their estrogen should be advised that the pigmentation may return and counseled on the proper use of photoprotection.
It is also worth inquiring about the patient’s skin care regimen. Patients who are using prescription topical retinoids, such as tretinoin, adapalene, or tazarotene, will experience much deeper and more rapid penetration of the acid into the skin. Although retinoids are used prior to medium and deep chemical peels to enhance penetration, they may produce a much deeper peel than expected or desired in patients wishing only a superficial chemical peel.
Patients may also be undergoing microdermabrasion, spa-administered chemical peels, or other aesthetician procedures that damage the skin barrier, enhancing acid penetration and yielding unexpected results.

Operative Approach
The peeling procedure for superficial, medium, and deep peels is somewhat similar, each deeper peel building on a more superficial skin wounding ( Table 2.1 ) .

Table 2.1 Chemical peel technique comparisons.

Superficial peels
Superficial peels usually consist of either a glycolic or salicylic acid solution applied to the face in three coats. Glycolic acid superficial peels are water-soluble (hydrophilic) in contrast to salicylic acid peels, which are oil soluble (lipophilic) .

Glycolic acid peels
Glycolic acid peels in concentrations of 10% or less may be applied by unsupervised aestheticians in a spa setting, but concentrations of 20% or higher should be applied by a physician or in a carefully supervised setting .
Glycolic acid peels are formulated by diluting a 70% stock saturated solution of glycolic acid in concentrations of 20, 30, 40, 50, and 60% with water. The most commonly used glycolic acid peels are :
• 20 and 30% for gentle skin exfoliation;
• 70% for mild dyspigmentation .
The peels can be administered in a weekly series with gradual 10% increases in strength from 20 to 70% to achieve a cumulative effect and enhanced improvement in photoaging. Glycolic acid peels are water soluble and therefore only peel a skin surface devoid of oil .

Salicylic acid peels
Salicylic acid peels are able to peel the skin surface as well as in the oily milieu of the pore. Salicylic acid peels are therefore preferred for patients wishing comedolysis as part of acne treatment or for patients wishing to remove retained hairs and other debris from within the pore .
Salicylic acid peels are formulated from salicylic acid powder, which is dissolved in either benzyl alcohol or ethanol in concentrations ranging from 10 to 50%. I prefer benzyl alcohol as solvent because it is less pungent .

Glycolic acid peels are water soluble and only peel a skin surface devoid of oil, whereas salicylic acid peels are lipophilic and peel not only the skin surface but also in the oily milieu of the pore.
10–20% concentrations of salicylic acid peels are solutions, whereas 30–50% peels are shake lotions and the salicylic acid must be resuspended prior to application .
Salicylic acid is unique in that it does not penetrate into the dermis making it an ideal superficial peel for patients with sensitive skin, rosacea, or other inflammatory skin diseases .

Peeling procedure
A superficial peel can be the desired treatment endpoint or it may be followed by a medium-depth peel, which is actually a two-step peeling procedure with a stratum corneum wounding procedure followed by a deep epidermal or superficial dermal wounding procedure .

Superficial peel

• The first step in peeling is to degrease the face and remove all skin care products and cosmetics. If the skin is not clean, the superficial peel will not penetrate and no skin improvement will be perceived. I prefer to use a triclosan solution to clean the face with aggressive gauze scrubbing, but any soap-based cleanser can be used .
• Following cleansing, the skin should be thoroughly dried and the patient placed on the exam table with a bedside fan blowing a gentle breeze across the face .
• Next, a rectal swab should be used to apply the 2 mL of superficial peel solution poured into a small shot glass ( Fig. 2.3A ) .
• The solution should be applied in three coats to the entire face. I begin with broad strokes across the forehead, moving down to both cheeks, then to the chin, upper lip, and lastly across the nose ( Fig. 2.3B ) .
• It is important to avoid applying the solution to the corners of the eye, nose, and mouth. Any junction between cornified skin and mucosa should be avoided because these areas tend to peel more deeply and a painful erosion may result .
• At all times, an eye should be kept on the skin of the patient to determine the degree of barrier damage. Superficial peels should only wound the stratum corneum and uppermost epidermis. The depth of the peel can be assessed by asking the patient about their level of discomfort. I typically ask the patient to rate the stinging and burning on a scale of 1–10 with 10 indicating extreme pain. The application of the peel solution should cease when the patient complains of discomfort at the 4–5 level, even if three coats have not been applied .
• It is also important to watch for reddening and whitening of the face. Reddening of the face indicates early wounding and vasodilation whereas whitening (also known as frosting) indicates deeper wounding and protein coagulation. The more confluent the whitening of the skin, the deeper the peel ( Fig. 2.3C ). Very minimal scattered whitening is all that should be achieved with a superficial peel. The peel is immediately neutralized with cool water on disposable washcloths wiped across the face until the stinging and burning has resolved. Neutralization is extremely important in glycolic acid peels because the acid will continue to wound the skin until removed. However, salicylic acid peels are self-neutralizing because the acid crystallizes on the skin surface. Thorough water rinsing is soothing to the skin surface. I usually completely rinse the skin three times and follow this by an application of a bland occlusive moisturizer, such as Cetaphil cream (Galderma, Ft Worth, TX). Further skin care considerations are discussed in the Skin care section .

Fig. 2.3 Superficial peeling procedure. A, 1–3 mL of the peel solution is decanted into a small glass crucible for application. B, A rectal swab stroked over the face is used to apply the peel solution to the skin surface. C, The confluence of the skin whitening is an indication of the depth of the peel.

Medium-depth peel

• It is most important to remove all grease from the skin surface when a superficial peel is preparation for a medium-depth peel. I prefer to use acetone on a gauze vigorously rubbed across the face following triclosan cleansing. This removes all traces of oil from the skin surface ensuring even uptake of all the peel solutions in both oily and dry facial areas .
• There is tremendous variability in the medium-depth prepeel. Some clinicians prefer glycolic acid, whereas others use a carbon dioxide slush peel or a mechanical microdermabrasion peel. My preference is to use a combination prepeel with both lipophilic and hydrophilic substances to prepare the skin surface and the pores for the medium-depth peel procedure. This prepeel solution is known as Jessner’s peel and is a combination of lactic acid, resorcinol, salicylic acid, and ethanol. It is applied in one to three coats to the skin surface with a rectal swab until early whitening of the skin is achieved .
• Once whitening has occurred with the prepeel, 25–35% trichloroacetic acid is quickly applied evenly to the entire face with a lightly moistened rectal swab. The strength of acid selected depends on the depth of the desired peel, which is determined by the degree and confluence of facial frosting ( Fig. 2.4A ) .
• At this point, the fan should be blowing briskly across the patient’s face and ice cold water compresses applied as soon at the desired amount of frosting has occurred ( Fig. 2.4B ) .
• After the burning has subsided, the face should be examined for any skip areas that might need to be touched up .
• It is not necessary to neutralize either the Jessner’s prepeel or the trichloroacetic peel because they are both self-neutralizing .
• A heavy layer of petroleum jelly is then applied over the entire face, followed by petroleum impregnated gauze, Telfa, and netting, if desired. The face should be rinsed with warm tap water at least twice daily and covered with petroleum jelly until re-epithelialization is well underway by postprocedure day 4. At this time, cosmetics can be worn and the patient is socially acceptable .

Fig. 2.4 Medium-depth peel. A, Facial appearance immediately after a mild trichloroacetic acid peel. B, Ice-cold disposable towels are placed over the face to decrease the warmth, stinging, and burning associated with facial peeling.

Deep chemical peels
Deep chemical peels :
• are not commonly performed because most patients who desire the results of a deep peel prefer to undergo a laser resurfacing procedure;
• are performed with phenol, which is cardiotoxic, requiring intra-operative monitoring, and produces permanent pigment lightening .


Optimizing outcomes

• Initiate nightly application of a retinoid 3 weeks prior to chemical peel.
• Remove all sebum and cosmetics from the face prior to initiating the peel.
• Apply the peel solution quickly and evenly to the entire face – if areas of the face are skipped, reapplication is required, which prolongs the procedure time and pain.
• Do not drip the peel solution into the eyes or outside the desired peel skin area.
• Some patients may prefer to take a sedative prior to the procedure, though reassuring conversation, careful fan placement, and quick application of ice cold towels can provide adequate pain relief for the short duration of the procedure.


Optimizing a medium-depth peel result

• Ensure even penetration of the acid over the entire face, especially on the oily areas such as the nose – this is achieved by having the patient use a retinoid nightly for 3 weeks prior to the peeling procedure. My preferred retinoid is 0.025% tretinoin cream, but other strengths of tretinoin (0.05 or 1%), adapalene, or tazarotene cream may be used. The retinoid should be discontinued for 1 month after the peel to allow healing to occur and then restarted to maintain the cutaneous peel effect for as long as possible. (Retinoids can also be used with superficial peels, but the strength of the superficial peel solution may need to be decreased).

Complications and Side Effects
Chemical peeling is a relatively safe procedure, but a few complications should be avoided. Proper patient selection to avoid using the procedure in dark complected patients and those with healing disorders is key to avoiding complications of scarring, hyperpigmentation, and hypopigmentation. In addition, patients who have a history of frequent herpes simplex infections of the peeled body area should be treated with preventive acyclovir, famciclovir, or valacyclovir on the day of the procedure to prevent dissemination of the herpes simplex virus in the wounded area.

Postoperative Care
The amount of postoperative care depends on the degree of the skin wound. Superficial peels require no postoperative care, whereas medium and deep chemical peels require application of petroleum jelly, to prevent undesirable water loss from the wounded skin surface, at least twice daily with warm tap water rinsing of the area for at least 4 days. At day 4, most patients can begin wearing cosmetics and use a foaming face cleanser accompanied by a simple oil-in-water moisturizer (Eucerin cream, Beiersdorf, Germany). It is best to follow up the patient 1 week after a medium or deep peel procedure to ensure that healing is progressing and there are no problems.
If the medium-depth peel is being performed to improve skin dyspigmentation, a hydroquinone-containing bleaching cream is recommended 1 week after the peel. This prevents repigmentation from UV exposure and hormonal influences. The use of a physical sun block, containing zinc oxide or titanium dioxide, may also be helpful to prevent UVA stimulation of the melanocytes.

Skin care
Postpeel skin care is important and includes the use of cleansers and moisturizers.
Skin cleansing is the chemical interaction of surfactant with the skin surface combined with physical rubbing. The physical rubbing and the chemical interaction are equally as important.
Proper skin cleansing removes sebum, apocrine and eccrine secretions, environmental dirt, bacteria, fungal elements, yeast, desquamating keratinocytes, medications, cosmetics, and skin care products while not removing intercellular lipids or damaging the brick and mortar structural organization of the stratum corneum.

Cleansers
There are a variety of skin cleansers, 1 - 3 including soaps, syndets, and combars ( Table 2.2 ), which can be placed on a variety of cleansing implements from the hands to a washcloth to a disposable face cloth.
Table 2.2 Skin cleanser categories and properties. Type of cleanser (commercial examples) Advantages Disadvantages Soap Excellent cleansing thorough sebum removal Can dry skin; not recommended for sensitive, healing or diseased skin Syndet (synthetic detergent) Combar More mild cleansing; recommended post-surgery; may be used for sensitive or diseased skin Not as thorough sebum removal Good cleansing; commonly combined with triclosan topical antibacterial; good choice for high-risk wound infections or contaminated body areas  

Synthetic detergents (syndets), particularly in the form of a foaming face wash, are the best post-procedure cleansers. Combars are a combination of soap and syndet and are useful post-surgically for the patient who is at risk for cutaneous infection.
True soap is a specific type of cleanser with an alkaline pH of 9–10 created by chemically reacting a fat and an alkali to create a fatty acid salt with detergent properties. Soap efficiently removes both sebum and intercellular lipids, making it an excellent general skin cleanser, but a poor choice following any type of surgical procedure resulting in a damaged barrier.
The need for good hygiene in a compromised barrier situation has led to the development of synthetic detergents, known as syndets ( Fig. 2.5 ). The most popular syndet cleansers contain sodium cocoyl isethionate with a neutral pH of 5.5–7. This more neutral pH removes fewer intercellular lipids, preventing further barrier damage during cleansing. These products, particularly in the form of a foaming face wash, are the best post-procedure cleansers.

Fig. 2.5 Cleansers. A variety of cleansers are illustrated, from left to right, a syndet bar soap, a foaming facial cleanser, and a lipid free cleanser.
The final category of traditional cleansers is combars, which combine soap and syndet cleansers in the same product with a pH of 7–9. Combars remove more sebum than a syndet cleanser, but less than a soap cleanser. Most deodorant cleansers fall into this category and contain triclosan as a topical antibacterial. Combars are useful post-surgically for the patient who is at risk for cutaneous infection.

Moisturizers
Moisturizers ( Fig. 2.6 ) 4 - 7 are applied to the skin following cleansing in the post-surgical patient to minimize transepidermal water loss, so creating an environment that is optimal for skin healing.

Fig. 2.6 Moisturizers. A variety of moisturizers are illustrated, from left to right, a lotion, a cream, and an ointment.
The three categories of substances that can be combined to enhance the water content of the skin are occlusives, humectants, and hydrocolloids:
• occlusives are oily substances such as petrolatum, lanolin, mineral oil, vegetable oils, dimethicone, and cetyl alcohol that retard transepidermal water loss by placing an oil slick over the skin surface;
• humectants are substances such as propylene glycol, hyaluronic acid, glycerin, sorbitol, gelatin, urea, sodium lactate, vitamins and proteins, that attract water to the skin, not from the environment, unless the ambient humidity is 70%, but from the inner layers of the skin - humectants draw water from the viable dermis into the viable epidermis and then from the nonviable epidermis into the stratum corneum;
• hydrocolloids are physically large substances, such as peptides and colloidal oatmeal, that cover the skin, therefore retarding transepidermal water loss.
A quality moisturizer will combine ingredients from all three categories to provide multiple mechanisms of moisturizing the skin.
A commonly marketed moisturizer formulation combines petrolatum (the most effective moisturizing ingredient presently known) with dimethicone to minimize greasiness and effectively retard 99% of the transepidermal water loss. The addition of glycerin to hold water in the skin with a peptide to create an artificial barrier complete the formulation. Incorporating vitamins, such as vitamin C or vitamin E, or botanicals (such as aloe, green tea, or soy) add distinction among products in the marketplace.
The biggest challenge in the delivery of anti-aging substances to the skin is the stratum corneum. An intact stratum corneum is key to the skin barrier and a necessary part of post-procedure healing, but impedes the penetration of many substances into the skin. This extremely important function means that the stratum corneum prevents infection and the entry of toxic foreign substances and allergens into the body. However, the barrier also prevents most large molecular weight proteins and botanicals from entering the skin and functioning as modulators of collagen production or topical antioxidants.
Probably one of the most effective moisturizer additives is sunscreen, which has the ability to both prevent and reverse photoaging.

Sunscreens
Sunscreens 8 - 19 are an important part of post-surgical skin care. Inflammation resulting from a face peel or other skin wounding procedure can cause hyperpigmentation, especially in the presence of UVA radiation, which stimulates melanin production by melanocytes.
Photoprotective mechanisms may be endogenous ( Table 2.3 ) or externally applied ( Table 2.4 ).
Table 2.3 Natural cutaneous UV protective mechanisms. Cutaneous structure Sun protective mechanism Compact horny layer Absorbs and scatters UV Keratinocyte melanin
1. UV absorbing filter
2. Free radical scavenger
3. Dissipates UV as heat
4. Undergoes oxidation in 300–360 nm range to produce immediate pigment darkening Carotenoid pigments
1. Membrane stabilizers
2. Quench oxygen radicals Urocanic acid Oxidized to stabilize UV-induced oxygen radicals Superoxide dismutase
1. Oxygen radical scavenger
2. Protects cell membrane from lipoprotein damage Epidermal DNA excision repair Repairs UV-induced DNA damage

Table 2.4 Sunscreen ingredient comparison.
Sunscreen ingredients can be classified into two major categories.
• Chemical ingredients undergo a chemical transformation, known as resonance delocalization, to absorb UV radiation and transform it to heat. This reaction occurs within the phenol ring, which contains an electron-releasing group in the ortho and/or para position. This chemical reaction is irreversible, rendering the sunscreen inactive once it has absorbed the UV radiation.
• Physical sunscreens, in contrast, are usually ground particulates that reflect or scatter UV radiation, absorbing relatively little of the energy. For this reason they have longer activity on the skin surface.
Sunscreen ingredients can be divided into the following three groups:
• UVA (320–360 nm) absorbers, such as oxybenzone, avobenzone, menthyl anthranilate;
• UVB (290–320 nm) absorbers, such as PABA derivatives, salicylates, cinnamates;
• UVB/UVA blocks that reflect or scatter UVA and UVB, such as titanium dioxide, zinc oxide.
Most modern sunscreen formulations are a blend of two to three different substances carefully selected to compliment one another and enhance product performance ( Fig. 2.7 ). However, raising the SPF above 30 only confers an incremental increase in photoprotection ( Fig. 2.8 ).

Fig. 2.7 Sunscreen protection. Sunscreens are combined to provide the broadest coverage of absorption spectra yielding optimal photoprotection in the UVB and UVA range.

Fig. 2.8 SPF and photoprotection. The relationship between SPF and the degree of photoprotection is not linear. This means there is very little increase in photoprotection beyond an SPF of 30.

UVA sunscreen ingredients
Proper UVA photoprotection is important because it is this spectrum of radiation that results in photoaging, skin pigmentation, and photocarcinogenesis.
Oxybenzone is a widely used weak UVA (it absorbs at 320 nm) absorber commonly used as a secondary sunscreen to increase the broad-spectrum protection of the formulation. It is an oil-soluble ingredient that can add to the sticky feel of a sunscreen if used in too high a concentration. It has been used in combination with 2–6-diethylhexylnaphthalate to stabilize avobenzone (also known as Parsol 1789), which is highly photounstable with 36% of the avobenzone destroyed shortly after sun exposure.
Oxybenzone may also be combined with menthyl anthranilate (also known as meradimate) to extend UVA photoprotection with a peak absorption at 336 nm. Meradimate is commonly used as a secondary UVA photoprotectant because it is a sticky oil and can decrease sunscreen aesthetics.

UVB sunscreen ingredients
The sunscreen ingredients that contribute the sun protection factor rating (known as the SPF), provide protection against UVB exposure, which contributes to sunburn and photocarcinogenesis.
The salicylates, such as octisalate and homosalate, are important UVB photoprotectants, with internal hydrogen bonding providing for maximal UVB absorption at 300–310 nm. Approximately 56% of sunscreens currently available use the salicylates as a secondary sunscreen active because of their minimal allergenicity.
86% of products with an SPF rating of 15 or higher contain octyl methoxycinnamate (also known as octinoxate), which has maximal absorption at 305 nm. Octinoxate has excellent photostability with only 4.5% degradation after UVB exposure and is commonly used in sunscreen-containing moisturizers and facial foundations.

Physical UVA/UVB absorbers
The physical UVA/UVB absorbers are titanium dioxide and zinc oxide.
• Titanium dioxide is usually micronized to contain particles of many sizes to provide optimal UV scattering abilities. It leaves a white film on the skin and is used mainly for beachwear products.
• Zinc oxide is usually available in a microfine form (i.e. it contains small particles of one size), making it appropriate for day wear in persons of all skin colors. Zinc oxide-based sunscreens provide the most complete post-procedure photoprotection, especially after completion of a chemical peel.

Conclusion
Chemical peeling is a versatile method of improving skin texture, pigmentation, and fine lines, especially on the face, but also on other body areas. It improves skin appearance by encouraging exfoliation while removing dyspigmented skin. It is an acquired art that requires no special equipment and can be performed for a relatively small investment.
Following a superficial, medium, or deep chemical peel, proper skin care is important to ensure optimal healing and longevity of the result and involves the use of mild cleansers to prevent barrier damage and moisturizers to enhance the water holding capacity of the skin. Sunscreens that provide both UVB and UVA photoprotection must also be applied to prevent unnecessary photodamage.
The combination of proper skin care and a well-executed cosmetic procedure will optimize skin appearance.

References

1. Willcox M.J., Crichton W.P. The soap market. Cosmet Toilet . 1989;104:61-63.
2. Wortzman M.S. Evaluation of mild skin cleansers. Dermatol Clin . 1991;9:35-44.
3. Wortzman M.S., Scott R.A., Wong P.S., et al. Soap and detergent bar rinsability. J Soc Cosmet Chem . 1986;37:89-97.
4. Draelos Z.D. Therapeutic moisturizers. Dermatol Clin . 2000;18:597-607.
5. Flynn T.C., Petros J., Clark R.E., et al. Dry skin and moisturizers. Clin Dermatol . 2001;19:387-392.
6. Rawlings A.V., Harding C.R., Watkinson A., et al. Dry and xerotic skin conditions. In: Leyden J.J., Rawlings A.V., editors. Skin moisturization . New York: Marcel Dekker; 2002:119-144.
7. Draelos Z.D. Moisturizers. In: Draelos Z.D., editor. Cosmetics in dermatology . 2nd edn. New York: Churchill-Livingstone; 1995:83-95.
8. Ichihashi M., Ueda M., Budiyanto A., et al. UV-induced skin damage. Toxicology . 2003;189:21-39.
9. Young A.R. Cumulative effects of ultraviolet radiation on the skin: cancer and photoaging. Semin Dermatol . 1990;9:25-31.
10. Gilchrest B.A. A review of skin ageing and its medical therapy. Br J Dermatol . 1996;135:867-875.
11. Matsumura Y., Ananthaswamy H.N. Toxic effects of ultraviolet radiation on the skin. Toxicol Appl Pharmacol . 2004;195:298-308.
12. Wulf H.C., Sandby-Møller J., Kobayasi T., et al. Skin aging and natural photoprotection. Micron . 2004;35:185-191.
13. Kawada A., Noda T., Hiruma M., et al. The relationship of sun protection factor to minimal erythema dose, Japanese skin type, and skin color. J Dermatol . 1993;20:514-516.
14. Roelandts R., Sohrabvand N., Garmyn M. Evaluating the UVA protection of sunscreens. J Am Acad Dermatol . 1989;21:56-62.
15. Diffey B.L. A method for broad spectrum classification of sunscreens. Int J Cosmet Sci . 1994;16:47-52.
16. Nash J.F. Human safety and efficacy of ultraviolet filters and sunscreen products. Dermatol Clin . 2006;24:35-51.
17. Gasparro F.P., Mitchnick M., Nash J.F. A review of sunscreen safety and efficacy. Photochem Photobiol . 1998;68:243-256.
18. Moloney F.J., Collins S., Murphy G.M. Sunscreens: safety, efficacy and appropriate use. Am J Clin Dermatol . 2002;3:185-191.
19. Tanner P.R. Sunscreen product formulation. Dermatol Clin . 2006;24:53-62.
Chapter 3 Non-surgical Facial Rejuventation with Fillers

Brian M. Kinney, David J. Rowe, David Stepnick
The rising interest in cosmetic surgery among the general population is so widespread that cosmetic procedures, surgical, and non-invasive, have essentially entered the popular lexicon. With the purification of bovine collagen and its subsequent clearance for marketing by the US Food and Drug Administration (FDA), soft-tissue filling first became practical in the 1980s. As minimally invasive cosmetic procedures grew from an occasional medical novelty, the purview of the rich and famous, their use became widespread in the 1990s, eventually to a commonly sought means of cosmetic enhancement for millions of people. In 1992 the American Society of Plastic Surgeons reported 41 623 collagen injections, the only type of exogenous filler generally available in the USA. In 2006, 388 316 injections were reported by its members and their use had been accepted in mainstream culture. If data on botulinum toxin is included, the numbers go beyond 1 million per year.



Summary

1. Facial aging is multi-factorial, and often due to a combination of ptosis, loss of skin tone, elasticity, perfusion, hydration, muscle function, and subcutaneous tissue volume.
2. Soft-tissue fillers are rapidly increasing in use and sophistication, but do not address all lost tissues.
3. Very few patients’ conditions are correctable by injection alone; a thorough understanding of combination therapy, including surgery, is essential.
4. Natural fillers are safer and generally preferred to synthetic, but do not last permanently.
5. Permanent fillers are synthetic, have more serious complications and require extremely careful injection techniques.
6. As more fillers become available, more understanding is required by the surgeon and more confusion is likely by the patients.
7. While minimally invasive in nature, injections must be guided by an accurate understanding of the surgical anatomy.
8. Complications are rare, but excellent results are more elusive than generally appreciated.
9. The nasolabial folds and the marionette lines are generally easier to manage than other regions.
10. Injections in the hands and on the trunk are less common, well-studied and efficacious than in the face.

Introduction
The rising interest in cosmetic surgery among the general population is so widespread that cosmetic procedures, surgical, and non-invasive, have essentially entered the popular lexicon. With the purification of bovine collagen and its subsequent clearance for marketing by the US Food and Drug Administration (FDA), soft-tissue filling first became practical in the 1980s. As minimally invasive cosmetic procedures grew from an occasional medical novelty, the purview of the rich and famous, their use became widespread in the 1990s, eventually to a commonly sought means of cosmetic enhancement for millions of people. In 1992 the American Society of Plastic Surgeons reported 41 623 collagen injections, the only type of exogenous filler generally available in the USA. In 2006, 388 316 injections were reported by its members and their use had been accepted in mainstream culture. If data on botulinum toxin is included, the numbers go beyond 1 million per year.
The choice of the appropriate filler, however, has become increasingly difficult. With the ever-expanding number of fillers and filler types, the surgeon must, not only maintain an adequate knowledge of the physiochemical properties of the filler types, but also must understand the differences in injection levels and techniques for each of the fillers. A thorough aesthetic evaluation of the patient as well as a complete discussion of the patient’s aesthetic goals and treatment preferences must be performed in order to achieve a treatment plan that is safe and realistic.

Soft Tissue Loss in the Aging Patient
Some of the features that a youthful face exhibits include smooth contours, few wrinkles, except in dynamic expression, and full subcutaneous tissues with minimal or no soft-tissue atrophy ( Fig. 3.1 ). Nasolabial, glabellar and crow’s feet skin folds are almost uniformly absent at rest, and minimally noticeable, even with muscular contraction. During aging of the normal, healthy adult, there is loss of soft-tissue fullness in the face, often beginning in the nasolabial folds and progressing inferiorly along the marionette lines. Lines in the upper face may show years earlier during dynamic expression than at rest. Lipoatrophy can distress the aging patient with resultant low self-image and self-esteem, depression and social isolation. 1, 2 With the severe rise in obesity in recent years, loss of facial fat due to aging may be partially offset due to fatty accumulation after weight gain.

Fig. 3.1 Location of rhytids in the aging face.
In the normal aging face there is gravitational pull on sagging skin, flattening of the youthful contours, accompanied by solar degeneration, variation in pigmentation, an increase in rhytids, capillary break-down, loss of muscle tonicity and progressive thinning of the skin and subcutaneous tissues ( Figs 3.2 and 3.3 ). One of the hallmarks of aging skin - and one for which we have essentially no topical or minimally invasive corrective solution - is poor elasticity, breakdown of elastic fibers and excess skin envelope. In essence, with an imbalance of soft tissue volume to skin envelope, there are three basic approaches: 1) fill up the lost tissue volume, 2) chemically peel, laser, or mechanical dermabrade or excise the excess skin, or 3) live with the difference. Because few patients have one isolated contributing factor, the ideal approach would often include volume restoration and treating the skin. However, many patients do not desire more aggressive treatment. Chemical peels and lasers chemically denude the superficial layers of the skin, but do not reduce the surface area of the skin sufficiently to balance the loss of soft tissue volume in any but the mildest conditions in the youngest patients. While they tighten the skin, in essence by cross-linking collagen and other proteins, they do not restore the elasticity of youth.

Fig. 3.2 The aging face: presence of rhytids and soft tissue descent.

Fig. 3.3 Architecture of rhytids.

Soft Tissue Loss in Disease Conditions
While less common, certain disease conditions cause premature loss of soft-tissue volume; some are genetic and some acquired. Congenital generalized lipodystrophy (autosomally recessive) results in lack of adipose tissue from birth. Familial partial lipodystrophy (autosomally dominant) causes progressive peripheral fat loss beginning at puberty and, typically, the facial fatty tissue will stay the same, or rarely gain fat, while the body atrophies. Mandibulosacral dysplasia (autosomally recessive) shows two forms: type A demonstrates peripheral fat loss with normal or excess facial fat, while type B shows generalized fat loss. Partial lipodystrophy (autoimmune mediated) presents during childhood or adolescence and the upper body, including the face, presents with fat loss. Excess fat is found in the legs and hips. Generalized lipodystrophy (immune mediated) presents during childhood or adolescence and shows generalized fat loss, including the face.
Acquired lipodystrophies arise from multiple mechanisms, but more commonly small localized areas of fat loss may occur from drug injections, local trauma or crush injuries, immune-mediated mechanisms, cancer or HIV, the most prevalent form. Highly active antiretroviral therapy (HAART) is associated with the condition, but its actual mechanism is unknown. There appears to be some interaction with protease inhibitors and nucleoside reverse transcriptase inhibitors. The HIV patient shows rapid loss of peripheral fat and fat in the face, occurring within 1 year of treatment. 3 Fat paradoxically accumulates in the abdomen, breast and dorsocervical spine. In the face, the buccal and temporal fat pads are most locally affected; however, there is loss of fat diffusely in the face. Fat loss may be rapid and progressive and is often permanent, refractory to steroid administration and dietary intervention. The prevalence has been reported as variable (18-83%) due to differing definitions. 4 Lipoatrophy in HIV patients can lead to compliance issues, reducing the effect of HAART and accelerating disease progression, fear of stigmatization and recognition. 5, 6

Indications



Indications

1. Nasolabial fold prominence
2. Marionette lines and secondary smile lines
3. Perioral lines
4. Paramental soft tissue atrophy
5. Tear trough atrophy
6. Temporal and buccal fat loss
7. Generalized cheek atrophy
8. Crow’s feet
9. Glabellar lines
10. Combination therapy with laser, chemical peel or facelift.

Skin lines, wrinkles and folds
By far the most frequently injected area, the nasolabial fold (NL), may be best evaluated by the standardized Lemperle scale of severity ( Fig. 3.4 ). Natural folds in the face are created by attachment of the facial muscles to the undersurface of the skin. No comparable scale is widely used in the marionette lines, the crow’s feet and/or other skin folds of the face. However, an appropriate approach would be to use the commonly accepted Lemperle scale. The NL fold may begin to appear in the early 20s and progresses with aging. While this scale is primarily focused on skin wrinkling, soft tissue loss is a contributing factor as well.

Fig. 3.4 Lemperle scale of nasolabial fold severity. A, Grade 0 contains no wrinkles or lines, but may show some minimal contour depression. B, Grade 1 shows just perceptible wrinkles. C, Grade 2 shows shallow wrinkles. D, Grade 3 shows moderately deep wrinkles. E, Grade 4 shows deep wrinkles with well-defined edges. F, Grade 5 shows very deep wrinkles with a redundant fold.

Facial lipoatrophy scale
A four-point grading system is commonly used to measure facial lipoatrophy ( Fig. 3.5 ). Grade 1 is characterized by small localized areas of fat loss, especially in the nasolabial folds. Grade 2 includes mentolabial folds (marionette lines) and may include concavity of the lips. Grade 3 progresses to malar fat atrophy, preauricular hollowing and shadowing of the cheeks and mandibular ridge, while Grade 4 demonstrates malar fat ptosis, temporal hollowing and protruding musculature and bones.

Fig. 3.5 Facial lipoatrophy scale. A, Grade 1 facial lipoatrophy. B, Grade 2 facial lipoatrophy. C, Grade 3 facial lipoatrophy. D, Grade 4 facial lipoatrophy.
(Photos courtesy of Ute Bauer, MD, 2004.)

Contraindications



Contraindications

1. Positive skin allergy test (in injections containing collagen).
2. Known sensitivity to injectate (e.g. collagen, hyaluronic acid, calcium hydroxlyapatite, etc.).
3. Severe skin disease e.g. psoriasis, eczema.
4. Severe systemic disease.
5. Active acne in the region of injection.
6. History of connective tissue disease.
7. Recent chemical peel or ablative laser treatment.
8. Recent use of aspirin, non-steroidal anti-inflammatories or other blood-thinning medications.
9. Previous lumps or nodules in the area of injection.
10. Dense scar tissue.
While there are many contraindications to surgical interventions, there are very few for injectables. This, along with their relatively low incidence of complications, is the factor contributing to their wide popularity. They are very easy to inject, but much more difficult to inject well. Careful attention to topical and deep anatomic detail is essential to avoid distortion of facial anatomy, lumps and nodules. In addition, even in patients with an undesirable outcome, effects rarely last longer than the prospective duration of the injection. This ranges from about 3 months with collagen to about 2 years for calcium hydroxyapatite, but may be permanent with polymethylmethacrylate synthetics. Patients with mild connective tissue diseases may be eligible for injection after a careful history and physical exam, but should be considered a relative contraindication. Active acne, psoriasis or eczema warrant withholding the procedure. A patient who has an apparent large softtissue volume loss may be corrected partially, but almost never should be fully corrected, as a significant portion of the defect may also be due to ptosis of soft tissues. To the extent the soft tissues have fallen they should be lifted; to the extent the soft tissues have atrophied, the volume should be restored.

Preoperative History and Considerations

Pre-procedure analysis
Paramount in the decision-making process as to the choice and location of injectable fillers are the patient’s physical characteristics and aesthetic goals. A complete pre-procedure assessment includes pre-procedure history and a site-directed physical/aesthetic examination, as well as patient education and informed consent. First, an accurate understanding of the patient’s aesthetic goals must be ascertained. Perhaps the most important consideration in the busy cosmetic clinic is an unreasonable expectation by the patient, e.g. viewing an injection as a facelift in a syringe. Part of this misperception is due to unreasonable promotion by some physicians and the titanic interest in the procedure by the fashion, beauty industries and the public at large in a youth-oriented culture.
It is therefore the surgeon’s obligation to include discussion of possibly relevant surgical as well as non-surgical procedures that may be needed to meet the patient’s expectations. If the patient is best suited for a surgical procedure and opts for a filler-type correction, one must carefully point out what will and what will not be corrected with the filler.
Age is an important factor, as approximately 80% of all injections are performed between the ages of 35 and 64. 7 Increasing age leads to the tendency of decreased immunogenicity, so, presumably, there would be less of an inflammatory response to a permanent or semi-permanent filler. However, thinner skin and dermal atrophy make superficial injection techniques risky, as lumpiness and color deformity may occur more readily. Avoidance of aspirin, NSAIDs, gingko biloba, St. John’s Wort, and high-dose vitamin E for 1-3 weeks prior to the injection is encouraged.

Injectable Fillers
We have truly entered the ‘filler revolution’ and the number of new fillers on the market is constantly increasing. 8 The first injectable filler that was approved by the FDA was bovine collagen (Zyderm/Zyplast; Inamed Aesthetics, Santa Barbara, CA). The need for skin testing and its lack of longevity were key issues hindering its widespread use. 9 Since this time, many classes of fillers have been approved by the FDA, with more likely in the future. Listed in this section is a brief description of each of the major injectable fillers currently being utilized in the USA.

Hyaluronic acid
Of the 9.2 million non-surgical cosmetic procedures performed in 2004, almost 900 000 included augmentation using injectable hyaluronic acid (HA) fillers. 10 Hyaluronic acid is a glycosaminoglycan that is a naturally occurring polysaccharide. Hyaluronic acid is an essential component of the extracellular matrix, essentially ubiquitous throughout all animal species. Therefore, it has no species or tissue specificity, making HA ideal from an immunologic standpoint. In its native form, catabolism of HA is rapid (hours to days), therefore stabilization via crosslinking is essential for utility as an injectable filler. HA is hydrophilic and able to retain 95% of volume with water. 11 Unique to HA is its ability to follow isovolemic degradation, a process by which the remaining molecules of HA are able to bind an increasing amount of water thus maintaining volume until the majority of product is degraded.
Currently, there are several HA derivative products approved by the FDA. All products are approved for mid-to-deep dermal implantation for correction of moderate-to-severe facial wrinkles and folds: 12 - 14 Restylane (Medicis, Scottsdale, AZ), Perlane (Medicis, Scottsdale, AZ), Juvederm (Allergan, Irvine CA), Captique (Allergan, Irvine, CA), and Hyalform (Allergan, Irvine, CA). Restylane was the first of the HA fillers to be FDA approved (12/2003); in initial studies by Narins et al it showed superiority to Zyplast with a smaller concentration of product. 15 Restylane has a HA concentration of 20 mg/ml, a gel particle size of 400 μm, and a 1% degree of crosslinking. 16 It is distributed in 0.4 ml and 1.0 ml disposable syringes. Wang et al 17 recently reported that, in addition to the physiochemical properties of Restylane, it may augment dermal filling by stretching fibroblasts and thereby stimulating de novo collagen formation.
Other HA fillers are similar to Restylane but differ in several key categories: concentration, particle size, and degree of crosslinking. Juvederm was FDA approved in June 2006 and has a slightly higher concentration of HA (24 mg/ml), a higher percentage of crosslinking, and has randomly shaped particles. In addition to Juvederm, two other formulations of Juvederm have been FDA approved. Juvederm Ultra is a thinner version of Juvederm. Juvederm Ultra Plus has a greater particle size and a larger degree of crosslinking, marketed to be utilized as a volumizer injected deeper than its predecessor. Perlane is similar in crosslinking to Restylane; however, like Juvederm Ultra Plus, it has a larger particle size intended to be placed deeper in the dermis and/or subdermis. Restylane, Juvederm, Juvederm Ultra, Juvederm Ultra Plus, and Perlane are all derived from non-animal stabilized HA (NASHA). NASHAs, coupled with the ubiquity of HA, render these injectables as having a low potential for immunogenic reaction. In contrast, Hylaform is derived from rooster combs and does confer immunogenicity. Puragen recently renamed as Prevelle Shape, has been approved in the EU for two years and is double cross-linked with the aim to better resist degradation ( Figs 3.6 , 3.7 and 3.8 ).

Fig. 3.6 Patient in her 50s 14 months after double cross-linked hyaluronic acid in the nasolabial folds.

Fig. 3.7 A, Patient in his 50 s 9½ months after injection of double cross-linked hyaluronic acid. B, At 12 months the left nasolabial fold has partially returned.

Fig. 3.8 A 57-year-old patient with double cross-linked hyaluronic acid. Almost full correction at 10½ months.

Table 3.1 Comparison of hyaluronic acid fillers chemistry and impact on clinical outcomes

Calcium hydroxylapatite
Synthetic calcium hydroxylapatite (CaHA) is a biocompatible substance with a similar mineral component to bones and teeth. TheCaHA scaffold theoretically allows for tissue ingrowth with no immunogenic or inflammatory response as well as no migration. Radiese(BioForm Medical, San Mateo, CA) is a suspension of 30% CaHAmicrospheres of 25-45 μm in diameter in a gel consisting of 1.3%carboxymethyl cellulose, 6.4% glycerin, and 36.6% sterile water.Radiesse was approved by the FDA in December 2006 for the correctionof soft-tissue wrinkles and folds; however, it was previously approvedfor laryngeal augmentation, soft-tissue marking, and filling/augmenta-tion of dental intraosseous defects and oral/maxillofacial defects. 18 It is also now approved for correction of HIV facial lipoatrophy. 19
Histologically, by 3 months, there is some residual phagocytosis ofthe gel substrate and a fine fibrous stroma between the CaHA microspheres ( Fig. 3.9 ). By 9 months, there is irregularity of the shape ofthe CaHA microspheres, presumably from enzymatic degradation. Noforeign body granulomatous reactions have been identified ( Fig. 3.10 ). 20 - 23 Radiesse has been reported to persist histologically from 2 to 7 years. 24

Fig. 3.9 Microspheres individually surrounded by delicate fibrous encapsulation 12 months after implantation.

Fig. 3.10 Six months after injection of upper and lower lips, nasolabial folds and the oral commissure.
(Photo courtesy of Miles Graivier, MD.)

Poly-L-lactic acid
Poly-L-lactic acid (PLA) is a synthetically polymerized lactic acid material first synthesized from vegetable sources in 1954 and used in multiple surgical devices, including suture materials (DEXON (Davis & Geck, Manati, Puerto Rico), VICRYL (Ethicon, Inc., Somerville, N.J.), and in resorbable plates and screws, as well as a vehicle for sustained drug release. Sculptra (New-Fill in Europe) is manufactured in Italy and distributed in the USA by Dermik Laboratories (Berwyn, PA - Sanofi-Aventis, Bridgewater, NJ). Sculptra is formulated into PLA microspheres (40-63 μm) suspended in a sodium carboxymethylcellulose carrier and reconstituted with sterile water. Sculptra was FDA approved in 2004 for correction of facial lipoatrophy in HIV patients ( Figs 3.11 and 3.12 ).

Fig. 3.11 A, Patient in her early 40s with facial atrophy after more than 6 months of seizure medications. B, Nine months after three injection sessions 4-6 weeks apart with poly-L-lactic acid injections in the temple and cheek. Her weight did not change appreciably.

Fig. 3.12 A, Septuagenarian patient prior to poly-L-lactic acid (PLA) injections in the hands. B, Eight months after three injections of PLA about 6 weeks apart in the dorsal hand, first through fourth web spaces. There is palpably increased soft tissue in the hands.
Following solubilization, the lactic acid degrades via the lactate/ pyruvate route, and is then eliminated as CO 2 through the respiratory system. 25 Histologically, no polymer is detected after 9 months. 21 Tissue filling is ultimately achieved by ingrowth of type I collagen (neocollagenosis). 26 Thus, the filling persists despite resorption of polylactic acid microparticles. Investigations in HIV lipoatrophy have revealed increased dermal thickness by threefold, as well as increasing the quality of life in this group of patients. 27, 28

Polymethylmethracylate beads coated in collagen
Polymethylmethracylate (PMMA) microspheres are insoluble, synthetic and chemically related to Plexiglas. PMMA is commonly used in orthopedics for permanent fixation and support of bony tissues. ArteFill (San Diego, CA) is composed of a 20% solution of PMMA microspheres 30-42 μm in diameter and suspended in a solution of partly denatured bovine collagen and 0.3% lidocaine. ArteFill received FDA approval in January 2007 for correction of facial wrinkles, thus making it the first permanent injectable wrinkle filler in the USA. 29 Patients must be skin tested for allergy to bovine collagen and possibly tested for reactivity to collagen. 30
Artecoll, the identical product with previous marketing nomenclature, has been implemented throughout the world since 1994. Reportedly 400 000 patients have been treated to date. 31, 32 The PMMA microspheres are non-biodegradeable and are unable to be phagocytosed by macrophages, due to their size and lack of electrical charge. Thus, soft-tissue augmentation is thought to be permanent. By 1 month post-injection, each individual microsphere is encapsulated by collagen, macrophages, and fibroblasts. Resorption of the bovine collagen and replacement with native collagen occurs within 1-3 months. The size of the Artecoll microspheres is unchanged by 9 months. 21, 33
Injected in small amounts and corrected less than 1 : 1 in volume, excellent results can be extremely pleasing clinically, as good as or better than any others. The injectate is permanent and may not show at all, or potentially after the normal soft-tissue atrophy of aging occurs years later. Experience has not ranged over sufficient years since introduction about 10 years ago to be sure of the clinical significance of this possibility. 34 If there is a complication, the results may respond to triamcinolone injection, or may require excision, because the body cannot resorb this synthetic polymer.

Polyacrylamide gel
Aquamid (manufactured by Ferrosan, Copenhagen, Denmark; distributed by Contura International, Soeberg, Denmark) consists of 2.5% crosslinked polyacrylamide and 97.5% water. Polyacrylamide injected into the subcutaneous tissues elicits a fibrous capsule that surrounds the gel by 6-9 months. 21 This material is currently not approved by the FDA; however, it is in use throughout Europe, South America, and the Middle East.

Other injectables
Silicone has a very small group of supporters, but it is not cleared by the FDA and has a past history of an extremely high incidence of complications, including severe scarring, distortion of anatomy and the need for surgical excision of skin, fibrosis and even muscle. Autogenous fat, a highly successful technique, is not within the scope of this chapter, but should always be considered when choosing a method of soft-tissue restoration.

Operative Approach

Anesthesia
While many patients are able to tolerate neurotoxin injections without the use of anesthesia, most patients require an anesthetic to ensure maximal comfort for the injection of fillers such as the HAs. Especially in extremely sensitive areas such as the lips, an otherwise good experience can leave lasting memories of anxiety and pain, which may curb a patient’s desire to have repetitive treatments. Areas such as the region under the eyes may require a much lower level of anesthesia, and, as such, choice of an anesthetic must be tailored to the patient, the material being injected, and the area of treatment.
Applying ice to the area to be injected is probably the lowest cost and easiest technique for decreasing the apparent pain. Many patients prefer this technique rather than either waiting for the topicals to take effect or experiencing the anesthesia which can be achieved with regional blocks.
Topical anesthetics include EMLA cream (a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%), L-M-X (lidocaine 4%), and Tetracaine cream. Compounding pharmacies may create other products utilizing these and various other available topical anesthetic agents. When a topical anesthetic is used, maximal effect is achieved if the product remains in place for 30-60 minutes after application. Rare serious side effects, such as methemoglobinemia with EMLA, may occur. The senior author (BK) has found that in over 90% of patients with triple anesthetic cream and slow, low-pressure injection technique, there is no need for local injection or regional block. Pain Ease®, topical dichlortetrafluoroethane and ethyl chloride (Gerbauer Company, Cleveland, OH), and similar products are topical refrigerants which can be applied to the skin just prior to needle insertion. The product is useful for the nasolabial folds and cheeks, and should not be used on the oral mucosa.
Nerve blocks provide the most effective and profound anesthesia. Local infiltration of an anesthetic agent is to be discouraged, since the volume of anesthetic changes the apparent volume of the area to be corrected with the filler material. Very small volumes of an anesthetic agent - 0.3-0.5 cc - properly deposited in the area where the nerves exit their foramina provide anesthesia without altering the tissue volume. Various choices are available, but lidocaine is the most commonly used agent.

Anatomical considerations

Superficial layers
Low crosslink density, small particle size hyaluronic acids are best close to the surface where the likelihood of lumpiness or nodularity is low. Collagen preparations may be injected here with low risk. The greater the crosslink density and the larger the particle size, the deeper the injection should be placed.

Deeper layers
CaHA and PMMA should be injected in deeper layers, not close to the surface due to their long duration and firmness. PLA, a volume restorer, should be injected in deeper layers. These injections are in large volumes and should not be placed close to the skin or targeted at rhytids.

Nasolabial folds
Threading, fanning, and serial droplet techniques can be employed. Of these, the threading technique provides good results and is an optimal choice for the nasolabial crease. An eyeliner pencil is easily visualized yet can be effortlessly removed. Patients then may lean back and receive the injections in a relaxed, semi-recumbent position. The needle is inserted to its hub in the deep dermal or immediate subdermal plane. HAs are injected into the deep dermis; CaHA is injected just below the dermis. Inspection and feel guide proper needle placement: dimpling of the skin with downward pressure on the needle signifies that the needle is, indeed, in the deep dermis. If the needle can be visualized through the skin, it is too superficial. If there is little resistance to the needle and the product, it is likely in the subcutaneous tissue.
Approximately three threads of product are placed, taking care to deposit the material in the valley beneath the nasolabial crease. The triangular area bounded by the nasal alar crease and the nasolabial fold should be filled. If the cheek above the crease is injected, the nasolabial fold will be accentuated rather than blunted. A key part of the procedure is firmly massaging the deposited material, molding it to fill the hollow, achieving a natural appearance without visible lumpiness.
Following injection, the patient is given ice to hold on the areas for 15 minutes to help minimize swelling and bruising. Results improve over 1 week or 2 as inflammation subsides. Especially with calcium hydroxyapatite, which is much denser than the surrounding soft tissue, the material is palpable for weeks to 2-3 months, at which point the carrier vehicle absorbs and degrades, and the tissue consistency resembles normal tissue. Patients should be so advised.
To achieve optimal results and longevity, the nasolabial folds must be maximally corrected. Less than maximal correction often contributes to patient dissatisfaction. Studies examining longevity treated patients to maximal correction and, as such, patients not receiving maximal correction cannot be expected to have as long-lasting a result. Indeed, complete correction and placement of the materials in the proper plane appear to be key factors for success. 17
HAs placed too superficially appear as a visible, raised blue line along the fold. Calcium hydroxyapatite appears white. For the HAs, the product can often be expressed by digital pressure or by nicking the dermis with an 18 gauge needle and expressing it with applied pressure. Hyaluronidase injections will break down the product if needed. Patients with deep, hyperdynamic creases or those with heavy cheeks may have a suboptimal result.

Marionette lines
The fanning technique is particularly useful in this region. Fanning involves introducing the needle at a 30 ° angle to the level of the deep dermis. The needle is passed back and forth medially and laterally to the fold by about 2 mm in each direction. Unlike the linear threading technique, the material is deposited both upon insertion and withdrawal of the needle, and bevel position is irrelevant. As with the nasolabial crease, if too much material is deposited superior/lateral to the fold, it may be accentuated instead of being reduced.

Paramental crease
As with other areas of the face, the paramental crease and prejowl sulcus results from a combination of descent of tissues, due to gravity and loss of elasticity, together with deflation and loss of volume in particular areas of the face. While surgical correction is the only way to lift and tighten the jowls themselves, fillers can be used in the pre-jowl sulcus to camouflage the appearance of the jowls. As this is not a discrete crease like the nasolabial creases and the marionette lines previously discussed, the material deposited needs to be more diffuse and slightly deeper. Subcutaneous placement is desired, whereas deep dermal placement may produce a lumpy appearance.

Glabellar lines
In general, glabellar rhytids are best and most frequently treated with botulinum toxin. However, for patients with particularly deep lines, the neurotoxin may not provide sufficient improvement to appropriately eliminate these creases. In such patients, a synergistic effect can be obtained by using a filler in combination with the neurotoxin. 33 Others have reported that concurrent injection of Restylane® and botulinum toxin increases the longevity of the former. 35 The serial puncture technique is used, staying in the mid-dermis. Injection occurs as the needle is being withdrawn. It may be useful to compress the supratrochlear vessels to minimize likelihood of intravascular injection.

Fig. 3.13 Techniques of injection. A, Serial puncture technique: multiple injections are placed sequentially along the length of the wrinkle or fold. Adjacent areas should join together into a continuous, smooth line without spaces. B, Linear threading technique: the full length of the needle is inserted into the middle of the fold and material is injected while gently withdrawing the needle longitudinally. Each thread should be as long as the needle inserted to the hub. C, Fan technique: the needle is inserted in the area as when using the linear threading technique, and after injecting in one line, the needle is kept under the skin and reinserted in a new line, repeated in a fan-shaped pattern. D, Cross-hatching technique or Lake technique: commonly used for poly-L-lactic acid and may be used for filling the cheeks with hyaluronic acid.
Bruising is not uncommon in this region. Multiple cases of skin necrosis and scarring have been reported in the literature, particularly in this region. 36, 37 Immediate care of prolonged skin blanch after injection involves massage to stimulate blood flow into the region. If this is not effective topical 2% nitroglycerine ointment can be applied.

Lower eyelids (nasojugal groove and tear trough regions)
One of the more difficult areas to treat successfully is that area of the lower eyelids. However, a good result is equated with high degrees of patient satisfaction. 38 Significant hollowing occurs as a result of pseudoherniation of orbital fat combined with descent of the buccal fat. This may also result as a result of cosmetic lower blepharoplasty. The thin, delicate nature of the skin makes this area a challenge. The area bruises very easily, especially in patients with clotting abnormalities, those prone to bleeding, or in whom pharmaceuticals are used that interfere with normal clotting. Fillers injected just beneath the surface of the very thin skin can be visible, and are to be avoided. For this reason, many clinicians are reluctant to inject the tear trough region. Surgeons who have an excellent understanding of the orbital and lid anatomy form having operated upon it in the past are well-prepared to inject in an entirely different plane than discussed with the other subsited thus far. The filler should be injected beneath the orbicularis muscle, overlying the periosteum, serially along the orbital rim. Surface irregularities can in this way be minimized. Undercor-rection is preferred to overcorrection. As the HAs are hydrophilic and attract water in the first few weeks after the filler is placed, complete correction can actually become overcorrection, and the eyes may take on a puffy appearance. More than any other area, bruising can occur and so patients need to account for this to ensure that whatever bruising does occur does not interfere with their lifestyle.

Lips
Fillers can be useful when patients complain of lipstick ‘bleeding’ onto the cutaneous lip, enhancing the lip border lessens or eliminates this problem. Similarly, in smokers, the fillers can re-inflate the fine lines that develop around the lips as a result of smoking. The lips are an extremely sensitive area and nerve blocks are virtually a necessity. Linear threading is essentially always used in place of serial puncture. The risk of hematoma (in the labial artery) is quite high compared to other areas of injection and careful observation is necessary. Immediate application of firm pressure is required, should it occur. In the midst of injection it is possible to monitor the flow of injection. Some prefer convexity of the mucosa surface and some prefer definition in the vermillion border; needle placement should be adjusted accordingly. The filler is injected carefully, as any irregular deposition will be obvious as the swelling diminishes. Ice should be used to minimize swelling, but even with ice, swelling may hide any lumpiness or irregularity. As such, the lips should be carefully palpated, and massaged to properly contour the lips. For patients with thin lips, the needle is reinserted and a second bead of filler is placed 1-2 mm inferior to the vermillion border, parallel to the first injection. This produces a favorable upwards roll to the lip.
Increased volume and lip body are achieved by injecting directly into the lip. The body of the lip is injected in a manner similar to the vermillion, in the area of the lip between the vermillion and the wet lip. The wet lip should not be injected, because at this depth, the labial artery is at risk of occlusion by the material and the theoretic risk of ischemia of the lip needs to be considered. Typical volumes needed to enhance the volume of the lip are 0.25-0.5 cc per lip. It is unusual to use more than 1.0 cc per lip. Deep vertical rhytids can be individually and directly injected, but should not be overcorrected.
Generally, HA, having supplanted the use of collagen in the last 3-4 years, is the injectate of choice in the lip ( Fig. 3.14 ). CaHA, PMMA and PLA are generally not indicated in the lips and should be used with great caution except in the hands of the experienced injector and the experienced patient who know the doctor well.

Fig. 3.14 Injection of double cross-linked hyaluronic acid (HA) for lip augmentation. A, Double cross-linked HA pre injection. B, Double cross-linked injection at 4 months. Lower lip eversion and decreased vertical upper lip lines are still improved. Volume loss has begun to occur.
Patients with a history of cold sores should receive antiviral prophylaxis, as injections can stimulate reactivation of latent herpes infection. These patients should receive Valtrex 500 mg bid on the day of treatment and for a total of 10 days of therapy.

Other important details
The patient should be in a position that best demonstrates the defect - usually in a near upright position. The head should be stabilized against a headrest. We like to have the patient examine closely the areas of treatment in a handheld mirror while we highlight the method of treatment prior to its start. After each injection the patient has an opportunity to view the partial result within an individual area and compare left to right.


Optimizing outcomes

• Correction must be optimized based on product hydration and swelling expected.
• Overcorrection and swelling is permissible immediately after underhydrated HA products.
• Permanent fillers should never be used to overcorrect volume.
• Slow, gentle injection without excess pressure is essential.
• During rapid, high-pressure injection the injectate will dissect along the path of least resistance, which may even be perpendicular to the long axis of the needle.
• Intra-injection monitoring of tissues is required for optimal contouring and volume restoration.
• Calcium hydroxlyapatite must be injected deep and in several sessions to avoid palpable or visible nodules.
• Adequate local anesthesia prevents facial muscle contraction and distortion during injection.
• Compounding pharmacies make available a triple anesthetic cream with 20% benzocaine, 8% lidocaine and 4% tetracaine, which works within just a few minutes, much faster than the standard topical anesthetics that may take up to 30-45 minutes to anesthetize adequately.

Complications and Side Effects

1. Pain
2. Erythema
3. Swelling
4. Bruising
5. Inflammation
6. Asymmetry
7. Hematoma
8. Allergy
9. Early resorption
10. Nodularity and purulence.
The first five on the list are relative common adverse events, are almost always transitory and responsive to palliative treatment. Asymmetry is almost always present, but those cases leading to dissatisfaction are relative uncommon. Hematoma, while relatively more uncommon, is also short-lived and generally easy to treat. Allergy implies exposure to protein, and in HA preparations it is residual from the production process of bacterial fermentation. Protein loads in HA preparations is in the order of 1 part per million. This is generally not a problem with CaHA and PLA, but PMMA has an outer coating of collagen and carries the risk of allergy, just as traditional collagen injection does. However, hypersensitivity reactions may occur many months after treatment. In a study of 709 patients injected with Hylaform or Resylane followed-up for 12 months or more, six developed delayed skin reactions 8 weeks after injections. 39 In a 1999 study, localized hypersensitivity reactions occurred in approximately 1 in 1400 patients, and adverse events were reported in one in 650 patients (0.15%). In 2000, when the amount of protein in the raw product decreased, those numbers fell to one in 5000 for hypersensitivity reactions and one in 1800 for adverse events (0.06%). Andre performed a retrospective study evaluating the incidence of adverse reactions after non-animal stabilized hyaluronic acid injections and found an overall 0.8% global risk of hypersensitivity reactions, of which 50% were immediate and resolved in under 3 weeks. 40
The incidence of purulence and nodularity amongst HA injections is not known, but may be between 1 : 1000 and 1 : 5000. This can be a devastating complication and can lead to scarring, and permanent contour alteration. Treatment includes various combinations of antihistamines, oral or parenteral antibiotics, hyaluronidase injection and triamcinolone injection depending on the clinical presentation.

Clinical examples


Fig. 3.15 Hyaluronic acid injection with expected immediate post-injection edema and erythema. Cold compresses immediately after injection and over the counter analgesics are all that are required.

Fig. 3.16 Asymmetry 14 months after double-cross-linked hyaluronic acid (Puragen) due to irregular resorption and underlying anatomical differences. This case is not a complication per se. Retreatment at the patient’s or physician’s discretion is permitted. A greater than 40% correction remains in a 120 kg male, almost 2 meters tall, not a typical patient. Early asymmetry may be due to missed diagnosis, incomplete correction or other causes.

Fig. 3.17 Nodularity without purulence. Late nodule formation with photos 9 months and 9 months and 1 day after injection. Nodularity resolved within a few days. The patient had reported several episodes between 3 and 9 months of temporary (1-2 day) appearance and spontaneous resolution of inflamed nodularity. Improvement was likely due to rapid resorption of hyaluronic acid (HA) after episodic breakdown of the long-standing normal connective tissue capsule. Connective tissue inflammation may be treated with triamcinolone injection and HA sequestrum may be treated with hyaluronidase enzyme injection.

Fig. 3.18 Early resorption at 4 months in a 1½ pack per day cigarette smoker who has used indoor tanning booths twice a week for many years. No other findings were seen.

Fig. 3.19 Hyaluronic acid injection in the nasolabial fold with nodule formation and inflammatory response. Multimodal treatment may include triamcinolone injection, hyaluronidase injection, oral antibiotics and antihistamines. Ultrasound treatments or hypodermic epidermoclysis may break down the connective tissue capsule.

Fig. 3.20 A, Nodularity following polymethylmethracylate (PMMA) injection. B, Biopsy of four sites after injection of PMMA microspheres.
(Photo courtesy of Claudio DeLorenzi, MD.)

Postoperative Care
Immediate post-injection treatment is minimal, but varies with each material. Generally, the patient is kept in the office for 5-10 minutes with cold compresses applied to monitor for hematoma, nodularity, palpability or other problems. No dressings are required and makeup may be applied before leaving the office. Much discussion has occurred about having patients refrain from vigorous physical activity for several days, but this has no scientifically validated foundation. It is left to the preference of the individual doctor and patient.
A 2-week appointment is essential to effectively evaluate theresults. Often patients will call with questions, and to answer most anexamination is required. With long-acting materials like CaHA andPMMA excessive injection at the first visit is likely to increase nodu-larity, palpability and overcorrection. It is much safer to assess thefinal endpoint of injection at 2 weeks rather than at the first injection.With increasing experience on the part of the doctor and the patient,the repeat visits may be canceled at the patients’ discretion. Pre- andpost-procedure photography is standard care in plastic surgery and isessential for the precise recognition of contour changes.
Long-term care is minimal, but follow-up is essential. Appoint-ments at 3, 6 and 9 months allow for the opportunity to performtouch-up procedures, monitor for the inevitable asymmetric resorbtionand consider complimentary procedures. The rare late complicationcan be discovered on these visits.

Conclusion
Soft-tissue injectables are among the safest and most satisfying procedures in plastic surgery. They go a long way to ameliorating the earlyeffects of aging; infectious, post-traumatic or acne scars; and soft-tissueatrophy of many etiologies. Many patients who are not clinically readyfor more advanced or invasive procedures, are not willing to undergosurgery, cannot afford the time or financial impact, or are just new toaesthetic procedures are ideal for this approach to rejuvenation. In anASPS survey 47% of patients who had a positive experience with injections would consider having surgery with the doctor with whom theyunderwent injection procedures.
It is important to understand the different chemistry and variationsin technique among the various materials available. While it is easyto perform injections, it is not easy to perform them excellently. Pres-ervation of the tissues, careful attention to topical, subcutaneous andmuscular anatomy, precise correction and meticulous injection technique is required. The ideal approach would be to ‘tissue engineer’ cutaneous and subcutaneous tissues. In the future, our choices willincorporate more advanced materials, with chemistry more closely analogous to our natural tissues.

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21. Lemperle G., Morhenn V., Charrier U. Human histology and persistence of various injectable filler substances for soft tissue augmentation. Aesthetic Plast Surg . 2003;27:354.
22. Mayer R., Lightfoot, Jung T. Preliminary evaluation of calcium hydroxylapatite as a transurethral bulking agent for stress urinary incontinence. Urology . 2001;57:434.
23. Probeck H., Rothstein S. Histologic observation of soft tissue responses to imported multifaceted particles and discs of hydroxylapatite. J Oral Maxillofac Surg . 1989;42:143.
24. Marmur E., Phelps R., Goldberg D. Clinical, histologic and electron microscopic findings after injection of calcium hydroxylapatite filler. J Cosmet Laser Ther . 2004;6:223.
25. Brady J., Cutright D., Miller R., et al. Resorption rate route, route of elimination, and ultra structure of the implant site of polylactic acid in the abdominal wall of the rat. J Biomed Water Res . 1973;7(2):155-156.
26. Vleggaar D., Bauer U. Facial enhancement and the European experience with Sculptra (poly-l-lactic acid). J Drugs Dermatology . 2004;3:542.
27. Valantin M., Aubron-Olivier C., Ghosn J., et al. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: Results of the open label study VEGA. AIDS . 2003;17:2471.
28. Moyle G., Lysakova L., Brown S., Sibtain N., Healy J., Priest C., Mandalia S., Barton S.E. A randomized open label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection. HIV Medicine . 2004;5:82.
29. Cohen S., Berner C.F., Busso M., et al. ArteFill: A long-lasting injectable wrinkle filler material - summary of the U.S. Food and Drug Administration trials and a progress report on 4 to 5 year outcomes. Plast Reconstr Surg . 2006;118(3):64S-76S.
30. Elson M. The role of skin testing in the use of collagen injectable materials. J Dermatol Surg Oncol . 1989;15:301.
31. Lemperle G., Romano J., Busso M. Soft tissue augmentation with artecoll: 10 year history, indications, technique, and potential side effects. Dermatol Surg . 2003;29:627.
32. Cohen S., Holmes R. Artecoll: A long-lasting injectable wrinkle filler material. Report of a controlled, randomized, multicenter clinical trial of 251 subjects. Plast Reconstr Surg . 2004;114:964.
33. Narins R., Bowman P. Injectable skin fillers. Clin Plast Surg . 2005;32:151.
34. Lemperle G., Fazio S., Nicolau P. Artefill: A third generation permanent dermal filler and tissue stimulator. Clin Plast Surg . 2006;33:551-565.
35. Carruthers J., Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg . 2003;29:802-809.
36. Glaich A.S., Cohen J.L., Goldberg L.H. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg . 2006;32(2):276-281.
37. Duffy D.M. Complications of fillers: overview. Dermatol Surg . 2005;31(4):1626S-1633S.
38. Hirsch R.J., Carruthers J., Carruthers A. Infraorbital hollow treatment by dermal fillers. Dermatol Surg . 2007;33(9):1116-1119.
39. Lowe N.J., Maxwell C.A., Lowe P., Duick M.G., Shah K. Hyaluronic acid skin fillers: Adverse reactions and skin testing. J Am Acad Dermatol . 2001;45:930.
40. Andre P. Evaluation of the safety of a non-animal stabilized hyaluronic acid in European countries: A retrospective study from 1997 to 2001. J EurAcad Dermatol . 2004;18:422.
Chapter 4 Botulinum Toxin

Michael A.C. Kane
Botulinum toxin type A injections are the most frequently performed cosmetic procedure in the United States. Initially an ophthalmologic drug, Botox (botulinum toxin type A) has become a cultural touch-stone, a topic for sitcoms and even an issue in presidential elections in just over a decade. Its importance in aesthetic plastic surgery simply cannot be overstated. Nearly 4 million procedures were performed in 2005. That is more than all liposuction, breast augmentation, rhinoplasty, facelift, and blepharoplasty procedures (essentially all of the procedures in this book) combined.



Summary

1. The key to successful rejuvenation using botulinum toxin A is an understanding of the functional anatomy.
2. Using the minimal effective dose minimizes a frozen, unnatural appearance.
3. Brow elevation depends on the relative weakness of the brow elevators vs brow depressors.
4. The dose must be based on estimated muscle mass, not rhytid depth.
5. Avoidance of medications that reduce platelet function will decrease ecchymosis.
6. The lower frontalis has the greatest effect on brow elevation.
7. Threading the injection through the lips gives a more natural result than the more common point technique.
8. Cooling the skin before injection minimizes discomfort.
9. A general rule is that injecting depressors more strongly than elevators will tend to give a gentle lift to the structure involved.
10. Overinjecting the mentalis can result in a ‘witch’s chin’ deformity and oral incompetence.


Introduction
Botulinum toxin type A injections are the most frequently performed cosmetic procedure in the United States. Initially an ophthalmologic drug, Botox (botulinum toxin type A) has become a cultural touch-stone, a topic for sitcoms and even an issue in presidential elections in just over a decade. Its importance in aesthetic plastic surgery simply cannot be overstated. Nearly 4 million procedures were performed in 2005. That is more than all liposuction, breast augmentation, rhinoplasty, facelift, and blepharoplasty procedures (essentially all of the procedures in this book) combined.
Eight neurotoxins are secreted by Clostridium botulinum . 1 Type A is a fully sequenced 1295 amino acid chain surrounded by other hemagglutinin and nontoxic nonhemagglutinin proteins for stability.
All type A preparations have the exact same 1295 chain amino acid as their active ingredient, but their different complexing proteins give them different properties. All type A toxins, however, have the same mechanism of action. The heavy chain binds to receptors on the cell membrane of the nerve, which allows the light chain to enter the cytoplasm where it cleaves synaptosomal associated protein 25 (SNAP 25). Because SNAP 25 is essential for the exocytosis of the acetylcholine-containing vesicle, this cleavage results in a presynaptic nerve blockade.
Dr Alan Scott, an ophthalmologist, pioneered the use of botulinum toxin type A in humans. His first publication, detailing the toxin’s effect on Rhesus monkeys, appeared in 1973. 2 He first injected the toxin into humans in 1977 (Scott AB, personal communication). His first publication concerning the injection of the toxin into humans was published in 1980. 3
For years, the toxin was an effective, though seldom used medication, limited to the field of investigational ophthalmology. Its primary uses were for blepharospasm and strabismus. There were rare anecdotal reports of its use for wrinkle reduction (Wyshynski PE, personal communication). 4 The first comprehensive report detailing its cosmetic usefulness was published by the Carruthers, an ophthalmologist/dermatologist team, in 1992. 5
Most patients have an initial excellent response for the first 3.5-4 months, with diminishing returns thereafter as the muscle regains its strength. However, when carefully scrutinized, it typically takes 6-7 months for all of the clinical effects to fade. As patients continue to have the toxin injected on a regular basis over 2 years, most begin to have an increased duration of action. 6 Initially, recovery appears to be facilitated by neurite sprouting as early as 8 weeks after injection. It also appears that the initially blocked nerve terminals recover their function. 7

Typically, after years of regular repeated injections the results last longer.
Anecdotally, and in one publication, 8 it appears that reconstituted toxin that has been allowed to sit unused for weeks may have the same initial effect, but a possibly decreased duration of action. 9
Botox is supplied as a freeze-dried crystalline complex in a vial containing 100 units. Although the package insert says to dilute the vial with 2.5 mL of non-preserved saline, I have used 4 mL of non-preserved saline to reconstitute a vial of Botox since 1991.

I use 4 mL of non-preserved saline to reconstitute a vial containing 100 units freeze-dried crystalline Botox, though the package insert says to dilute it with 2.5 mL of non-preserved saline.

Indications



• Glabellar rhytids
• Complications from aesthetic surgical procedures
• Hyperhidrosis

Contraindications

• Disorders of neuromuscular transmission, such as myasthenia gravis and Lambert-Eaton syndrome
• Aminoglycoside antibiotics may potentiate effects of the toxin
• Pre-pregnancy, pregnancy and breastfeeding (though no evidence to suggest potential harm)
The FDA cosmetic approval for Botox is only for glabellar rhytids in patients under 65 years of age, but I have used it in my practice for patients in their eighties and I have injected every muscle in the face.
Most Botox injections in my practice are off-label. Because the toxin acts upon presynaptic nerve terminals, it is most commonly injected into the muscle where these terminals reside. It is not an all or nothing phenomena. A certain amount of toxin will block a certain number of terminals. Therefore, fine control over the amount of denervation desired is possible. Despite the common use of the word paralysis when discussing the toxin, it is rare that this is the desired effect. Rather, there is a selective weakening of the musculature to achieve a pleasant cosmetic effect.
There are many components to facial aging including thinning of the dermis, elastosis, loss of facial volume, genetic factors, gravity, skeletal changes, smoking and facial animation. Certain rhytids are primarily caused by facial movement. Others are primarily caused by other factors as well as a component of animation. If a wrinkle is partially caused by muscular action, it can be treated with botulinum toxin A, which is why nearly all facial rhytids can be treated by the toxin with varying degrees of success. How well a rhytid responds to treatment with the toxin depends on how much of the rhytid results from factors other than animation.

Complications from aesthetic surgical procedures
Many complications from aesthetic surgical procedures can be effectively treated with Botox.
• Incomplete corrugator or procerus resection after browlift can be treated with Botox. If excessive downward muscle pull on the brows is seen in the early postoperative period, it can be treated aggressively, maintaining brow elevation.
• Surgical misadventures with chin augmentation can lead to mentalis disinsertion and dimpling of the chin. Careful injection of the superficial mentalis can treat this effectively.
• Overly elevated brows after browlift can be dropped with aggressive frontalis injection.
• Prolonged spasm of the pectoralis major after breast augmentation can be treated with injection of the lower pectoralis major.
• Facial nerve injuries after surgery or trauma can often be effectively masked by weakening the unaffected muscle on the other side of the face. For a marginal mandibular nerve injury after facelift, this usually entails injecting the contralateral depressor anguli oris muscle.

Hyperhidrosis
Botox injection can decrease secretion of the eccrine glands in the axillae, palms and soles of the feet. Care must be taken to inject the Botox intradermally in the palms and soles to minimize the risk of weakening the muscles of the hands and feet. Results for this application typically last approximately 6 months.

Contraindications
Botox injection is contraindicated in disorders of neuromuscular transmission, such as myasthenia gravis and Lambert-Eaton syndrome. It should not be used in patients on aminoglycoside antibiotics because they may potentiate the effects of the toxin. 10
Although there is no evidence to suggest potential harm, I do not treat pregnant women, women actively attempting to become pregnant, or those who are breastfeeding.
The toxin does not cross the blood brain barrier. 11

Preoperative History and Considerations

Dosage
Just as all patients are different, so are their muscles. Having standard doses ignores these differences. Men typically require higher doses because their muscle mass tends to be larger. Despite these obvious truths, a constant request after presentations is for some ballpark dose as a good starting point for a neophyte injector. I will therefore refer to doses in this text with the reservation that it is up to each injector to determine the optimum dosage for their patient and that there are no true standard doses.

Although there are no true standard doses, doses are given in this text because I am often asked what is a good starting dose for a neophyte injector. It is, however, up to injectors to determine the optimum dosage for each patient.

Functional anatomy
The absolute key to becoming a proficient Botox injector rather than a technician is understanding the functional anatomy of the face.
Anatomy texts have shown us the location of the different muscles of the face and described their origins and insertions. However, although these texts allow for expected, slight anatomic variations, they do not prepare us for the overwhelming differences in functional anatomy between individuals.
A classic paper that deals with functional anatomy is Rubin’s description of the different smile patterns from 1974. 12 Although all individuals have the same mimetic muscles, their smile patterns are very different depending on which muscles dominate within the group. Even within a single muscle, different portions of that muscle can dominate and severely alter animation. The key is to analyze each patient’s face and discern which portions of which muscles dominate facial activity and cause wrinkles or unaesthetic shaping of the face.

Glabella

Operative Approach
The glabella was the first area to be treated cosmetically with Botox . 6 Surgical debulking of the glabellar musculature is an established practice and chemodenervation of these muscles has much the same effect.
Even in a seemingly straightforward area of the face such as the glabella, there is a great deal of variation in functional anatomy. When frowning, most people primarily bring their brows together and depress them, whereas others primarily frown in a vertical pattern, dramatically depressing their brows and yet others actually raise their medial brows while moving them medially, resulting in a quizzical look. Despite minor anatomic variations, the functional anatomy is drastically different.

Operative technique

• My median dose for treating the corrugators and procerus muscles is 17.5 units for women and 20 units for men .
• After observing the patient through normal animation during the consultation, I ask them to frown, then relax, then frown again, then scrunch their nose as if smelling something unpleasant repeatedly. This allows me to gauge which sections of which muscles dominate and to target those areas specifically with Botox .


Horizontal frowners

• For a horizontal frowner, I displace the forehead and brow cephalad and then with my non-injecting hand fix 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 significantly 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 portions 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, artificial 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 classification 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 ).

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 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 first, 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-headlights 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 flattening 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 controversial, with publications in both the plastic surgical and dermatologic press saying that Botox could only depress the brows or at best tha 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 concomitant 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 functional 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 .

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 fillers 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.

Neck

Operative Approach
Platysmal bands are another area where Botox injections can yield excellent results. Two articles on neck injection were published simultaneously in 1999 with drastically different dosage, patient populations, 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 platysma 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.

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.

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 finger 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 final 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 superioris 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 converts canine smilers into Mona Lisa smilers. Injecting Mona Lisa smile patients results in an exaggerated Mona Lisa smile that most patients find unattractive.
• Patients with gummy smiles are basically extreme canine smile pattern patients. This group benefits the most from Botox injection 19 ( Fig. 4.4A&B ). Gummy smilers often smile asymmetrically, requiring 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.

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 technique
The technique for this injection is relatively straightforward once the patient has been determined to be a candidate. It changes the functional 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 finger of the non-injecting hand is pressed firmly against the inferior portion of the nasal bone where it meets the maxilla. Thus, half of the finger 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 disastrous sequelae of a few misplaced units.
Slight weakening of the superficial fibers of the orbicularis oris muscle helps to alleviate the overlying rhytids caused by this sphincter with or without concomitant filler 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 superficial 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 deficit in the labiomental area, and a prolonged duration of filler 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 ) .

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 first injection. The second injection on each side lies midway between the first 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 refined 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 fillers were used and the horizontal width of the mouth appears less. The lower face has been reshaped. 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.
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 difficulty, and even oral incompetence. Despite these risks, over half of my Botox patients receive injections to the lower face or neck .

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 superficial, 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 .

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

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 J.L. Botulinum A toxin in ophthalmology. Surv Ophthalmol . 1991;36:28-46.
2. Scott A.B., Rosenbaum A., Collins C.C. Pharmacologic weakening of extraocular muscles. Invest Ophthalmol Vis Sci . 1973;12:924-927.
3. Scott A.B. Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. Ophthalmology . 1980;87:1044-1049.
4. Clark R.P., Berris C.E. Botulinum toxin: a treatment for facial asymmetry caused by facial nerve paralysis. Plast Reconstr Surg . 1989;84:353-355.
5. Carruthers J.D.A., Carruthers J.A. Treatment of glabellar frown lines with Clostridium botulinum A exotoxin. Dermatol Surg . 1992;18:17-21.
6. Kane M.A.C. 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 D.M., Almeida A.T.D., et al. Multicenter, double-blind study of the efficacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application. Dermatol Surg . 2003;29:523-529.
9. Kane M.A.C. Discussion: efficacy 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 J.L., Swenson P., Glasgow L.A. Potentiation of Clostridium botulinum toxin by aminoglycoside antibiotics: clinical and laboratory observations [Abstract]. Pediatrics . 1981;48:951-955.
11. Brin M.F. Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl . 1997;6:146-168.
12. Rubin L.R. 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 S.J. Orbicularis oculi muscle flaps: a technique to reduce crow’s feet and lateral canthal skin folds. Plast Reconstr Surg . 1980;65:206.
15. Kane M.A.C. Classification 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 M.A.C. 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 M.A.C. The effect of botulinum toxin injections on the nasolabial fold. Plast Reconstr Surg . 2003;112(suppl 5):66-72S.
20. Kane M.A.C. The functional anatomy of the lower face as it applies to rejuvenation via chemodenervation. Facial Plast Surg . 2005;21:55-64.
21. Kane M.A.C. Eyelid ptosis following botox injections to the face. American Society of Plastic Surgeons Meeting, Los Angeles. October 13, 2000.
Chapter 5 Laser Facial Resurfacing and Dermabrasion

Richard O. Gregory
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 first 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



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 (CO 2 ) 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/cm 2 in a sufficiently 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 60 ° and 70 °C, 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 fires 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 benefit.
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.


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 first 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 neovascularization. The technology was soon applied to vascular birthmarks, 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 preferentially 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 chromophores such as water, xanthophyll, and melanin that would compete with the hemoglobin to absorb the laser energy. Since nearly all lasertissue 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 confinement of energy (heat) within a structure can be controlled by limiting the exposure time. This thermal relaxation time is proportional to the size 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 nanosecond 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 specific 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 disruption. 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 selective 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 confinement 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 first laser which was specifically 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 flash 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 minimizing 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 (CO 2 ) 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 duration and energy density. Although the traditional carbon dioxide laser does not meet any of the parameters of the theory of selective photothermolysis, nevertheless this laser can be designed to achieve satisfactory 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 superficial basal cell carcinoma can be removed with these lasers, however, due to a lack of histologic confirmation 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 sufficient 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 difficulty was overcome in accordance with the theory of SPTL, mentioned above.
There are generally two methods of achieving the necessary energy in a sufficiently 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/cm 2 in a sufficiently 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 60 ° and 70 °C, 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 resurfacing with chemical peel and dermabrasion showed similar healing and results, with the exception of the phenol peel which required considerably 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.

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