Concise Manual of Cosmetic Dermatologic Surgery

CONCISE MANUAL OF
COSMETIC
DERMATOLOGIC
SURGERY
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CONCISE MANUAL OF
COSMETIC
DERMATOLOGIC
SURGERY
Neil Sadick, MD
Weill Medical College of Cornell University
New York, New York
Naomi Lawrence, MD
Marlton, New Jersey
Ron Moy, MD
UCLA Medical Center
Los Angeles, California
Ranella J. Hirsch, MD
Skincare Doctors
Cambridge, Massachusetts
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DOI: 10.1036/0071453660
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DEDICATION
We would like to acknowledge Samuel Stegman, Theodore

Tromovitch, and Richard Glogau—-authors of the previous
volumes Flaps and Graft in Dermatologic Surgery and Manual of
Cosmetic Surgery, upon which this present book is modeled. It is
through their pioneering efforts as leaders in dermatologic surgery
that this present volume has become a reality. All dermasurgeons
have profited from their wisdom, education, instruction, and guidance.
The present publication is dedicated to Dr. Stegman,
Dr. Tromovitch, and Dr. Glogau in remembrance to their
contribution to the field of cosmetic and reconstructive
dermatologic surgery.
Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use.
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CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . ix Chapter 8: Hair Transplantation . . . . . . 73

Neil Sadick
Chapter 1: Approach to the Chapter 9: Evaluation and Treatment

Dermasurgery Patient . . . . . . . . . . . . . 01 of Varicose and Telangiectatic
Neil Sadick
Leg Veins . . . . . . . . . . . . . . . . . . . . . . 81
Neil Sadick
Chapter 2: Facial Flaps and Grafts . . . . 09
Naomi Lawrence Chapter 10: Lasers . . . . . . . . . . . . . . . 91
Neil Sadick
Chapter 3: Chemical Peels . . . . . . . . . . 31
Ranella J. Hirsch Chapter 11: Lower Lid Blepharoplasty. 101
Ron Moy
Chapter 4: Dermal Fillers . . . . . . . . . . . 37
Ranella J. Hirsch Chapter 12: Upper Lid Blepharoplasty 107
Ron Moy
Chapter 5: Botulinum Toxin
Injections . . . . . . . . . . . . . . . . . . . . . . 47 Chapter 13: Forehead Lift . . . . . . . . . 113
Ranella J. Hirsch Ron Moy
Chapter 6: Liposuction . . . . . . . . . . . . 57 Chapter 14: Minimal Incision

Naomi Lawrence Facelift and Facelift . . . . . . . . . . . . . 119
Ron Moy
Chapter 7: Fat Transfer . . . . . . . . . . . . 69
Naomi Lawrence Index . . . . . . . . . . . . . . . . . . . . . . . . 127
vii
PREFACE
Concise Manual of Cosmetic Dermatologic Surgery is Illustrative diagrams demonstrating step-by-step tech-
meant to be an all-inclusive guide for physicians entering nique of each procedure can help the dermasurgeon
the field of cosmetic surgery, including both residents as entering this field to begin a comprehensive mastery of
well as physicians who wish to expand their knowledge each of the procedures presented.
in this arena. It is the hope of the authors that physicians reading
The book includes information regarding reconstruc- this book will enhance their knowledge and begin to
tive techniques, i.e., flaps and grafts, so as to enhance expand the number of cosmetic procedures within their
readers’ overall surgical skills. It details in an illustrative practice settings.
how-to fashion all of the other cosmetic procedures com- The goal of Concise Manual of Cosmetic Dermatologic
monly practiced by dermasurgeons. Topics covered Surgery is to expand the number of practicing cosmetic
include hair transplantation, lasers, fillers, liposuction, dermasurgeons and guide more individuals inclined in
aesthetic usage of neurotoxins, and aesthetic approaches this regard to pursue this clinical path.
to the management of cosmetic veins. A section describ-
ing the workup, approach, and evaluation of the aes-
thetic patient is also included.
What makes this volume unique is its uniform consis- Neil Sadick
tency in each chapter’s presentation. Pearls to clinical Naomi Lawrence
success highlight this illustrative approach. Sections that Ron Moy
outline indications as well as contraindications and Ranella J. Hirsch
avoidance pitfalls also help this illustrative paradigm.
ix
CHAPTER 1
0 Chapter Title
Approach to the Dermasurgery Patient
Neil Sadick, MD Accutane, herbal preparations, and beta-blockers as
well as history of topical agents, i.e., alpha hydroxy
acids, retinoids, etc., must be elicited.
In order to assure a successful outcome in a derma-
● Knowledge of pacemaker insertion is also of importance.
surgery patient, the initial patient consultation is of
utmost importance. This initial encounter can be divided ● An elicited history of heart murmurs or joint or heart
into 10 specific areas (Table 1.1). Careful attention to prosthesis may necessitate the institution of appropri-
these factors will ensure a greater probability of a suc- ate antibiotic prophylaxis.
cessful surgical outcome. A carefully prepared medical ● Fainting tendencies are important to document
questionnaire may be helpful in this regard. because appropriate therapeutic measures may be
ready on a stand-by basis and more importantly, it may
KEY POINTS FOR SUCCESS be helpful in distinguishing this entity from true
● Complete and detailed medical history and physical seizures.
examination. ● HIV and hepatitis status may be elicited by history at
● Understanding of patient’s medication history and any the time of initial consultation, but should also further
potential drug interactions. be ruled out by appropriate serologic testing when
blood-disseminating procedures are contemplated.
● Appropriate antibiotic prophylaxis when indicated.
This will help to protect both the physician and the
● Detailed informed consent (including outlining of all staff as well as the patient when invasive bloodborne
relevant complications). procedures are being contemplated.
● Photographic documentation. ● Smoking—Smoking may create vascular compromise
● Realistic expectations. when undermining a large flap, such as in rhytidec-
● Fee structure consultation for a given procedure. tomy procedure. Smoking also increases the risk of
DVT after liposuction and may impede healing after
● Careful postoperative care and monitoring.
ablative resurfacing.
MEDICAL CONSIDERATIONS
(TABLE 1.2)
TABLE 1.2 ■ Medical Considerations for the
● Medications—A detailed history of ingestion of antico- Dermatology Patient
agulants, aspirin, NSAIDS, platelet inhibitors, vitamin E, Medications
Anticoagulants, iticlopamide, platelet inhibitors,
vitamin E, Accutane, herbal preparations,
TABLE 1.1 ■ Clinical Checklist for Screening the beta-blockers
Dermatology Patient Allergens
● Patient’s medical/surgical history Pacemakers
● Present medications/interactions Heart murmurs
● Decision on antibacterial/antiviral/antifungal prophylaxis Joint prosthesis
● Psychosocial history Fainting tendencies
● Informed consent HIV/hepatitis
● Photography Smoking
● Patient expectation Genetics
● Complication risks Keloid formation
● Postoperative course/care Coagulopathy
● Insurance reimbursement/fee structure Pregnancy
2 | Concise Manual of Cosmetic Dermatology Surgery
● Genetics—History of keloid formation in the patient or MEDICATIONS—DRUG INTERACTION
a related family member should be elicited and con- (TABLE 1.4)
sidered as a relative risk potential.
● Direct questions toward specific drugs (Accutane,
● Allergies—An allergy history of anesthetics, topical
aspirin, Ecotrin, Coumadin, Estrogen, Plavix, vitamin E,
agents, and adhesives should be elicited.
herbal preparations, beta-blockers, NSAIDS, Ticlid, etc.).
● Finally, a detailed history of possible coagulopathies ● Role of discontinuance of platelet inhibiting drugs is con-
should be obtained by documented history of easy
troversial. This is especially important in more extensive
bruisability or excessive bleeding with trauma as well
procedures such as liposuction, hair transplantation,
as by serologic evaluation of quantitative platelet func-
and ambulatory phlebectomy. In such cases, discontin-
tion and clotting parameters.
uance is recommended 1 week prior to surgery.
● Pregnancy—Ascertaining of last menstrual period will ● Herbal preparations are a frequent cause of impaired
allow utilization of all classes of medications and anes-
platelet function and should be recognized in a
thetic agents.
detailed medical history. A list of common preparations
● A sample patient questionnaire is presented in Fig. 1.1. and suggested guidelines for discontinuance is pre-
sented in Table 1.5.
SURGICAL CONSIDERATIONS
(TABLE 1.3) ANTIBIOTIC PROPHYLAXIS
A detailed surgical history is also of importance in pre- ● Most common pathogens are Staphylococcus epider-
dicting outcomes and preventing complications. The fol- mides, for incision and drainage or curettage or cutting
lowing are important queries to consider: of normal skin, and Staphylococcus aureus, for surgi-
● Previous surgeries cal manipulation of diseased or overtly infected skin.
● Antibiotic prophylaxis is most important in patients
● A detailed surgical history, i.e., previous abdominal
procedures prior to considering liposuction, is of with prosthetic valves or artificial joints.
importance. This may also elicit occult coagu- ● A list of recommended antibiotic regimens is pre-
lopathies or unusual healing tendencies (i.e., keloid sented in Table 1.6.
formation). ● Antiviral prophylaxis is important when ablative resur-
● Previous artificial prostheses facing procedures are performed or a history of recent
● Prosthetic joints may require appropriate antibiotic herpes infection is elicited.
prophylaxis. ● Suggested guidelines are
● Pacemaker/defibrillators ● valacyclovir (Valtrex) 500 mg b.i.d. for 5 days, begin
● Pacemakers or defibrillators may necessitate the use 1–2 days prior.
of alternative modalities other than electrosurgery for ● famcyclovir (Famvir) 250 mg b.i.d. for 5 days, begin
hemostasis. 1–2 days prior.
● Scarring tendencies
● Examination of previous surgical sites may give clues
as to the probability of hypertrophic scarring or TABLE 1.4 ■ Common Problems: Medications
keloidal tendencies in a given individual. Requiring Considerations in the Dermasurgery Patient
Accutane
Aspirin
TABLE 1.3 ■ Surgical Considerations for the Coumadin
Dermatology Patient NSAIDS
● Previous surgeries Plavix
● Artificial prostheses Vitamin E
● Pacemaker/defibrillator Estrogen
● Keloid tendencies Beta-blockers
TABLE 1.5 ■ Clinically Important Effects and Perioperative Concerns of Eight Herbal Medicines and
Recommendations for Discontinuation of Use Before Surgery
Herb: Common Relevant Pharmacological Preoperative
Name(s) Effects Perioperative Concerns Discontinuation
Echinacea: purple Activation of cell-mediated Allergic reactions; No data
coneflower root immunity decreased effectiveness
of immunosuppressants;
potential for immunosuppression
with long-term use
Ephedra: ma huang Increased heart rate and Risk of myocardial ischemia At least 24 h
blood pressure through and stroke from tachycardia before surgery
direct and indirect and hypertension; ventricular
sympathomimetic effects arrhythmias with halothane;
long-term use depletes endogenous
catecholamines and may cause
intraoperative hemodynamic instability;
life-threatening interaction with
monoamine oxidase inhibitors
Garlic: ajo Inhibition of platelet Potential to increase the risk of At least 7 days
aggregation (may be bleeding, especially when before surgery
irreversible); increased combined with other medications
fibrinolysis; equivocal that inhibit platelet aggregation
antihypertensive activity
Ginkgo: duck foot Inhibition of platelet- Potential to increase the risk of At least 36 h
tree, maidenhair activating factor bleeding, especially when combined before surgery
tree, silver apricot with other medications that inhibit
platelet aggregation
Ginseng: American Lowering of blood glucose; Hypoglycemia; potential to increase At least 7 days
ginseng, Asian inhibition of platelet the risk of bleeding, potential to before surgery
ginseng, Chinese aggregation decrease the anticoagulation
ginseng, Korean (may be irreversible); effect of warfarin
ginseng increased PT-PTT in
animals; many other
diverse effects
Kava: awa, Sedation, anxiolysis Potential to increase the sedative At least 24 h
intoxicating effect of anesthetics; potential before surgery
pepper, kawa for addiction, tolerance, and
withdrawal after abstinence
unstudied
St. John’s Wort: Inhibition of neurotrans- Induction of cytochrome P450 At least 5 days
amber, goat mitter reuptake, enzymes, affecting cyclosporine, before surgery
week, hardhay, monoamine oxidase warfarin, steroids, protease inhibitors,
Hypericum, inhibition is unlikely and possibly benzodiazepines,
klamath weed calcium channel blockers, and many
other drugs; decreased serum
digoxin levels
Valerian: all heal, Sedation Potential to increase the sedative No data
garden heliotrope, effect of anesthetics; benzodiazepine-
vandal root like acute withdrawal; potential to
increase anesthetic requirements
with long-term use
TABLE 1.6 ■ Antibiotic Prophylaxis for High-Risk Patients During Cutaneous Surgery
Primary Pathogen Alternative Therapy in Patients
Surgical Procedure of Concern Preferred Regimen Allergic to Penicillin
Incision or curettage Staphylococcus epidermidis Dicloxacillin, 2.0 g orally Erythromycin, 1.0 g orally
of normal skin 1 h before surgery; 1 h before surgery;
then 1.0 g, 6 h later then 0.5 g, 6 h later
Incision or curettage of Staphylococcus aureus Same as above Same as above
diseased or overtly
infected skin
●
PSYCHOSOCIAL HISTORY photographic consent
● signed by patient/physician/witness
● Try to obtain patient motivations for a given cosmetic
● touch-up policy
procedure, i.e., recent spouse or partner separation,
loss of a loved one, job insecurity, etc. ● This form should be signed by the patient, the physi-
● Be careful of the patient who is undergoing multiple, cian, and a witness in a dated format and should be
frequent procedures in this regard. copied and given to the patient for his/her individual
●
record.
Patients with unrealistic expectations at the initial
patient consultation should be approached with caution.
PHOTOGRAPHY (TABLE 1.8)
INFORMED CONSENT ● Photography is a necessity in the pre- and postopera-
tive evaluation.
● The cornerstone of procedural success and medicole-
● Photography should be standardized in terms of lighting,
gal safety is based upon this document (Table 1.7).
distance, background, markers, hairstyles, and clothing.
● Exact procedure delineation, indications, treatment alter-
natives, and full complication profiles remain the corner-
■ Keys of Importance
stone of this binding physician–patient document.
● High-grade camera.
● Key components of the informed consent include
● Proper light sources.
● exact procedure delineation
● Standard background—blue or black best.
● procedure alternatives
● Standardization of views is of importance.
● indications for procedure
● Front view should include the top of the head to the
● full complication profile
sternal notch.
● procedural fee
● Side profile should include the top of the head to just
above the sternal notch and the nasal tip to the occiput.
● Professional photography may be preferable in
TABLE 1.7 ■ Components of Informed Consent
selected cases.
Exact procedure delineation
Procedure alternatives
PATIENT EXPECTATIONS
Indications for procedure
Full complication profile There are several factors that will affect the odds of opti-
Procedural fee mizing patient results when performing dermasurgical
Photographic consent procedures.
Signed by patient/physician/witness ● Over-promising results/mismatch of patient–physician
Touch-up policy expectations.
Chapter 1: Approach to the Dermasurgery Patient |5
Patient Medical/Surgical History Questionnaire
Name _________________________________Date of Birth_____________Age________Occupation_______________________
Dermatologic History Referred by:____________________________________________________ _
1. Reason for visit_____________________________________________________________________________________________
How long has this been going on?_________________________________________________________________________
What areas are affected?_________________________________________________________________________________
How has it been treated?_________________________________________________________________________________
2. Other skin conditions_______________________________________________________________________________________
3. Topical (skin) medications_________________________________________________________________________________ _
4. Other products applied to your skin__________________________________________________________________________ _
Medical History (includes system review)
Do you have or have you had any of the following?

Yes No Yes No Yes No
High Blood Pressure [ ] [ ] Anemia [ ] [ ] Stomach/Bowel Problem [ ] [ ]
Heart Disease [ ] [ ] Glaucoma [ ] [ ] Recent Weight Loss [ ] [ ]
Cardiac Pacemaker [ ] [ ] Cancer [ ] [ ] Tobacco Use [ ] [ ]
Rheumatic Fever [ ] [ ] Arthritis [ ] [ ] Keloids/Excessive Scar [ ] [ ]
Heart Murmur [ ] [ ] Liver Disease or Hepatitis [ ] [ ] Cold Sore/Fever Blister [ ] [ ]
Mitral Valve Prolapse [ ] [ ] Hay Fever/Allergies [ ] [ ] Radiation Therapy [ ] [ ]
Artificial Joints [ ] [ ] Seizures [ ] [ ] Ultraviolet Light Tx [ ] [ ]
Stroke [ ] [ ] Kidney/Bladder Problem [ ] [ ] History of Skin Cancer [ ] [ ]
Diabetes [ ] [ ] Asthma or Lung Problems [ ] [ ]
HIV Infection [ ] [ ]
Do you need antibiotics before surgical or dental procedures? [ ] [ ]

List any other medical problems or surgeries and Please list all medications you are using (including
Explain any of above if needed non-prescription, aspirin, birth control pills, vitamins)
_________________________________________________ _______________________________________________
_________________________________________________ _______________________________________________
Family history of skin cancer/skin diseases _______________________________________________
_________________________________________________ Women Only: Are you… Yes No
_________________________________________________ Pregnant or think you may be? [ ] [ ]
_________________________________________________ Nursing (breast-feeding)? [ ] [ ]
List any allergies (including medications) Taking oral contraceptives? [ ] [ ]
_________________________________________________ Taking hormone replacements? [ ] [ ]
Information Request (check if you would like more information)

Wrinkle treatments [ ] Filler/Botox [ ] Hair transplantation [ ] Liposuction [ ]
Chemical peels [ ] Leg veins [ ] Laser hair removal [ ] Pigmentation [ ]
Laser treatment + (dark spots, blood vessels) [ ] Skin cancer [ ]
__________________________________________ _______________ _______________ ____________

Signature of patient (or parent if minor) Date Physician’s initials Date
FIGURE 1.1 Patient medical/surgical history questionnaire

TABLE 1.8 ■ Important Features in Photography TABLE 1.9 ■ Postoperative Care Considerations
Background Same color background, for better Wound care (dressings, ointments)
contrast; standardize background to Bandages
black or blue Duration sutures remain in place
Lighting Even and continuous light source, Compression garments/hosiery
bright light with backlights to Antibiotic coverage
decrease shadowing, allows for Activity restrictions
accuracy Restarting of medications (i.e., aspirin, anticoagulants,
Proper Professional camera, digital, correct etc.) as well as topical agents
equipment flash, proper computer program
Repetition Standardized positions for patient poses
● Patients undergoing follicular unit hair transplanta-
tion may experience some degree of crusting at
recipient sites for 7–10 days.
● Not explaining adequate complication profiles.
● Patients undergoing endovascular laser procedure
● Lack of photographic documentation.
may experience tightness in the treated greater
● Poor postoperative follow-up. saphenous vein segment for 5–10 days.
● Inability to recognize inappropriate psychological ● Postoperative care, i.e., wound dressings after ablative
motivations. laser resurfacing procedures, compression after lipo-
Perhaps the most important pitfall in this setting is over- suction or ambulatory phlebectomy are also important
promising results and mismatch of patient–physician factors for patient consideration to be discussed and
expectations. Conservative or realistic expectations, which planned for at the initial consultation.
may be easily overachieved, are a good general approach ● Poor postoperative follow-up may lead to inferior
to ensure patient satisfaction with a given procedure. results and a higher complication profile.
● Patients also need to be instructed as to when they can
COMPLICATION RISKS resume medications, such as aspirin, anticoagulants,
etc., following surgical intervention or topical agents,
● A major factor leading to patient dissatisfaction is an unex-
such as retinoid or alpha hydroxy acids, following chem-
pected complication that has not been well explained.
ical peels or other ablative resurfacing procedures.
● A detailed discussion of the majority of expected com-
plications, which are signed and documented, will help INSURANCE REIMBURSEMENT/FEE
to minimize this scenario. STRUCTURE
● Patient should be adequately informed about the fee of
POSTOPERATIVE COURSE/CARE a given procedure that is being considered.
(TABLE 1.9) ● They should also have a reasonable understanding as
● During the preoperative consultation, the patient to whether this is a covered procedure by insurance or
should be told of the postoperative course including considered cosmetic in nature.
wound care, bandages, antibiotic coverage, activity ● Preoperative clearance by a given insurance carrier is
restrictions, and the time duration for which the suture often necessary and may be required to be accompa-
needs to remain in place. nied by a letter of medical necessity, an appropriate
● For example, in the Restylane treatment the patient instance, i.e., symptomatic varicose veins, botulinum
may expect swelling at injection sites for 24–48 toxin therapy for hyperhidrosis, etc.
hours. Botulinum toxin may take 3–7 days to show ● This document should be signed by both the patient
effects. and the physician and included in the medical record.
● Postoperative bruising after liposuction may last for ● A sample of an informed fee consent is presented in
2–3 weeks. Fig. 1.2.
Chapter 1: Approach to the Dermasurgery Patient |7
SURGERY FEE CONSENT
I hereby consent to and authorize Dr. Sadick and/or his assistants to perform the
operative procedure stated upon me.
Procedure: _________________________________ Fee: _________________________

________________________________________________________________________
________________________________________________________________________
I fully understand the necessity and/or elective reasoning of this procedure which has
been explained to me by Dr. Sadick and/or his assistants.
I acknowledge I have been explained in detail the charges for these services and I am
fully aware I am responsible for full payment at the time the services are rendered. I
understand that cosmetic procedures are not covered by insurance carriers.
__________________________________ ______________________________
DATE PATIENT SIGNATURE
__________________________________ ______________________________
DATE DOCTOR
WITNESS
FIGURE 1.2 Surgery fee consent
CONCLUSION 5. Shiffman MA. Dangers of herbs when performing

surgery. Int J Cos Surg Aesthetic Dermatol 2000;
Careful consideration of detail in obtaining a complete 2:95–97.
medical history, matching patient expectations with 6. Ang-Lee M, Moss J, Yuan C. Herbal medicines and
physician capabilities, detailed informed consent with perioperative care. JAMA 2001;286:208–216.
appropriate photographic documentation, detailed 7. Goldsmith SM, Leshin B, Owen J. Management of
informed consent, and adequate postoperative follow-up patients taking anticoagulants and platelet inhibitors
will lead to gratifying results and fewer complications prior to dermatologic surgery. J Dermatol Surg Oncol
when performing many of the procedures presented in 1993;19:553–559.
the following chapters. 8. Alcalay J, Alkalay R. Controversies in perioperative
management of blood thinners in dermatologic
surgery: Continue or discontinue? Dermatol Surg
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metic patient. Am J Cos Surg 2003;20:143–147. Preoperative monitoring of warfarin in cutaneous
2. Foster CR. A plastic surgeon’s perspective. In: T Romo, surgery. Br J Dermatol 2003;149:386–389.
III, AL Millman (eds.). Aesthetic Facial Plastic 10. Richards KR, Stasko T. Dermatologic surgery and
Surgery, Thieme, New York, 2002. the pregnant patient. Dermatol Surg 2002;28:
3. Galitz RM. Traditional photo documentation. Aes- 248–256.
thetic facial plastic surgery. In: T Romo, III, AL Mill- 11. Kovich O, Otley C. Perioperative management of
man (eds.). Aesthetic Facial Plastic Surgery, anticoagulants and platelet inhibitors for cutaneous
Thieme, New York, 2002. surgery: A survey of current practice. Dermatol Surg
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In: T Romo, III, AL Millman. Aesthetic Facial Plastic 12. Shiffman MA. Estrogen and thromboembolic disor-
Surgery, Thieme, New York, 2002. ders: Should patients stop hormones prior to cosmetic
surgery? Int J Cos Surg Aesthetic Dermatol 2002;4: inflammatory drugs. Arch Dermatol 1996;132:
213–215. 161–166.
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events associated with perioperative interruption of to discontinuation of warfarin and aspirin therapy
antiplatelet and anticoagulant therapy. Dermatol perioperatively for cutaneous operation. J Am Acad
Surg 2002;28:992–998. Dermatol 2003;48:233–237.
14. Billingsley EM, Maloney ME. Intraoperative and post- 17. Wagner RF, Grande DJ, Feingold DS. Antibiotic pro-
operative bleeding, problems in patients taking war- phylaxis against bacterial endocarditis in patients
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agents. Dermatol Surg 1997;23:381–385. 1986;122:799–801.
15. Otley CC, Fewkes JL, Frank W, Olbricht SM. Com- 18. Robins P. The Ten Commandments: What every sur-
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CHAPTER 2
0 Chapter
Facial Flaps
Title
Naomi Lawrence, MD
TABLE 2.2 ■ Rotation Flaps
Simple rotation
KEY POINTS OF SUCCESS Bilateral rotation
O to Z rotation
● Flaps are most commonly performed for defects after
Dorsal nasal (back-cut) rotation
cancer extirpation.
● Tissue rearrangement is best performed after margin
evaluation either through Mohs technique, frozen sec-
tions, or permanent section evaluation. ● The flap is typically sized to be three to four times the
● There are four primary flap categories: advancement, area of the primary defect.
rotation, transposition, and interpolation. ● Adding a back-cut into the pedicle is a common varia-
tion (the dorsal nasal flap, for example). This allows a
greater arc of rotation and is not detrimental to flap
FLAP TYPES
survival as the flap has a broad pedicle by design.
■ Advancement Flaps (Table 2.1)

●
■ Transposition Flaps (Table 2.3)
In advancement flaps, the flap movement is primarily
from one direction (lateral, superior, or inferior). ● Movement of the transposition flap is tangential or per-
● The length-to-width ratio is typically in the range of 3:1 pendicular to the defect over normal adjacent skin.
to 4:1. ● Flap movement uses both advancement and rotation.
● Advancement flaps are commonly employed in a bilat-
eral motion by using two flaps to close one central
■ Interpolation Flaps
defect. Often, these flaps may be used at a cosmetic
junction to avoid crossing an important anatomic bor- ● These flaps move remote skin into the area of the
der such as the lip, nose, or brow. defect attached to a pedicle of skin, subcutaneous
tissue, and sometimes muscle. This pedicle is then
taken down with the flap inserted into the defect after
■ Rotation Flaps (Table 2.2) 2–3 weeks.
● The rotation flap moves in two directions along an arc
from the primary defect. GENERAL PRINCIPLES OF TISSUE
MOVEMENT
● Cutting the skin ALWAYS creates a scar.
TABLE 2.1 ■ Advancement Flaps ● Younger patients have skin with high elasticity leading
Unilateral advancement more commonly to “stretch-back” and resultant
Sliding H (Bilateral) advancement “stretch-mark” scars compared to older patients
A to T advancement
Burow’s triangle advancement
Mercedes advancement
Island pedicle flap TABLE 2.3 ■ Transposition Flaps
V to Y advancement Rhombic flap
Antia-Buch Bilobed flap
Lip wedge resection Melolabial flap
whose skin has less elasticity in addition to rhytides ● Healing on the face is, in general, superior to nonfacial
and skin folds to camouflage scars. healing. This is most likely due to the greater vascular-
● Boundaries between cosmetic units provide scar cam- ity of this area.
ouflage.
● Restoring contour, particularly on a convex surface, is ■ Forehead
important to minimizing deformity. ● Midline defect
● In a concave area or some areas on the trunk and ● Vertical primary closure
extremities, consider second intention healing. The
With M-plasty at glabella to preserve inter-brow distance
cosmetic result may be better than that from any
● Advancement
reconstruction.
● Unilateral
● If possible, choose skin for the flap that matches
the missing skin in color, texture and sebaceous ● Bilateral (sliding H) (Fig. 2.1)
quality. ● Lateral Defect
● To choose the type of flap and best direction of tissue ● Horizontal primary closure
movement, pinch the surrounding skin to look for area ● Vertical or oblique closure also acceptable
of greatest laxity.
● Rotation (Fig. 2.2 and 2.3)
● Look for flap counter-movement, i.e., even though you
may determine that most of the movement may be Potential Limitations: Lack of mobility necessitates long
from one direction, all of the skin around the defect will flaps with little movement.
move somewhat. Consider how this may affect the final
cosmesis. ■ Eyebrows
● Always consider the effect of movement on any free ● Above the brow
margin. Distortion of a free margin causes both func-
● Primary
tional and cosmetic problems.
● Advancement
● Undermine widely and generously bury subcutaneous
suture to minimize trap-door effect (outward puckering Unilateral or bilateral (sliding H or A to T) O to Z
of the flap). (Fig. 2.4 and 2.5)
● Know the anatomy of the surgical area to minimize risk Burow’s triangle advancement
of damaging important underlying structures. ● Rotation: O to Z
A B
FIGURE 2.1 A. Forehead defect. B. Sliding H—immediately postsuture
Chapter 2: Facial Flaps | 11
A B
FIGURE 2.2 A. Cheek defect. B. Rotation—immediately postsuture
A B
FIGURE 2.3 A. Cheek defect. B. Rotation—immediately postsuture
A B
FIGURE 2.4 A. Brow defect. B. A to T—immediately postsuture
A B
FIGURE 2.5 A. Brow defect. B. Sliding H—immediately postsuture
● Within the brow ● Lid wedge advancement

● Advancement: Unilateral or bilateral ● Medial canthus
● Island pedicle ● Second intention
● Rotation: V to Y Advancement (Fig. 2.6) ● Primary closure
● Rotation
Potential Problems: Shorter brow and brow elevation.
To Z (Fig. 2.8 and 2.9)
Dorsal nasal (Fig. 2.10) (rotation with back-cut)
■ Eyelid
Potential Problems: Free margin distortion and webbing
● Upper: Primary horizontal skin graft (anticipate contraction for second intention healing).
● Lower
● Primary (vertical oblique)
●
■ Cheek
Horizontal with deep anchoring sutures to prevent
ectropion ● Medial
● Graft (Fig. 2.7) ● Primary
● Advancement (Mustarde) ● Rotation: O to Z
A B
FIGURE 2.6 A. Brow defect. B. V to Y—immediately postsuture
A B
C
D
FIGURE 2.7 A. Lower lid defect. B. Lower lid defect.

C. Graft—immediately postsuture. D. Lower lid defect.
E E. Graft—immediately postsuture
A B
FIGURE 2.8 A. Inner canthus defect. B. O to Z recon-

C struction planning. C. O to Z—1 week postoperative
A B
FIGURE 2.9 A. Inner canthus defect. B. O to Z—immediately postsuture
A B
FIGURE 2.10 A. Nasal sidewall defect. B. Dorsal

nasal—immediately postsuture. C. Dorsal nasal—
C 9 months postoperative
● Advancement (Fig. 2.11) ● A scar line at the lower lid/cheek junction (such as with
● Mustarde (Fig. 2.12) the Mustarde) results in lower lid edema, which can
persist for 6 months up to 1 year.
● Crescentic (Fig. 2.13)
● For the rotation flap, use the back-cut at the glabella
● Mid
(dorsal nasal flap) for the upper limb.
● Primary ● Anchor the upper margin of the V to Y advancement to
● V to Y advancement (Fig. 2.14) the deep tissues to prevent ectropion.
● Infraocular (see lower lid) ● In a patient with lower lid laxity, always consider can-
● Lateral thopexy.
● Primary
● Rotation
■ Nose
● Sidewall
Tips
● Primary (Fig. 2.15)
● Avoid distortion of the lower lid, upper lip, and corner
● Advancement (Fig. 2.16)
of the mouth.
● Dorsal nasal (Fig. 2.17 and 2.18)
● Scars on the mid-cheek (convex surface) are often
most apparent. ● Full-thickness graft
A B
FIGURE 2.11 A. Cheek defect. B. Advancement—immediately postsuture
A B
FIGURE 2.12 A. Cheek defect. B. Mustarde—immediately postsuture
A B
FIGURE 2.13 A. Cutaneous lip defect. B. Advancement—immediately postsuture
A B
FIGURE 2.14 A. Cheek defect with planned reconstruction. B. V to Y—immediately postsuture
A B
FIGURE 2.15 A. Nasal sidewall defect. B. Primary—immediately postsuture
A B
FIGURE 2.16 A. Nasal tip defect. B. Advancement—immediately postsuture
A B
FIGURE 2.17 A. Nasal sidewall defect. B. Dorsal

nasal—immediately postsuture. C. Dorsal nasal—
C 9 months postoperative
A B
FIGURE 2.18 A. Nasal defect. B. Dorsal nasal—immediately postsuture (Figure continues.)
● Upper dorsum
● Primary
● Advancement (dorsal nasal)
● Full thickness graft
Nasal tip
● Primary
● Island pedicle (Fig. 2.19)
● Dorsal nasal (Fig. 2.20)
● Peng (bilateral dorsal nasal)
C
● Bilobed transposition (Fig. 2.21)
FIGURE 2.18 (continued) C. Dorsal nasal—6 months
● Paramedian forehead (Fig. 2.22)
postoperative
A B
FIGURE 2.19 A. Nasal defect. B. Island pedicle—

immediately postsuture. C. Island pedicle—3 months
C postoperative
A B
FIGURE 2.20 A. Nasal defect. B. Dorsal nasal—

immediately postsuture. C. Dorsal nasal—11 months
C postoperative
A B
FIGURE 2.21 A. Nasal defect. B. Bilobed—immediately postsuture (Figure continues.)
C D
FIGURE 2.21 (continued) C. Bilobed—2 months

postoperative. D. Bilobed—2 months postoperative.
E E. Bilobed—2 months postoperative
A B
FIGURE 2.22 A. Forehead flap—immediately postsuture. B. Forehead flap—8 months postoperative

21
A B
FIGURE 2.23 A. Ala defect. B. Rhombic—immediately

C postsuture. C. Rhombic—1 month postoperative
● Melolabial ● Nasal ala

● Rhombic ● Small and laterally placed defect? Consider a rhom-
● Ala bic flap from the nose/cheek crease.
● Medial defect? Consider a V to Y advancement.
● Rhombic (Fig. 2.23)
● Lateral defect? Consider a meilolabial flap.
● V to Y advancement
● Nasal tip
● Meilolabial (Fig. 2.24)
● Rotation ● Lateral defect, 1.5 cm or less? The bilobed transpo-
sition is often the best choice. You can use the
Tips bilobed transposition for defects up to 2 cm, but it
● Nasal sidewall cannot be used for defects placed too far superiorly
● Very small defect or laterally placed? Use the junction of on the nose or on an excessively short nose as the
the nose and the cheek and consider a primary closure. inner canthus does not allow for good pivotal move-
● Have the patient squint so as to best direct the ment of tissue.
ellipse of a primary closure. ● Small defect, 1–1.5 cm? If centrally placed and skin
● Is the distal-medial sidewall defect at the junction laxity permits, use a primary closure (make sure to
with the tip anteriorly? Consider advancement using take appropriate dog-ears—often this means
the alar crease to hide the lower incision and remove extending the lower triangle into the columella).
excess around the crease of the ala with the cheek. ● Small central or off-center defect? Consider the
● Large defect? Consider the dorsal nasal flap (rotation island pedicle. If superiorly based, the blood supply
with a back cut) or a full-thickness skin graft. is more tenuous. These can also be laterally based.
A B
C D
FIGURE 2.24 A. Nasal defect. B. Meilolabial—

immediately postsuture. C. Meilolabial—2 months
postoperative. D. Meilolabial—4 months postoperative.
E E. Meilolabial—4 months postoperative
● Dorsal-nasal flap: Can also be used in tip defects of ■ Lips

1–1.5 cm.
● Bilateral dorsal nasal (Peng flap): For large defects ● Pink portion only (usually lower lip)
(2 cm) of the skin and subcutaneous tissue. A small ● Wedge resection (Fig. 2.25)
amount of cartilage may be missing, but the struc- ● Mucosal advancement (Fig. 2.26)
ture must be intact or replaced.
● Central upper
● The paramedian forehead flap and meilolabial inter-
● Bilateral advancement (Fig. 2.27)
polation flaps are also used for large defects (⬎2 cm)
on the nasal tip. ● Primary
A B
FIGURE 2.25 A. Lower lip defect. B. Wedge

resection—immediately postsuture. C. Wedge
C resection—5 months postoperative
A B
FIGURE 2.26 A. Lower lip defect. B. Mucosal advancement—immediately postsuture (Figure continues.)
C D
FIGURE 2.26 (continued) C. Mucosal advancement—1 week postoperative. D. Mucosal advancement—1 week
postoperative
A B
FIGURE 2.27 A. Upper lip defect. B. Bilateral advance-

ment—immediately postsuture. C. Bilateral advancement—
1 week postoperative. D. Bilateral advancement—
4 months postoperative (Figure continues.) D
E F
FIGURE 2.27 (continued) E. Bilateral advancement—8 months postoperative. F. Bilateral advancement—
9 months postoperative
● Lateral upper crease. The cheek advancement blunts the boundary

● A to T advancement (Fig. 2.28) between the upper lip and the cheek.
● One can use the Burow’s advancement in conjunction
● Burow’s advancement (Fig. 2.29)
with a small mucosal advancement to repair a defect
● Island pedicle (Fig. 2.30)
that encompasses a small portion of the pink upper lip.
● Cheek advancement
Tips
■ Chin
● The philtrum is an important three-dimensional unit
that should not be distorted. ● Primary
● Wedge resection of the lower lip causes shortening and ● Rotation: A to T
cannot be done if the defect width is greater than one-
Tip
third that of the lower lip length.
Scars often become fibrotic and require a series of
● Mucosal advancement: Undermining on the mucosal steroid injections to soften. Hypertrophic scars are more
side should be wide and may extend close to the common in this area.
gingival sulcus. This flap results in a thinner lip. If it
is done in a male, they may require hair removal, as
■ Ear
the whisker hairs may irritate the lower lip.
● Helical rim
● With a large lateral upper lip defect, the island pedicle
flap has the advantage of restoring the nasolabial ● Primary (wedge)
A B
FIGURE 2.28 A. Upper cutaneous lip defect. B. A to T—immediately postsuture
A B
FIGURE 2.29 A. Upper cutaneous lip defect. B. Burrow’s advancement—immediately postsuture
A B
FIGURE 2.30 A. Upper cutaneous lip defect. B. Island pedicle—immediately postsuture (Figure continues.)
● Antia-Buch advancement (Fig. 2.31 and 2.32)
● Postauricular transposition
● Primary (along edge) (Fig. 2.33 and 2.34)
● Conchal bowl: Second intention
● Earlobe
● Primary
● Advancement
● Postauricular
● Primary
C ● Advancement
FIGURE 2.30 (continued) C. Island pedicle—5 months ● Rotation
postoperative
A B
C D
FIGURE 2.31 A. Helix defect. B. Helix defect. C. Antia-buch—immediately postsuture. D. Antia-buch—1 month
postoperative
A B
C D
FIGURE 2.32 A. Presurgery. B. Helix defect. C. Antia-

buch—immediately postsuture. D. Antia-buch—1 year
E postoperative. E. Antia-buch—1 year postoperative
● Transposition thin the helical rim cartilage and close primarily with-
● Second intention out affecting contour significantly.
● Preauricular: Primary ● Wedge resection works best for small defects.
Tips ● Antia-Buch shortens the length of the ear, but restores
● The conchal bowl and the postauricular area heal best contour. A unilateral Antia-Buch works well for defects
by second intention. less than 2 cm. If the defect is greater than 2 cm, a
● If the defect on the helical rim is not deep, one can bilateral flap is necessary.
A B
FIGURE 2.33 A. Helix – defect. B. Primary—immediately postsuture
A B
FIGURE 2.34 A. Helix defect. B. Primary—immediately postsuture
SUGGESTED READING 3. Robinson JK, Hanke WC, Senglemann RD, Seigel

DM. Surgery of the Skin. Procedural Dermatology.
1. Wheeland RG. Cutaneous Surgery, 1st edn. WB Saun- Elsevier Mosby, Philadelphia, PA, 2005.
ders, Philadelphia, PA, 1994.
2. Baker SR, Swanson NA. Local Flaps in Facial Recon-
struction, 1st edn. Mosby, St Louis, MO, 1995.
CHAPTER 3
0 Chapter Title
Chemical Peels
Ranella J. Hirsch, MD ● Deeper peels create necrosis and inflammation in the
epidermis, papillary, or reticular dermis depending on
the depth of the peel.
KEY POINTS OF SUCCESS
● Choose the appropriate candidates, i.e., realistic expec- PHARMACOLOGY—CHEMICAL
tations. PEELING
● Peels can be done on face and body; the latter ● Certain variations are unavoidable such as differences
requires reduced acid strengths. in skin type and biologic response.
● Prepare patient for related down time. ● While techniques such as method and pressure of
● If appropriate, prophylaxis with antiviral medications. application may vary from clinician to clinician, such
● Prepare patient for necessary aftercare (sun avoid- variances can be standardized.
ance, gentle cleansing). ● Pharmacological anomalies in the preparation itself
can actually be a source of significant variation.
MECHANISM—CHEMICAL PEELING ● USP-grade material ought to be used. The initials after
● Chemical peeling refers to the application of exfoliating a drug or chemical name indicate that the material so
agents to produce a controlled partial thickness skin labeled meets the standards of the United States Phar-
injury with the intent of improving skin color and tex- macopoeia. The USP is a compendium that provides a
ture. A better cosmetic appearance is realized when legal standard for the identity, purity, strength, and
the most sun damaged layers are removed and quality of listed drugs.
replaced with newer, more normalized tissue.
● With more superficial peels, the process yields stimu- PREPARING THE SKIN FOR
lation of epidermal growth through selective removal of CHEMICAL PEELING
the stratum corneum (Table 3.1) Goals in optimizing skin preparation are to:
● Reduce wound healing time
● Permit more uniform penetration of the peeling agent.
TABLE 3.1 ■ Classification of Peeling Agents ● Decrease the possibility of postinflammatory hyperpig-
Very superficial mentation
Glycolic acid Jessner’s solution TCA 10% ● Determine which products a particular patient can
10–40% 1–2 coats tolerate
Superficial ● Reinforce the need for ongoing maintenance and
Glycolic acid Jessner’s solution TCA 10–30% establish guidelines for patient compliance
40–70% 3–5 coats
Medium depth VARIABLES AFFECTING DEPTH
OF PEEL
Glycolic acid TCA 35–50% Augmented TCA
70% and (Jessner’s plus ● Selected peeling agent
greater TCA, glycolic ● Concentration of the peeling agent
⫹TCA) ● Number of applications of the agent applied
Deep ● Application technique
Phenol 88% Baker Gordon ● Level of preparation prior to application of peeling
phenol formula
agent (was skin degreased?)
TABLE 3.2 ■ Peel Types and Depth of Penetration INDICATIONS FOR CHEMICAL
PEELING (TABLE 3.3)
Type of Peel Penetration Depth of Peel
Must match appropriate chemical peeling agent to cor-
Superficial Epidermis to upper papillary dermis rect depth of peel as determined by the indication being
Medium depth Papillary dermis to upper reticular treated. Since it is difficult to assess the depth of damage
dermis with naked eye, so a Woods light examination, which is
Deep Mid-reticular dermis and below easily performed in the clinic setting, is an ideal test.
● Wood’s Lamp is a black light that emits light at a wave-
length of 354 nm.
● When the skin is viewed with this apparatus, areas of
● Was skin primed in preparation for the peel?
epidermal pigmentation become more pronounced
● Skin type (thick or thin) and areas of deeper dermal pigmentation become less
● Anatomic location of skin to be peeled pronounced.
● Duration of contact that the peeling agent has with the ● Simply stated, the worse a patient appears under
skin Wood’s light examination, the easier their pigmentation
is to treat.
CLASSIFICATION OF PEEL DEPTHS
(TABLE 3.2)
● Very superficial (exfoliation)—Thins or removes the ■ Clinical Hyperpigmentation
stratum corneum and does not create a wound below ● Most common types of hyperpigmentation include
the stratum granulosum.
● Freckles (ephelides)
● Superficial peels—Necrosis/destruction anywhere
● Lentigines
from the epidermis to the papillary dermis as far as the
● Flat seborrheic keratoses
basal cell layer.
● ● Nevi
Medium depth—Necrosis of the epidermis and
destruction extends to all of papillary dermis. ● Melasma
● Deep peels—Necrosis of epidermis and papillary der- ● Postinflammatory hyperpigmentation from a variety
mis extending into the reticular dermis. of primary cutaneous insults (Fig. 3.1)
TABLE 3.3 ■ Peel Results with Lesion Subtypes and Depth (Summary of Peel Results
with Lesion Subtypes and Depth)
Excellent Results Variable Results Poor Results
Epidermal peels
Ephelides Lentigines Seborrheic keratoses
Epidermal melasma and Mixed (epidermal and dermal) Dermal melasma and
postinflammatory melasma and postinflammatory postinflammatory
hyperpigmentation hyperpigmentation hyperpigmentation
Dermal peels
Ephelides Seborrheic keratoses Nevi
Lentigines
Epidermal melasma and Mixed (epidermal and dermal)
postinflammatory melasma and postinflammatory
hyperpigmentation hyperpigmentation
Chapter 3: Chemical Peels | 33
A B
FIGURE 3.1 A. Hyperpigmentation on left side of face before treatment. B. Improvement after a series of salicylic acid
peels and topical application of 4% hydroquinone. (Photographs courtesy of Pearl E. Grimes, MD; reprinted with permis-
sion from Avram et al., Color Atlas of Cosmetic Dermatology, McGraw-Hill, New York, 2007)
● Mild to severe dermatoheliosis ● Jessner’s solution (Fig. 3.3)

● Epidermal melasma and assorted pigmentary disorders ● Resorcinol
(Fig. 3.2) ● Salicylic acid (Fig. 3.4)
● Inflammatory acne ● TCA (trichloroacetic acid)
● Epidermal growths including actinic keratoses ● Hydroxy acids—Alpha-hydroxy acid (AHA) peels exert
effects in the epidermis at the level of the stratum
corneum. Studies have shown that sustained AHA use
■ Wrinkling
for 6 months leads to a 25% increase in epidermal
● Fine wrinkles are the result of epidermal thinning and thickness, which correlates histologically with a thinner
can appear as crosshatched lesions on the face. They stratum corneum with a more organized basket weave
can be described by their crépe-y or cigarette paper epidermal pattern.
type of appearance.
● Mimetic wrinkles are the result of repeated movement.
CHEMICAL PEELING—FREQUENCY
● Accordion pleating is due to loose redundant skin with
epidermal and dermal atrophy in addition to a loss of ● Very superficial chemical peels can be performed once
elasticity. weekly.
● Folds are the result of downward skin sagging and ● Superficial (intraepidermal) peels can be repeated
gravity. every 2–4 weeks.
● Medium depth (papillary dermis) peels can be
repeated every 3–6 months.
PEELING AGENTS
These are general guidelines only and can be adapted
● Retinoids depending on the complications and indications. Never
● 5-FU (5-Fluorouracil) re-peel a patient who has residual sensitivity or erythema
A B
FIGURE 3.2 A. Epidermal melasma unresponsive to topical bleaching creams. B. Mild improvement noted following
two 50% glycolic acid peels. (Reprinted with permission from Avram et al., Color Atlas of Cosmetic Dermatology,
McGraw-Hill, New York, 2007)
A B
FIGURE 3.3 A. Pale white color immediately following a Jessner peel. B. Solid white color immediately following is
Jessner/35% TCA peel. (Reprinted with permission from Avram et al., Color Atlas of Cosmetic Dermatology,
McGraw-Hill, New York, 2007)
Chapter 3: Chemical Peels | 35
● With medium depth peels, the sensation is more
uncomfortable.
● We encourage patients to take two acetominophen 60
minutes prior to the procedure for analgesia, and find
that this along with a cool fan is typically adequate for
comfort.
● Talkesthesia is also extensively used.
● With deeper medium peels assorted other sedatives are
advisable including the use of intramuscular meperedine,
hydroxyzine, diazepam, and if appropriate IV sedation.
CHEMICAL PEELING—NONFACIAL
Nonfacial wounds take longer to reepithelize because there
are fewer pilosebaceous units present in nonfacial areas.
■ Contraindications
● Absolute: Pregnancy
● Relative: Oral cold sores
FIGURE 3.4 Frosting is a sign of self-neutralization of ■ Procedure

salicylic acid peel. Here it is being applied for acne ● Level of injury/depth of skin penetration quantifies clas-
scars in a patient with type IV skin. This superficial sification of peels as superficial/medium/deep strength.
peel is relatively safe in darker skin phototypes. ● Must match patient pathology to appropriate peel depth.
(Reprinted with permission from Avram et al., Color
● Important to realize that any classification of peeling
Atlas of Cosmetic Dermatology, McGraw-Hill,
New York, 2007) agents is an approximation since an agent that pro-
duces a superficial peel in one patient may yield a
medium strength peel in another.
from a previous peel. Such patients have not completely ● For example, a man with thick oily skin that was not
healed and will experience an exaggerated response to primed prepeel treated with 25% TCA on a cotton
any additional peeling. swab will likely only develop a superficial intraepi-
dermal peel.
CHEMICAL PEELING—ANESTHESIA ● By contrast, a thin skinned woman who is properly
primed and has 25% TCA applied from a soaking
● Setting realistic expectations is critical in the course of
gauze will likely have a medium depth peel from the
management of the pain due to chemical peeling.
same 25% TCA application.
● Inform patients that there is going to be some dis-
● As a consequence, we recommend in clinical practice
comfort with the process.
that all dermasurgeons
● A brief but not constant burning slowly builds and
● Standardize their peels specifically
typically reaches crescendo when the applied
● Prime all patients in a similar fashion
product is at maximal erythema or frost on the
skin. ● Apply the acid with a similar technique
● With superficial peels, anesthesia is typically not ● Doing so greatly reduces some of the extraneous vari-
necessary. ables that can affect final outcome.
SUGGESTED READING 4. Brody HJ. Variations and comparisons in medium-
depth chemical peeling. J Dermatol Surg Oncol 1989;
1. Camacho FM. Medium-depth and deep chemical 15(9):953–963.
peels. J Cosm Dermatol 2005;4(2):117–128. 5. Rubin MJ. Trichloroacetic acid and other non-phenol
2. Tse Y, Ostad A, Lee HS, et al. A clinical and histologic peels. Clin Plast Surg 1992;19(2):525–536.
evaluation of two medium-depth peels. Glycolic acid 6. Monheit GD. Combination medium-depth peeling: the
versus Jessner’s trichloroacetic acid. Dermatol Surg Jessner’s ⫹ TCA peel. Facial Plast Surg 1996; 12(2):
1996;22(9):781–786. 117–124.
3. Matarasso SL, Glogau RG. Chemical face peels. Der- 7. Monheit GD. Medium-depth chemical peels. Dermatol
matol Clin 1991;9(1):131–150. Clin 2001;19(3):413–425, vii.
CHAPTER 4
0 ChapterFillers
Dermal Title
Ranella J. Hirsch, MD ● Hyaluronic acid is a naturally occurring polysaccharide
sugar in the dermis.
● Unlike collagen, it has neither species nor tissue
KEY POINTS FOR SUCCESS
specificity; the chemical structure is uniform
● Judicious patient selection. throughout nature.
● Detailed pretreatment medical and psychosocial ● In the skin, it forms the elastoviscous fluid matrix in
history. which collagen fibers, elastic fibers, and other inter-
● Detailed informed consent covering reasonable and cellular fibers are embedded.
severe risks. ● The amount of hyaluronic acid in the skin decreases
● Pre- and post-photography. with age, resulting in reduced dermal hydration and
● Precise knowledge of relevant cutaneous anatomy. increased wrinkling.
● Radiesse is a product made of injectable calcium
● Technique dependent—correct depth of placement is
critical (Fig. 4.1). hydroxylapatite, a matrix material of bone and tissue.
● This bioengineered product serves as a scaffold for
native cells, including osteoblasts and fibroblasts, to
yield long-term soft tissue correction.
PHARMACOLOGY—DERMAL FILLERS ● It is best reserved for patients who have had good
● Collagen-based products include those from human experience with other soft tissue augmentation
and bovine sources. products.
FIGURE 4.1. Recommended filler injection depths. (Reprinted with per-

mission from Avram et al., Color Atlas of Cosmetic Dermatology, McGraw-
Hill Medical, New York, 2007)
38 | Concise Manual of Cosmetic Dermatologic Surgery
●
INDICATIONS Volume restoration to the lips, melolabial folds and
marionette lines is widely performed.
● Treatment for tissue contour defects resulting from
● Restoration of the jawline contour is another very
loss of
effective use of filler materials.
● dermal tissue due to both aging and chronic envi-
● There is a recognized synergy with botulinum toxin:
ronmental damage;
● Botulinum toxin reduces mimetic effect on wrinkles
● subcutaneous fat;
and folds.
● supporting tissues.
● Dermal fillers function by promoting support for
● Can serve to fill preexisting facial defects or augment facial structures.
existing facial structures.
● When used in conjunction, each prolongs the effects
● Rhytids in the upper third of the face are largely dynamic of the other.
in origin and the result of muscular movement as
opposed to sun damage and physiological aging alone.
● In the upper third of the face, uses include restoring CONTRAINDICATIONS—ABSOLUTE
volume to augment temporal lipodystrophy.
● Allergy to bovine collagen, certrain meat products, and
● Under the lateral third of the brow, uses include assorted antibiotics.
● elevating a ptotic lateral brow segment; ● Any history of severe allergy manifested by docu-
● correcting nasojugal fold depression. mented history of anaphylaxis.
● In the central third of the face, fillers can
● fill preexisting asymmetry;
CONTRAINDICATIONS—RELATIVE
● replace volume to the sinking malar eminence
● History of keloid formation or the development of
(Fig. 4.2);
●
hypertrophic scars.
improve the nasal contour.
● History of oral cold sores (antiviral prophylaxis required).
● augment scars secondary to acne, chickenpox and
● Allergies to local anesthetics.
trauma.
● ● Active infection or inflammation at the site of treatment.
The lower third of the face includes the most popular
anatomic area treated—the nasolabial folds. ● Active koebnerizing inflammatory skin disease.
A B
FIGURE 4.2. A. Facial lipoatrophy with “sunken cheek appearance” prior to treatment. B. Improvement in cheek
volume after treatment. (Reprinted with permission from Baumann, Cosmetic Dermatology, McGraw-Hill Medical,
New York, 2002)
Chapter 4: Dermal Fillers | 39
PREOPERATIVE PLANNING procedures such as liposuction, hair transplantation,
and ambulatory phlebectomy than in implantation of
temporary dermal fillers. In cases where it is necessary
■ Patient Evaluation—Aesthetic
to discontinue use, discontinuance is recommended
● Are fillers the most appropriate therapeutic modality? 1 week prior to surgery, with clearance obtained from
Or, is the patient a candidate for other therapies, i.e., the treating physician.
botulinum injections, laser treatment, surgery, etc.? ● History of smoking—Smoking creates an increased
● Age-related changes of the lower face include risk of vascular compromise and contributes to
● atrophy of both the upper and lower lips; decreased longevity of the injected product.
● actinic changes of the mucosal surface and the ver-
milion border; ■ Psychosocial History
● atrophy at the corners of the mouth with a resultant ● Evaluate patient’s motivations for a given cosmetic pro-
downturned appearance. cedure, e.g., recent spouse or partner separation, loss
● Even subtle changes in the lips and the surrounding of a loved one, job insecurity, etc.
tissue can produce significant improvement. ● Proceed with care in a patient who is undergoing mul-
● Evaluate patient’s goals for the procedure—use hand tiple, frequent procedures with minimal satisfaction or
mirror to permit specific delineation of their perceived is doctor shopping.
trouble spots. ● Patients identified as having unrealistic expectations at
● Clarify realistic versus unrealistic expectations. the initial patient consultation should be approached
with caution—realistic expectations are a cornerstone
■ Medications and Drug Interactions of successful therapy.
● Direct questions toward specific drugs isotretinoin

■ Informed Consent
(Accutane), aspirin, warfarin (Coumadin), estrogen,
clopidogrel bisulfate (Plavix), vitamin E, herbal prepa- ● Document reasonable risks; best to prepare an
rations (St. John’s Wort), beta blockers, NSAIDS, ticlo- informed consent document with an attorney familiar
pidine (Ticlid) (Table 4.1) with local standards of care.
● Discontinuance of platelet-inhibiting drugs is contro- ● Must delineate exact procedure, indications for ther-
versial. This is especially important in more extensive apy, treatment alternatives, and complication profile.
TABLE 4.1 ■ Medications and Herbs That Can Affect Hemostasis

Medications Mechanism of Action Details
Aspirin Irreversibly inhibits cyclooxygenase Discontinue 7 days prior to injection
Garlic Inhibits platelet aggregation and Taken for migraines, arthritis and
thromboxane B2 in vitro cardiac health
Ginger Enhances anticoagulant effects For use in management of nausea
of Warfarin and vomiting
NSAIDs Reversibly inhibit platelet COX-1 Discontinue 7 days prior to injection
(Non-aspirin nonsteroidal
anti-inflammatory drugs
Plavix (Clopidogrel) Oral platelet aggregation inhibitor Discontinue 5 days pretreatment
Vitamin E Decreases platelet adhesion Mild anticoagulant effect can be
increased significantly when taken
with aspirin and garlic
Warfarin Oral Vitamin K antagonist Discontinue 3–4 days pretreatment
● Consent for photography advisable. TECHNIQUE
● The form should be signed by the patient and a witness ● Wrinkles come in assorted depths, thus treatment
in a dated format and should be copied and made
must be tailored according to the individual patient.
available to the patient for his/her individual record.
● More superficial rhytids respond best to intradermal
treatment.
■ Photography ● Deeper rhytids typically have a subcutaneous compo-
●
nent, with or without a muscular element, and are best
Allow for objective data recording prior to procedure.
approached from the subcutaneous space.
● Pre- and posttreatment photography is essential.
● Duration of correction with any filling substance
● Optimal to standardize for lighting, distance, back- depends on multiple factors, such as the
ground, and remove distractions such as jewelry and
● type of material implanted;
hairstyles.
● procedural technique;
● amount of product;
■ Selecting the Right Filler ● particular nature of the defect.
● If necessary, is skin testing an option for patient? ● Chronic mechanical stresses on the treatment site may
● Time constraints—risks of bruising and untoward shorten the lifespan of a given product.
effects vs. product longevity. ● Regular maintenance is necessary with nonpermanent
● Are the rhytids superficial, medium, or deep; must fillers.
assess for use of appropriate product.
● Folds and wrinkles that are readily distensible respond ■ Injection Techniques
best to therapy with dermal fillers.
● Any of the following three injection techniques (Fig. 4.3)
● Deep, nondistensible, and “ice pick” type scars, which
can be used:
do not easily efface with manual stretching of adjacent
● Serial puncture—multiple injections into the mid-
skin, will not respond well.
dermis.
● Does patient understand that with select modalities
● Injections are medial to the fold being addressed.
(i.e., poly-L-lactic acid [Sculptra]) multiple treatments
would be required? ● Injected material is then massaged for even distri-
● For greater longevity or duration of effect, is patient a bution.
candidate for semipermanent or permanent filler ● Threading—a 30-gauge needle is used.
injection? ● Needle advanced at a 30-degree angle below the
● The patient must comprehend that permanent prod- depth of the fold.
ucts have attendant permanent risks (nodules, granu- ● Injecting the filler as the needle is withdrawn.
lomas, hardening, etc.).
● Result is an even filling of the fold depth.
● Fanning—a technique used for diffuse volume filling.
■ Volume Selection ● Involves multiple 30-degree mid-dermal pathways
● An appropriate volume of the selected filler material is formed out from the groove to elevate the superior
critical. Undercorrection in order to decrease patient angle evenly.
costs will only yield an unsatisfied patient and is thus
best avoided.
■ Injection Sites
● We recommend beginning a therapeutic session by
assessing an approximate sense of the facial asymme- Nasolabial folds (Fig. 4.4)
try, predicting the total amount of filler that will be ● Colloquially termed “smile lines,” these are the creases
needed, and then dividing half of the allotted material from the nose to the side of the oral commissure
for the contralateral fold. separating the cheek from the upper lip.
is often an appearance of undercorrection through-
out the treatment unit.
● Anatomically, the facial vein and artery traverse this
triangle; inadvertent intravascular placement can
yield tissue necrosis and must be avoided.
Lips (Fig. 4.5)

● There are two components to lip enhancement:
● Improvement of the defined lip line with injections
along the cutaneous/vermilion border; this is partic-
ularly useful for patients who complain of lipstick
bleeding into the vertical lip rhytids.
● Increasing the volume of the lip body.
● Linear threading with implantation into the potential
space between the lip mucosa and the skin along the
vermilion border is best achieved with the syringe held
parallel to the long axis of the lip.
● A 0.5-inch needle will reach 20–25% of the lip line in
most patients and so four to five threading injections
should cover the entire lip. We use a 30- or 31-gauge
needle bent at 45 degrees, with more superficially
FIGURE 4.3. Injection techniques. A. Linear threading placed filler in the white roll.
technique. B. Serial puncture technique. Fanning is a
● Increased lip volume is achieved by judiciously direct-
technique in which the needle direction is continually
ing the injection into the bulk of the vermilion.
changed without removing the needle. (Reprinted
● By holding the syringe parallel to the long axis of the
with permission from Avram et al., Color Atlas of
Cosmetic Dermatology, McGraw-Hill Medical, New lip and using a threading technique, the filler is
York, 2007) injected along the “wet line” of the red of the lip—
the line at which the dry outer mucosa meets the
moist inner mucosa.
● It is important to inject uniformly as the needle is
● Wrinkles that extend from the angle of the nose to
withdrawn from the track to create a smooth and
the corner of the upper lip are a frequent site for soft
symmetrical enlargement of the lip bulk.
tissue replacement.
● For sharpening the philtrum, the injector can hold
● The goal of the treatment of the nasolabial creases is
the syringe vertically, perpendicular to the upper lip
to correct volume deficits in the deep dermis.
to define below each philtral crest. Ideally, the nat-
● Depth of the fold is the key determinant of the final ural shape of the Cupid’s bow is preserved and
volume used for replacement, and placement of an enhanced.
adequate filler volume is an essential tenet of ther-
● Semipermanent and permanent fillers are not rec-
apy.
ommended for lip augmentation due to the increased
● Effacing the nasolabial fold involves injecting with a risk of product migration and the risk of granuloma
needle at a depth of 1–2 mm depending on the depth formation.
of the rhytid.
● It is ill-advised to have the patient assess symmetry at
● Injection should involve injecting the entire expanse of the time of lip augmentation because localized areas of
the nasolabial crease to the nasal ala. swelling can develop. It is advisable to assess symme-
● Include the mildly depressed triangle just immedi- try after a week or two has passed rather than risk
ately lateral to the ala; if this area is not treated, there overcorrection.
FIGURE 4.4. A. The linear threading method of injection is

used to treat nasolabial folds. (Reprinted with permission
from Avram et al., Color Atlas of Cosmetic Dermatology,
McGraw-Hill Medical, New York, 2007.) B. Preoperative
photograph. C. Postoperative photograph. (B and C
reprinted with permission from Baumann, Cosmetic
C Dermatology, McGraw-Hill Medical, New York, 2002)
Oral commissures ● In both cases, we use a bent 30-gauge needle

● The lower melolabial folds and a droopy chin are directed medially.
addressed with medium-depth fillers. Improved out- ● Full correction of this area is advisable.
comes can be seen with BTX-A injected into the depres-
sor anguli oris muscle in appropriate candidates. Jawline restoration
● Aim is to restore rounded angularity characteristic of a
● Our preferred technique involves fanning to the corners
of the mouth, whereas a serial threading technique is youthful jawline.
ideal for placement in the lower melolabial folds. ● We prefer a linear threading technique in this region.
A B
FIGURE 4.5. Technique for lip architecture

restoration—linear threading of filler into the body
of the lip. B. Preoperative photo (prior to treatment).
C. Postoperative appearance (1 week after the proce-
dure). Note improvement in the lip corners and in the
defined lip line. (B and C reprinted with permission from
Baumann, Cosmetic Dermatology, McGraw-Hill Medical,
C New York, 2002.)
Periocular rhytids (Fig. 4.6) ● Ideally, the smallest bore needle possible should be
● “Crow’s feet” that radiate from the lateral ocular can- used and in a very superficial plane.
thus; dynamic rhytids should be addressed with botu- ● Minimal force should be applied to the plunger with
linum toxin and fillers serve best as adjunct. serial injections to fill the rhytids.
● Periorbital skin is exquisitely thin with a rich vascular
supply that makes filler treatment very unforgiving. Nasojugal crease
There can frequently be the risk of visible product and ● Given the tight anatomy of this space, we recommend
significant post-treatment purpura.
the use of limited product volume.
● Placement is best under the orbicularis oculi muscle.
● Too superficial placement of the material can
yield a bluish tint secondary to the Tyndall effect
and is best avoided by proper depth of the place-
ment.
● Use the nondominant hand to protect the globe at all
times. Have the patient lean the head on something
firm for the injection.
● Instruct the patient to turn off any distractions, e.g.,
FIGURE 4.6. Injection sites for periorbital lines are deep
in the lateral orbicularis muscle as shown. (Reprinted with cellular telephones, spit out gum or hard candy.
permission from Avram et al., Color Atlas of Cosmetic ● Semipermanent fillers are ill-advised in this anatomic
Dermatology, McGraw-Hill Medical, New York, 2007.) location.
Glabellar complex
●
COMPLICATIONS
Primary treatment involves judicious use of botulinum
toxin to address the hypertrophy of the bilateral corru- ● Bruising and swelling are both expected sequella and
gator supercilii and midline. are best managed preoperatively with proper patient
● For patients in whom there remain deeply etched par- preparation.
allel lines despite appropriate muscular immobility, ● Swelling is typically a 24–48-hour phenomenon, but
fillers are an appropriate addition. the bruising can last for as long as a week.
● The deep placement required to treat this area makes ● Coverage makeup such as Dermablend (L’Oreal,
the use of deeper fillers absolutely contraindicated. New York) can be very helpful.
● Immediate postoperative cold therapy can also help.
POSTOPERATIVE CARE ● Rare complication is the reactivation of latent labial
● Following injection, the injector can perform gentle herpes simplex.
massage; however, this can increase posttreatment ● Ideally, prophylaxis prevents such an occurrence.
bruising and must be done with care. ● If recurrence does happen, the appropriate course
● Cool packs (frozen peas are an excellent option) of systemic antivirals will manage the situation.
should be applied in a 15-minute on and 15-minute off ● To avoid the Tyndall effect,
course during the first 24 hours.
● remove the material via direct removal procedure
● Encourage the patient to elevate the head as much as (incision with an 11 blade and expressing it out);
possible so as to decrease posttreatment edema.
● use a QS 1064-nm YAG laser device, as recently
Advise patients to sleep elevated on an extra pillow the
reported;
evening after the procedure.
● judicious injection of hyaluronidase if an HA filler.
● If extensive swelling known to occur and there are no
● Necrosis represents the most concerning complication.
other contraindications, pretreatment with low-dose
diuretic (OTC) or oral corticosteroids can be considered. ● If localized pain or blanching develops acutely
● Instruct the patient to avoid vitamin E, aspirin, and during treatment, immediately discontinue injec-
NSAID ingestion for the first postoperative week. tion and manually massage the area until color
returns.
● If needed for analgesia, give acetamenophin (Tylenol)
● If blanching remains, apply warm water compresses
or prescription-strength analgesics.
to the area; this helps in quick vasodilatation.
● For procedures involving the mouth, it is best to limit
● Have the patient take an aspirin immediately to pro-
the posttreatment diet to soft-to-chew foods for the first
2 days. Advise the patient to avoid any contact sports mote vasodilatation.
where the area treated might be injured. ● Apply nitroglycerin paste every 2 hours for 24 hours
● The patient must be instructed to contact the treating and then every 4–6 hours; the patient must be warned
physician immediately if there is significant bleeding, about the severe headache that can ensue.
pain, irregular swelling, dusky discoloration, eye pain, ● Injection of hyaluronidase provides an important
blurred vision, vision loss, or headache (Table 4.2). adjunct to resolution; there are several recent protocols
(see Suggested Reading).
TABLE 4.2 ■ Side Effects

SUGGESTED READING
Common Rare
1. Landau M. Combination of chemical peelings with
Erythema Local hypersensitivity
botulinum toxin injections and dermal fillers. J Cosm
Swelling Formation of granulomas
Dermatol 2006;5(2):121–126.
Pain/Tenderness Abscess development
2. Fernandez-Acenero MJ, Zamora E, Borbujo J. Gran-
Bruising Necrosis and sloughing
ulomatous foreign body reaction against hyaluronic
Acneiform eruption
acid: Report of a case after lip augmentation. Der-
Reactivation of latent HSV
matol Surg 2003;29(12):1225–1226.
3. Friedman PM, Mafong EA, Kauvar AN, Geronemus 11. Jones D. HIV facial lipoatrophy: Causes and treat-
RG. Safety data of injectable nonanimal stabilized ment options. Dermatol Surg 2005;31(11 Pt 2):
hyaluronic acid gel for soft tissue augmentation. Der- 1519–1529; Discussion 1529.
matol Surg 2002;28(6):491–494. 12. Biesman B. Soft tissue augmentation using Resty-
4. Klein AW. Skin filling: Collagen and other injectables lane. Facial Plast Surg 2004;20(2):171–177; Dis-
of the skin. Dermatol Clin 2001;19(3):491–508. cussion 178–179.
5. Narins RS, Brandt F, Leyden J, et al. A randomized, 13. Hirsch RJ, Cohen JL, Carruthers JD. Successful
double blind, multicenter comparison of the efficacy management of an unusual presentation of impend-
and tolerability of Restylane versus Zyplast for the ing necrosis following a hyaluronic acid injections
correction of nasolabial folds. Dermatol Surg 2003; embolus and a proposed algorithm for manage-
29(6):588–595. ment with hyaluronidase. Dermatol Surg (in
6. Goldberg RA, Fiaschetti D. Filling the periorbital hol- press).
lows with hyaluronic acid gel: initial experience with 14. Glaich AS, Cohen JL, Goldberg LH. Injection necro-
244 injections. Ophthal Plast Reconstr Surg 2006; sis of the glabella: Protocol for prevention and treat-
22(5):335–341; Discussion 341–343. ment after use of dermal fillers. Dermatol Surg
7. Maas CS. Botulinum neurotoxins and injectable 2006;32(2);285–290.
fillers: minimally invasive management of the aging 15. Brody HJ. Use of hyaluronidase in the treatment of
upper face. Facial Plast Surg Clin North Am 2006; granulomatous hyaluronic acid reactions or unwanted
14(3):241–245. hyaluronic acid misplacement. Dermatol Surg
8. Lowe NJ, Grover R. Injectable hyaluronic acid 2005;31:8;893–897.
implant for malar and mental enhancement. Derma- 16. Hirsch RJ, Narurkar V, Carruthers JD. Management
tol Surg 2006;32(7):881–885; Discussion 885. of hyaluronic acid induced tyndall effects. Lasers
9. Carruthers JDA, Carruthers A. Facial sculpting and Surg Med 2006;38(3):202–204.
tissue augmentation. Dermatol Surg 2005;31(11 Pt 17. Hirsch RJ, Carruthers JDA, Carruthers A. Infraorbital
2):1604–1612. hollow treatment by dermal fillers. Dermatol Surg
10. Klein AW. In search of the perfect lip: 2005. Derma- 2007;33:1–4.
tol Surg 2005;31(11 Pt 2):1599–1603.
CHAPTER 5
0 Chapter Title
Botulinum Toxin
Ranella J. Hirsch, MD ● After both treatments, a collateral sprouting of new
nerve terminals occurs over time; however, the original
functional endplate is established so that sprouts
KEY POINTS FOR SUCCESS regress as the clinical effects of botulinum subside.
● Careful patient selection.
● Detailed informed consent. AVAILABLE PRODUCTS
● Pre- and postphotography. ● Type A toxins: Botox (Allergan, Irvine, CA) and Dysport
● Knowledge of precise anatomy for optimal place- (Ipsen, Berkshire, England).
ment. ● Type B toxin: Myobloc (Elan, San Francisco, CA).
● Injecting the underlying muscles, not the overlying ● Botox was approved by the United States Food and
wrinkles. Drug Administration in April 2002 for the cosmetic
● Technique dependent—treatment must be individual- treatment of glabella; other cosmetic uses are off-label.
ized for each patient.
● Goal is to soften rhytids without total loss of expression. MEDICAL CONSIDERATIONS
● To minimize purpura, medications to avoid include anti-
PHARMACOLOGY—BOTULINUM TOXIN coagulants (warfarin (Coumadin), heparin), NSAIDS,
aspirin, platelet inhibitors, isotretinoin, vitamin E, and
● Seven distinct serotypes A, B, C, D, E, F, and G, which assorted herbal preparations.
vary by size and cellular mechanism of action.
● Check for history of smoking. Smoking creates an
● Botulinum toxins A and B are commercially available; increased risk of vascular compromise and contributes
these are composed of different strains of Clostridium to decreased longevity of the injected product.
botulinum bacteria.
● Inquire about known allergy to medications and/or
● Both botulinum toxins A and B are 150-kD dichain anesthetics.
polypeptides composed of a heavy chain and a light
● Inquire about tendency to faint so that appropriate pre-
chain linked by a disulfide bond. The heavy chain is
ventative measures can be provided.
responsible for select binding of the toxin molecule to
● Confirm that female patients of childbearing age are
presynaptic cholinergic nerve terminals, whereas the
light chain acts inside the cell to prevent acetylcholine neither pregnant nor lactating.
vesicle release. ● Check for history of keloid formation or tendency for
poor scarring.
MECHANISM OF ACTION—
BOTULINUM TOXIN PSYCHOSOCIAL HISTORY
● Realistic expectations are critical—What is the motiva-
● It smoothes dynamic rhytids by inhibiting the activity at
tion to undergo the procedure?
the neuromuscular junction.
● Beware of patients who have had multiple procedures
● Within the target cell, light chain of type A cleaves
done by various clinicians with minimal satisfaction.
SNAP-25 or light chain of type B cleaves VAMP.
● It binds to the motor nerve terminals and inhibits the
release of acetylcholine via cleavage of SNAP-25—a
INFORMED CONSENT
protein necessary for the docking and release of ● Document reasonable risks, which are optimally
acetylcholine filled vesicles, resulting in temporary reviewed by an attorney familiar with local standards of
chemical denervation of affected muscle. care.
● Delineate the exact procedure, indications for therapy, ● Procerus pulls the forehead skin inferiorly and deter-
treatment alternatives, and complications. mines medial eyebrow height.
● Consent for photography advisable. ● Vertical perioral rhytids, commonly referred to as
● The form should be signed by the patient and the wit- “smoker’s lines,” or “lipstick bleeders,” are the prod-
ness in a dated format and should be offered to the uct of repeated activity of the orbicularis oris muscle.
patient for his/her individual record. Orbicularis oris is a sphincter muscle that permits clo-
sure and puckering of the lips.
● Fibers that comprise orbicularis oris are derived from
PHOTOGRAPHY
buccinators and zygomaticus major and minor, riso-
● Pre- and posttreatment photography advisable. rius, and depressor anguli oris.
● Standardize lighting, distance, and background. ● Orbicularis oris plays an important role in communica-
● Remove distracting jewelry and clothing. tion especially in mastication and phonation and
hence the dermasurgeon’s primary challenge is to
treat rhytids while preserving optimal functioning.
DOSAGE
● Both Botox and Dysport are available in lyophilized
INJECTION SITES
form, which must be reconstituted with saline prior to
clinical use. Preserved saline has been noted to pro-
vide a beneficial mild analgesic effect. ■ Glabellar Complex—Frown Lines
● Myobloc is available as a stable, nonpreserved aque- ● Four muscles are entirely responsible for the down-
ous solution that may be further diluted. ward and inward movements of the brow—corrugator
●
superciliaris, orbicularis oculi, procerus, and depres-
Higher concentration injections allow for very low vol-
sor supercilii.
ume injections with precise toxin placement and little
spread to nontargeted areas. Lower concentration injec- ● To inject glabellar frown lines, the technique involves
tions deliberately spread the toxin over a wider area. five to seven injections with the total dosage depen-
●
dent on the particular brow to be treated.
The amount of saline to be used for the reconstitution
depends upon the particular clinical use and whether ● An average female brow with normal muscular volume
the amount of neurotoxin diffusion desired is more or requires 25–30 U while male brow with greater muscle
less. For example, in the neck bands more diffusion is mass requires 35–45 U. More toxin may be needed to
desired and thus a lower concentration would be ben- optimize results, especially in heavy brows.
eficial, whereas in the treatment of the glabellar furrow ● First, inject 5–10 U into the procerus at the midline
a discretely focal effect of botulinum is desired in order point just above the point joining the medial brow
to avoid diffusion into the levator palpebrae superioris and the contralateral medial canthus. Immediately
with a possible resultant ptosis. postinjection, massage horizontally to encourage dif-
fusion into the depressor supercilii. Second, insert
RELEVANT FACIAL MUSCULATURE needle at the medial canthus directly into the head
(FIG. 5.1) of the corrugator just above the bony supraorbital
ridge. Inject 4–7 U, then slightly withdraw the needle
● Frontalis is a large, vertically oriented muscle that without removing from the skin. Advance with the tip
inserts superiorly to the galea aponeurotica and inferi- pointing superiorly and inject an additional 3–7 U,
orly to the procerus, the orbicularis oculi, the corruga- approximately 1 cm above the previous injection.
tor supercilii, and the eyebrow skin. (Fig. 5.2)
● Frontal belly of occipitofrontalis raises the eyebrow and ● If lateral brow elevation is desired and is appropriate
is responsible for transverse forehead lines. (in patients with a more horizontal baseline brow),
● Orbicularis oculi is the sphincter of the eye; orbital por- an additional 3–5 U can be injected 1 cm above the
tion depresses the eyebrow and the palpebral portion supraorbital notch bilaterally in the midpupillary
affects the eyebrow and lid. line.
Chapter 5: Botulinum Toxin | 49
Epicranial aponeurosis
Procerus (galea aponeurotica)
muscle
Frontalis
muscle Corrugator
muscle
Nasalis Orbicularis
muscle oculi muscle
Levator labii Zygomaticus

superioris minor muscle
alaeque nasi
muscle Zygomaticus
major muscle
Levator
superioris muscle
FIGURE 5.1 A. Upper and midfacial musculature
■ Brow Lift—Lateral ■ Brow Lift—Medial

● Eyebrow ptosis is common and creates the negative ● Drooping brow creates an unintentional tired and
impression of being tired. angry appearance.
● Eyebrows can be elevated by successful injection of ● Injecting 10–20 U Botox into the procerus and 5–10 U
the depressor musculature, thus permitting the brow into each medial corrugator weakens the medial brown
elevators to act unopposed. Lifting is most likely the depressors, thus permitting frontalis to elevate the
result of partial weakening of central frontalis fibers by medial brow.
diffusion of the toxin.
● In a study on dose range, Carruthers reported that
approximately 30 U is an optimal dose for this indication.
● With lateral brow ptosis, inject at the superolateral
■ Combination Brow Lifting
orbital rim where the fibers of orbicularis oculi curve ● Injecting in both the procerus and the lateral brow, at
from horizontal to vertical. Injecting at the point just its junction with the temporal fusion line, produces a
above where the temporal fusion line reaches the bony brow lift of 1–3 mm and reveals more of the prized eye-
orbital rim produces a subtle lateral brow lift. lid skin in both females and male patients.
● Dose of 4–6 U in females and 7–10 U in males. ● The result is a rested and alert appearance.
Levator labii superioris
alaeque nasi muscle
Epicranial aponeurosis
(galea aponeurotica)
Auriculofrontalis muscle
Auricularis superior muscle
Auricularis anterior muscle
Zygomaticus major muscle

Levator labii Parotideomasseteric fascia
superioris Risorius muscle
muscle
Orbicularis oris muscle
Depressor anguli oris muscle
Zygomaticus Depressor labii inferioris muscle
minor muscle
Mentalis muscle
Platysma muscle
FIGURE 5.1 (continued) B. Lower face and neck musculature. (Reprinted with permission
from Avram et al., Color Atlas of Cosmetic Dermatology. McGraw-Hill Medical, New York,
2007)
Eyebrow—special considerations Eyebrows—cautions

● Characteristic of a well-proportioned female brow: The ● If the patient has a low-lying brow, treatment of the
medial aspect should begin at a point defined by a line forehead lines should be avoided or limited to 4 cm or
drawn from the lateral nose through the medial more above the brow.
canthus of the eye. ● The lower 2.5–4 cm of the frontalis muscle moves
● Lateral female brow should end at a point defined by a upward to elevate the eyebrows; older patients often rely
line starting from the lateral nose upward through on this movement to raise the brows for vision and the
lateral canthus. loss of this ability with Botulinum therapy is undesirable.
● Lack of expression can be the result of too lateral ● The glabella and the entire forehead should not be
injection of the frontalis (lateral to midpupillary injected in a single session to minimize risk of ptosis, if
line). it can be avoided.
● Injection in the forehead should always be above the ● Women frequently shape the brows artificially hence it
lowest fold produced when the patient is asked to is critical to rely on the bony landmarks and not on the
elevate the brow. actual brow location.
FIGURE 5.2 A & B. Injection sites for glabellarfrown

lines. C. Glabellar complex before BTX-A injection and
D. 3 weeks after BTX-A injection. (Reprinted with per-
mission from Avram et al., Color Atlas of Cosmetic Der-
matology. McGraw-Hill Medical, New York, 2007) D
■ Horizontal Forehead Lines ● Avoid injecting lower than 2–3 cm above brow because
the lower fibers of frontalis are the focus of most of its
● These lines are the product of the anterior frontalis elevating action.
portion of the occipitofrontalis muscle.
● The frontalis inserts superiorly into the galea and infe-
riorly into the procerus, corrugator supercillii, orbicu- ■ Crow’s Feet
laris oculi, depressor supercilii, and brow skin.
● Crow’s feet are the result of the vertically oriented fibers
● It is crucial to recognize that this represents sole brow of orbicularis oculi and the elevators and retractors of
elevator, yielding brow ptosis as a significant concern of the corner of the mouth, zygomaticus, and risorius.
poor injection technique. Anyone with significant prein-
● The goal is to weaken only the lateral part of orbicularis
jection brow ptosis must either be excluded or be
oculi.
injected with extreme care.
● Crow’s feet injections must be placed outside the bony
● Critical goal is to weaken but not paralyze the frontalis.
orbital margin to avoid diffusion to the extraocular
● Concomitant treatment of the brow depressors with 10 muscles in which case diplopia can result.
U into the procerus and 5 U into each lateral orbicularis
● They should not be placed less than 1 cm above the
yields reduced downward force, causing brow depres-
zygomaticus notch in order to avoid the potential of
sion for the elevating frontalis muscle to counteract. If
midfacial and lip ptosis.
this approach is taken, as little as 10–20 total U are
● Inject up to 12–15 U per side at three or four injection
needed (2–4 U in each of the four or five sites) across
the forehead. It is advisable to massage the forehead sites. (Fig. 5.4)
upward and obliquely immediately after injecting to ● Aim for as superficial injection (dermal) as possible to
provide a smooth brow appearance. (Fig. 5.3) minimize bruising.
FIGURE 5.3 A. Injection sites for horizontal forehead

lines. B. Forehead lines prior to BTX-A treatment. C. The
same patient one month after treatment. (Reprinted with
permission from Avram et al., Color Atlas of Cosmetic
B Dermatology. McGraw-Hill Medical, New York, 2007)
FIGURE 5.4 A. Injection sites for periorbital lines.

B. Periorbital lines prior to treatment with BTX-A. C. The
same patient 6 weeks after treatment. (Reprinted with
permission from Avram et al., Color Atlas of Cosmetic
B Dermatology. McGraw-Hill Medical, New York, 2007)
● Visual avoidance of vessels with magnifiers is also
advisable to minimize purpura.
■ Hypertrophic Orbicularis Oculi

● Popular in patients of Asian ethnic origin or in patients
desiring a wider eye shape.
● Injection of 2–4 U of Botox into the lower pretarsal
orbicularis 3 mm below the inferior ciliary margin in
the midpupillary line relaxes the palpebral aperture.
● Do not perform in patients with a negative pretreat-
ment snap test or those who have had a previous abla- FIGURE 5.6 Injection sites for the perioral muscles.
tive resurfacing or a lower blepharoplasty (increased (Reprinted with permission from Avram et al., Color
risk of ectropion.) Atlas of Cosmetic Dermatology. McGraw-Hill Medical,
New York, 2007)
■ Mid Face
As a general rule, the mid- and lower facial musculature
requires by and large much smaller unit injections than ● “Botox sign” is what is referred to by the lay media as a
do the muscles of the upper face. Overdosing the mid sign of Botulinum injection and represents recruitment
and lower facial musculature can yield a facial palsy that of the upper nasalis in compensation for the inability to
can last for approximately 6 months. It is advisable to mobilize the forehead rhytids and is best avoided.
treat conservatively, have patients return, and slowly
increase the dose.
■ Repetitive Nasal Flare
● Muscular fibers of the dilator naris bridge the dorsum
■ Nasalis of the nose closer to the tip and insert into the lateral
● Contraction of the muscular fibers of upper nasalis alar cartridges. When contracted, these muscles yield
yields radial rhytids at the tip of the nose, colloquially dilatation of the nares.
termed “bunny lines.”
● Bunny lines are treated with 3–5 U placed high on the ■ Perioral Rhytids
dorsum of the nose away from the lip elevators located
● Injection of 1–2 U per lip quadrant as symmetrically as
in nasofacial groove (Fig. 5.5).
possible across the philtrum can create a pseudoever-
sion of the lips (Fig. 5.6).
● Great care must be taken to avoid creating a paresis of
the orbicularis oculi with a resultant interference with
elocution and suction, however this must be covered in
the informed consent as it is rarely unavoidable.
● Unpredictably, some patients complain of lost proprio-
ception after the treatment.
■ Upper Gum Show

FIGURE 5.5 Injection sites for upper nasal root
rhytides (bunny lines). (Reprinted with permission from ● This affects people with a naturally short upper lip;
Avram et al., Color Atlas of Cosmetic Dermatology. when they smile both the incisor base and the gum
McGraw-Hill Medical, New York, 2007) line become visible.
FIGURE 5.7 Injection sites for frown lines. (Reprinted FIGURE 5.8 Injection sites for the platysma muscle
with permission from Avram et al., Color Atlas of Cos- complex. (Reprinted with permission from Avram et al.,
metic Dermatology. McGraw-Hill Medical, New York, Color Atlas of Cosmetic Dermatology. McGraw-Hill
2007) Medical, New York, 2007)
● Injecting 1 U of Botox into each lip elevator complex in ● Raising a wheal as in a deep dermal injection is prefer-
each nasofacial groove relaxes the upper lip so it able to reduce the risk of bruising.
cannot fully retract. ● We limit each session to injections of 10–20 U because
of the immediate proximity of the muscles of degluti-
nation and speech.
■ Depressor Anguli Oris/Frown
● Downward movement of the lateral corners of the POSTOPERATIVE COURSE/CARE
mouth is caused by the action of the depressor anguli
● Botulinum toxin may take 3–8 days to show effect.
oris in association with aging and the normal course of
photodamage (Fig. 5.7). Advise patients not to expect immediate results.
● We recommend that patients remain vertical for 2–3
● Injecting too medially can affect the lip depressor mus-
cles and by extension elocution and smiling. hours after the injections and utilize the treated mus-
culative as much as possible in the 60 minutes subse-
● Zygomaticus major is the direct antagonist to the
quent to injection to promote binding of the toxin.
depressor anguli oris; thus, weakening DAO with 3–5
● Patients are urged to avoid manipulation of the treated
U of Botox allows zygomaticus to elevate mouth cor-
ners to a more horizontal position. areas for several hours postinjection.
EFFICACY
■ Mentalis
● Peaks in 3–4 weeks and declines after 3–4 months.
● Can get apple-dumpling appearance
However, there are some individuals who experience
● Injection technique is to stay low at the point of the sustained efficacy for as long as 6–12 months.
mentum and avoid the depressor labii. ● Anecdotally, patients who have undergone a series
of treatment seem to require less frequent reinjec-
■ Cervical Injections/Necklace Lines tions.
● The platysmal muscle is a larger muscle on the super-
ficial anterior neck. COMPLICATIONS: TREATMENT AND
●
PREVENTION
The simplest approach is to inject 1–2 U of Botox,
approximately 1 cm apart, along each necklace line ● Pain—decreases with use of topical anesthetics or
followed with gentle massage postinjection (Fig. 5.8). application of coolants (ice, cold air).
● Edema and erythema—minimize with the application 2. Carruthers A, Carruthers JDA. Botulinum toxin type A:
of ice immediately prior to and after the injection. history and current cosmetic use in the upper face.
● Ecchymosis and purpura—can be reduced by asking Semin Cutan Med Surg 2001;20:71–84.
the patient to avoid the ingestion of NSAIDS, aspirin, 3. Carruthers JDA, Carruthers A. Botox use in the mid
and other procoagulants prior to injections. and lower face and neck. Semin Cutan Med Surg
2001;20:85–92.
● In addition, minimizing the amount of injections, and
4. Klein AW. Complications and adverse reactions with
postinjection manipulations is also helpful.
the use of botulinum toxin. Semin Cutan Med Surg
● Headache—patients identified to be at risk can be pre- 2001;20:109–120.
treated with OTC acetaminophen. 5. Said S, Meshkinpur A, Carruthers A, Carruthers JDA.
● The major factor leading to patient dissatisfaction is an Botulinum toxin A: its expanding role in dermatology
unexpected complication that has not been well and esthetics. Am J Clin Dermatol 2003;4(9): 609–616.
explained. 6. Frampton JE, Easthope SE. Botulinum toxin A (Botox
● Detailed discussion of the majority of expected compli- Cosmetic): A review of its use in the treatment of
cations, which are signed and documented, helps to glabellar frown lines. Am J Clin Dermatol 2003;4(10):
minimize this scenario. 709–725.
7. Lowe NJ, Ascher B, Heckman M, Kumar C, Fraczek
S, Eadie N. Botox Facial Aesthetics Study Team. Dou-
SUGGESTED READING ble-blind, randomized, placebo-controlled, dose-
1. Semchyshyn N, Sengelmann RD. Botulinum toxin: A response study of the safety and efficacy of botulinum
treatment of perioral rhytids. Dermatol Surg 2003;29: toxin type A in subjects with crow’s feet. Dermatol
490–495. Surg 2005;31(3):257–262.
CHAPTER 6
0 Liposuction
Naomi Lawrence, MD ● It is not for the treatment of obesity. Liposuction as a
treatment of obesity is an experimental procedure and
should not be performed.
● It should not be performed on persons who fulfill DSM-
● Choose an appropriate candidate who has a stable IV criteria for body dysmorphic disorder.
weight pattern and reasonable expectations that you can ● It is not for the treatment of cellulite.
meet.
● It can be used successfully to treat a number of adi-
● Perform a thorough assessment of the area.
pose-related disease conditions and to assist in soft tis-
● Consider and determine the relative contribution of the sue remodeling and reconstruction.
following to the deformity: ● It can be used for cosmetic contouring:
● fat compartments—deep (or below muscle) and ● Face—jowls, buccal, and lateral nasolabial area.
superficial,
● Neck—lateral neck and submental areas.
● bone structure, and
● Trunk—anterior abdomen, iliac crest, lateral trunk,
● skin thickness.
posterior waist, back, and gynecomastia (when due
● Estimate the amount you think will be suctioned and to fat in both males and females).
compare to actual aspirate. ● Extremities—lateral trochanteric area and buttocks,
● This exercise will train you to have a sense of what medial anterior and posterior thigh, suprapatellar
can be removed from a particular area. and medial patellar areas, calves, ankles, and upper
● If the amounts differ by more than 200 cc, consider outer arms.
whether the muscle mass or deep fat compartment ● Other indications
was underestimated. ● Lipomas, single or multiple.
● Make safety the top priority in performing liposuction. ● Gynecomastia or pseudogynecomastia in males and
● Use a good tumescent technique. females.
● Monitor the patient when appropriate. ● Lipodystrophy, especially that related to Cushings
● Minimize the use of sedative medication. disease or HIV disease.
● Maintain an ACLS certification. ● Axillary hyperhidrosis and bromhidrosis.
● Have the appropriate resuscitative equipment and ● Lymphedema.
medications on hand. ● Evacuation of hematomas and seromas.
● The patient will see a good portion of the result in a ● Reconstruction
week, but the area will continue to improve over the ● Flap elevation and movement.
following months as the skin retracts.
● Subcutaneous fat debulking, following flap and full
● Delay touch-ups, ideally for 1 year, but minimum
thickness grafting procedures.
6 months.
CONTRAINDICATIONS
INDICATIONS
● Absolute
● The primary purpose of liposuction is to contour dis-
● Hematologic abnormalities that cannot be corrected
proportionate areas of fat deposition in patients, close
● Abdominal hernia
to their ideal body weight, with realistic expectations of
changes in contour and not weight loss. ● Anticoagulant medication
● Pregnancy ● Some of these patients may be allergic to the methyl-
● True allergy to lidocaine (very rare) paraben preservative in the anesthetic and so use
preservative-free lidocaine—Xylocaine-MPF (Astra,
● Body dysmorphic disorder
USA Inc., Westborough)
● Consider additional discussion or a waiting period in
● Epinephrine—this is an endogenous catecholamine
case of
and so true allergy is not possible.
● weight cycling,
● Many patients are sensitive to the effects of epi-
● unrealistic expectations, nephrine in the dental setting as the oral mucosa is
● recent large weight loss, or highly vascular and absorption is rapid.
● very low calorie diet (VLCD). ● Majority of the patients do not have a problem with
● The following may necessitate medical clearance: tumescent anesthesia as epinephrine is infused into
the adipose, which has a low vascularity.
● Diabetes
● The use of 0.65-mg epinephrine (rather than 1 mg)
● Cardiac disease
in each tumescent liter and preoperative 0.1-mg
● Hypertension clonidine (Boehringer, Ingelheim) in patients with
● Chronic disease BP ⬎ 100/70 minimizes the incidence of epineph-
● Liver disease rine-induced tachycardia.
● Immunosuppression
● Patient at risk for thromboembolism ■ Medication
● Any medication or herbal supplement (Tables 6.1 and
PREOPERATIVE CONSIDERATIONS
6.2) that prolongs bleeding time.
■ History ● Warfarin, clopidogrel bisultate (Plavix, Bristol-Myers
Squibb), aspirin, nonsteroidals—-contraindicated.
● Medical—see contraindications.
● Discontinue 2 weeks prior to surgery with medical
● Surgical—any previous surgeries in the area to be lipo- clearance.
suctioned, hernias, or if there is some change in the
● Drugs that interfere with lidocaine metabolism
underlying anatomy.
(Table 6.3). Management strategy:
● Allergies/medicine sensitivities.
● Discontinue with medical clearance or substitution.
● Medications.
● Decrease the maximum dose of lidocaine from 55
mg/kg to 35 mg/kg.
■ Allergy ● Hormones
● Antibiotic—patient receives IV cephalosporin (Ancef, ● A high dose of estrogen increases the risk for throm-
Merck & Co) 30 minutes prior to procedure. If the boembolism from any surgery, particularly if the
patient is allergic to penicillin or cephalosporin, then to patient is a smoker, or within the first year of therapy
give oral clindamycin (Watson) the night before the (see Refs. 1–3).
procedure. ● Low-dose oral contraceptives—-probably extremely
● Latex—Wear latex-free gloves and use latex-free low risk. Management strategy:
dressings. For high dose, or hormonal replacement in smokers,
● Lidocaine—True allergy to lidocaine is extremely rare stop the hormone prior to surgery with medical clear-
and is currently a contraindication to tumescent anes- ance.
thesia as there is no alternative local anesthetic with For low-dose oral contraceptives (OCP), counsel the
safety testing. patient and give the option of discontinuing OCP and
● If a patient has a questionable history of allergy to using alternative contraceptive methods or accept-
lidocaine, it is best to send him/her for allergy testing. ing the minimal risk associated with continuing.
Chapter 6: Liposuction | 59
TABLE 6-1 ■ Herbs Affecting Coagulation
Coagulant Anticoagulant Antiplatelet
Agrimony Alfalfa (Coumarin constituent) Angelica
Alfalfa (vitamin K) Angelica Aspen
European mistletoe Anise Black cohosh
Goldenseal Arnica Borage seed oil
Plantain Asafoetida Capsicum
Stinging nettle Bogbean Celery
Yarrow Boldo Clove
Borage seed oil Dong quai
Bromelain Feverfew
Danshen Fish oils
Dong quai Garlic
Fenugreek Ginkgo
Fucus Ginseng
Ginger Licorice
Ginseng Onion
Horse chestnut Poplar
Horseradish Turmeric
Meadowsweet Vitamin E (alpha-tocopherol)
Northern prickly ash Willow bark
Papain
Passionflower
Pau d’arco
Quassia
Red clover
Roman chamomile
Safflower
Southern prickly ash
Sweet clover
Sweet vernal grass
Tonka bean
Wild carrot
Wild lettuce
■ Physical Examination (see Fig. 6.1) ● Bone structure may be responsible for asymmetry in
any area.
● Skin features of the area—striae, cellulite, scars, skin
● Muscle
tone, and elasticity
● Bone structure ● Examine the abdomen. A poorly toned rectus allows
● Neck—forward placed hyoid bone can make the abdominal contents to protrude and contribute to
neck angle more obtuse. the bulk and rounded shape of the abdomen.
● The shape of the pelvis and the orientation of the femur ● In the upper arm, poorly toned muscle may be as
socket can contribute to the shape of the outer thigh. important as fat deposits to girth.
TABLE 6.2 ■ Medicines Affecting Coagulation
4-Way Cold Tablets Clinoril Tablets Ketoprofen Capsules
Adprin – B Tablets Congesprin Lanorinal Tablets
A.S.A. Enseals Cope Tablets Lodine Capsules/Tablets
A.S.A. tablets Coricidin Lodine XL
Aches-N-Pain Tablets Coumadin Lortab
Advil Darvon Compound Pulvules Magan Tablets
Alcohol Darvon Compound –65 Magnaprin Arthritis Captabs
Aleve Tablets Darvon with A.S.A Pulvules Magsal Tablets
Alka-Seltzer Products Darvon-N with A.S.A. Marnal Capsules
Amigesic Capsules Dasin Capsules Marthritic Tablets
Anacin Tablets and Capsules Doan’s Pills Maximum Bayer Aspirin
Anaprox, Anaprox DS Tablets Dolobid Tablets Measurin Tablets
Anodynos Tablets Dristan meclo Fenamate Capsules
Ansaid Tablets Duoprin-S Syrup Meclomen Capsules
APC Duradyne Tablets Mediipren Tablets and Caplets
Argesic Tablets Easprin Menadol Tablets
Artha-G Tablets Ecotrin Tablets Meprogesic Tablets
Arthralgen Tablets Emagrin Tablets Micrainin Tablets
Arthritis Bayer Timed Release Aspirin Empirin Tablets Midol 200 Tablets
Arthritis Pain Formula Tablets Emprazil Midol, All products
Arthopan Liquid Endodan Tablets Mobidin Tablets
Arthrotec Epromate Tablets Mobigesic Tablets
Ascodeen Equagesic Tablets Momentum Tablets
Ascriptin, all products Equazine M Tablets Motrin Tablets
Asperbuf Tablets Etodolac Nalfon Capsules/Tablets
Aspergum (chewing gum) Excedrin Tablets and Capsules Nalfon Pulvules
Aspirin Feldene Capsules Naprosyn Tablets/suspension
Asprimox Tablets Fenoprofen Tablets Naproxen Tablets
Axdone Fiorgen PF Tablets Neocylate Tablets
Axotal Tablets Fiorinal Tablets Norgesic/Norgesic Forte Tablets
Bayer, all products Fluriprofen Tablets Norwich Extra-Strength Tablets
BC Tablet and Power Gelpirin Tablets Nuprin Tablets and Cap[lets
Brufen Gensan Tablets Orphengesic
Buf-Tabs Goody’s Headache Powder Orudis Capsules
Buff-A Comp Tablets and Capsules Halfprin Tablets Oruvail Capsules
Buffaprin Tablets Haltran Tablets Pabalate
Bufferin, all products Ibu-Tab Tablets Pabalate-SF Tablets
Buffets II Tablets Ibuprin Tablets PAC Tablets
Buffex Tablets Ibuprobm Tablets and Caplets Pamprin_IB Tablets
Buffinol Tablets Indochron E-R Capsules Pepto-Bismol Tablets and
Cama Arthritis Pain Reliever Indocin Capsules/Suspension Suspension
CataFlam Tablets Indocin Suppositories Percodan/Percodan-Demi Tablets
Cephalgesic Indocin-SR Capsules Phenaphen
Charcol Indomethacin Capsules Piroxicam Capsules
Children’s Aspirin Indomethacin Suspension Ponstel Capsules
Chindren’s Advil Suspension Isollyl Improved Tablets/Capsules Presalin Tablets
Children’s Motrin Suspension Ketrolac Tablets Relafen Tablets
TABLE 6.2 ■ Medicines Affecting Coagulation (continued )
Robaxisal Tablets Soma CMD Tolmetin Tablets/Capsules
Rufen Tablets St. Joseph Adult Chewable Toradol Injection/Tables
S-A-C Aspirin Trendar Tablets
Saleto Tablets St. Joseph Cold Tablets fo Tricosal Tablets
Saleto-200,400,600,800 Tablets Children Tri-Pain Tablets
SalFlex Tablets St. Joseph Aspirin for children Trigesic
Salocol Tablets Sulindac Tablets Trigesic Tablets
Salsalate Tablets Supac Trilisate Tablets a& Liquid
Salsitabs Tablets Synalogos Capsules Vanquis Caplets
Sine-Aid Synalogos-DC Capsules Verin
Sine-Off Talwin Compound Tablets Voltaren tablets
SK-65 Compound Capsules Tolectin 200,600 Tablets Zactin
Soma Tolectin DS Capsules Zorprin Tablets
● Examine bulk—anterior thigh, calves, upper back ● Oxygen

and arms, and buttocks are all areas where muscle ● Continuous blood pressure monitor (if IV or IM seda-
bulk may be responsible for a significant portion of tion is to be used)
the contour.
● Adipose
Neck and abdomen have superficial and deep com- ■ Instrument Tray (see Fig. 6.2)
partments. Deep compartment fat cannot be
Cannulas
“pinched away” from the underlying muscle. ● A diameter of 3 mm or less for most procedures
In each area examine with muscles flexed to deter- (12–16 gauge) (see Fig. 6.3A)
mine the amount of adipose that is suctionable. ● Aggressive (Fig. 6.3B)
Tip: As you perform the physical examination, explain to
● Moderate cannulas (Fig. 6.3C)
the patient how much of the protuberance is suctionable
fat and how much is due to bone structure, muscle, or ● Aspiration pumps and powered pumps (Tiemann/Bern-
deep fat. Give the patient the percentage improvement sco Co., Hauppauge, NY; HK Surgical, San Clemente,
they will gain from liposuction. CA; Byron Medical, Tuscon, AZ) (Fig. 6.4)
■ Preoperative Labs
● SMA20 (general chemistry profile) TECHNIQUE
● CBC with differential and platelets—-complete blood Two weeks prior to surgery:
count including platelet count and cell differential ● Pictures are taken.
● PT/PTT (protime/prothrombin time) ● Consent is signed.
● Hepatitis screening profile ● Patient is counseled.
● HIV screen ● Bloodwork is ordered.
● Urine pregnancy test (morning of the surgery day) ●Payment is made.
One week prior to surgery:
■ Surgical Suite Setup
● Bloodwork is checked.
● Emergency medication cart One day prior to surgery:
● Defibrillator ● Patient’s chart is reviewed.
TABLE 6.3 ■ Drugs That Interfere with Lidocaine Metabolism
Antiarrhythmic drug Benzodiazepines
amiodarmone (Cordarone) alprazolam (Xanax)
Anti-histamines (H2 blockers) diazepam (Valium)
cimetidine (Tagamet) flurazepam (Dalmane)
midazolam (Versed)
Beta blockers
triazolam (Halcion)
propranolol (Inderol)
Antiseizure medications
Calcium channel blockers
carbamazepine
amiodarone (Cordarone)
divalproex (Depakote)
diltiazam (Cardiazam)
phenytoin (Dilantin)*
felodipine (Plendil)
valproic acid (Depakene)
nicardipine (Cardene)
nifedipine (Procardia) Antidepressants
verapamil (Calan) amitriptyline (Elavil)
clomipramine (Anafranil)
Cholesterol-lowering drugs
flouxetine (Prozac)
cervistatin (Baycol)
fluvoxamine (Luvox)
atorvastatin (Lipitor)
nefazodone (Serzone)
lovastatin (Mevacor)
paroxetine (Paxil)
simvastatin (Zocar)
sertraline (Zoloft)
Antibiotics
ciprofloxacin (Cipro) Anti-neoplastics
clarithromycin (Biaxin) tamoxifen (Nolvadex)
erythromycin Protease inhibitors/antivirals
Antifungal medications diethyldithiocarbamate
fluconazole (Diflucan) indinavir
itraconazole (Sporanox) nevirapine (Viramune)
ketoconazole (Nizoral) nelfinavir (Viracept)
miconazole (Monistat) ritonavir (Norvir)
Immunosuppresants saquinavir (Invirase)
cyclosporine
● Determine the maximum dose of anesthesia. ● Vital signs—if BP ⬎ 100/70, then 0.1-mg clonidine
● Write the anesthesia order. given PO.
● ● IV is placed and the antibiotic given (1-g cefaxolin—
Patient takes lorazepam 0.5–1.0 mg, the night before
the surgery. give 1 slow push over 5-minutes)
● Patient puts on sterile panties with assistance.
● Room is set up (if this surgery is the first procedure of
the morning). ● Surgical scrub of all areas with patient in standing position.
● Patient (in standing position) is marked with a sterile
pen (Fig. 6.5).
● Patient is assisted into an appropriate position on the
■ Surgery Day sterile drape and sterile towels are draped to catch
● Patient takes 0.5–1.0-mg lorezepam 1 hour prior to the drainage and to cover the patient.
procedure. ● Local for incision sites are drawn up onto a sterile field.
● Urine pregnancy test on arrival at the office. ● Sterile infusion tubing is hooked up.
Patient Name________________________ Date_________________
Body Habitus: Thin Normal Mild obese Morbid obesity
______________________________________________________________________
Extent of suctionable adiposity: Mild Moderate Extensive
_______________________________________________________________________
Skin Quality – Elasticity: Poor Adequate Good
________________________________________________________________________
Cellulite: Mild Moderate Severe
________________________________________________________________________
Stria: Absent Present Extensive
________________________________________________________________________
Muscle Tone: Poor Average Good
________________________________________________________________________
Abdominal adipose ___________deep compartment
Neck adipose __________superficial compartment
Scars from previous surgery: None ___________________________________
Hernia: Absent Present
_______________________________________________________________________
Asymmetry: Absent Present
_______________________________________________________________________
FIGURE 6.1 Physical examination of
Notes:__________________________________________________________________
the patient preoperatively should
_______________________________________________________________________ include this information
■ Anesthesia
● Tumescent anesthesia is prepared by a licensed med-
ical personnel only (see tables/tips).
● Liter 0.9% sodium chloride solution
● 0.65-mg epinephrine, 1:1000
● 500-mg lidocaine (25 cc, 2% lidocaine) for a 0.05%
solution
● Bicarbonate (8.4%) in 1:10 dilution with lidocaine
(i.e., if 25 cc used, add 2.5-cc bicarbonate
FIGURE 6.2 The instrument tray for liposuction
● Tips on anesthesia
● Warm liter bag before adding medicine.
FIGURE 6.3 A. For most procedures 12–16-gauge

cannula are used. Sometimes. B. moderate cannula or
B C. aggressive cannula are needed
● Save the empty bottles used in mixture so that the

physician can double check the amount used.
● Use 0.1% solution in more sensitive areas such as
abdomen (particularly around the umbilicus) and
upper and inner thighs.
● Be consistent in the method of mixing—always use
the same percent of lidocaine.
● If during suctioning you run into a “hot spot,” i.e., an
area that has incomplete anesthesia, re-infuse with a
higher concentration of lidocaine (such as 0.1%).
Accessing the area from a different entry site can
also be helpful.
FIGURE 6.4 Aspiration pump ● Entrance sites are anesthetized with 1% lidocaine with
epinephrine and small stab incisions made.
● Proper positioning is very important for a good result in
all areas.
● Special considerations:
● Abdomen (see Fig. 6.6)
● approach from traditional lower entrance sites.
● approach from side entrance using three to four
sites both to
● cross tunnels in lower abdomen and
● form tunnels in upper abdomen.
● Have patients lie on their side to get to a mid-deep
fat compartment.
● Outer thigh (Fig. 6.7):
● Use positioning pillow to avoid over-suctioning
over trochanteric bulge.
● Use upper and lateral entrance sites.
FIGURE 6.5 The patient is marked with a sterile pen in

standing position
● Infusion rate is set between 2 and 3 on the Klein pump X

(correlates to 25–125 cc/min). X
● Infuse all areas.
● Infusion tips:
Take care not to stretch entrance sites.
Allow infusion to dissect ahead of advancing the X X
cannula.
Superficial and deep.
In face and neck, use a 25-gauge, 1.5-inch needle
to perform infusion.
Infusion endpoint—-Area is swollen, indurated, and
begins to blanch slightly beyond the edges of the
marked area.
■ Suction Procedure
● For best aspirate quality (high fat, low fluid, least blood
tinged), allow the anesthesia to sit for 15 minutes after
initial infusion before suctioning.
● When suctioning multiple areas, return to first infusion
site to suction. FIGURE 6.6 Abdominal liposuction
X
X
FIGURE 6.8 Liposuction of the inner thigh

X
● As an area becomes flaccid, have an assistant

place countertraction on the skin to improve case
of fat removal.
● Endpoint:
● Tunnels are empty, little fat left in aspirate, mostly
blood tinged fluid.
● Pull up on cannula toward dermis (with suction
off) to look for residual fat pockets.
● Pinch suctioned areas between thumb and fore-
FIGURE 6.7 Liposuction of the outer thigh finger (Fig. 6.10) to feel a thinned adipose layer (in
comparison to what was felt presuctioning).
● Inner thigh (see Fig. 6.8): POSTOPERATIVE CARE

● Use positioning pillow and high-step position. ● Patient showers—hand towel is given to the patient
● Finish in frog leg position to check anterior feath- and is shown how to compress areas to drain some of
ering only. the residual fluid out of the entrance sites.
● ● Absorbent pads placed over incision sites that may
Arms (Fig. 6.9):
need to be changed several times in the first 24 hours.
● Lateral position.
● Compression garment—firm but not so much that it
● Check Klein “bent arm position.”
restricts normal movement; the garment is to be used
● Fibrous areas: for 1 week.
● Start with a thin, aggressive tip cannula (such as a ● Intermittent application of ice in the first 24 hours.
16-gauge Capistrano) to break up the area.
● Drainage is copious at first, but stops usually by noon
● A powered liposuction machine is good for this too. of the following day.
● Follow with a larger diameter cannula having a ● Once drainage stops, each incision site should be cov-
less aggressive tip. ered with an ointment (such as Vaseline, Chese-
● Perform deep tunneling first. brough-Pond’s, Greenwich, CT) and a spot Band-Aid.
● Criss-cross the tunnels to minimize uneven retraction. ● Patient instruction sheet (Fig. 6.11) is given to the patient.
X
X
X
B
A FIGURE 6.9 A&B Liposuction of the arm
COMPLICATIONS AND FOLLOW UP

● Some patients gain weight after the procedure.
● A gain of 5–10 pounds can negate improvement in a
small abdomen.
● Always measure the preoperative weight and the
dimensions of the area.
● Vasovagal reaction is not uncommon.
Skin ● Most patients respond to the Trendeleburg position.
Superficial Fat ● IV access also allows the physician to use fluids.
Deep ● Poor healing of incision sites can be due to traumati-
Fat
zation during the procedure or noncompliance with
applying Band-Aid.
● Use at least two access sites for each area and do
not stretch the skin around the site excessively.
● Remind patients both with written instructions and a
FIGURE 6.10 After the procedure the pinch technique phone call, on the first postoperative day, to wear
should allow appreciation of a thinned adipose layer Band-Aid.
LIPOSUCTION SURGERY
POST-OP INSTRUCTIONS
1. Rest the day of surgery. Use ice on all areas for the first 24 hours. This will
help with swelling and discomfort. Use the ice twenty minutes out of every
hour that you are awake.
2. The day after surgery-up for meals, bathroom and light activity. Second day
begin normal activity without heavy lifting. You may shower.
3. Kotex pads should be worn under compression garment, and on top of

insertion sites while they are draining.
4. Spot bandage and Vaseline applied to insertion sites until seen 1 week post
liposuction.
5. Wear compression garment and binder (if given one) immediately post-op
until 24 hours AFTER noted time that drainage from insertion sites has
stopped. (Drainage usually ceases 12-24 hours after surgery). When
removing the compression garment you should do so in a seated position.
6. If wearing binder — wear for 24 hours.

Compression garment 24 hours first and second day, then 12 hours a day for
1 week.
7. You may shower, but please do not soak in the tub while the insertion sites
are open.
8. Be available by phone the next day.

FIGURE 6.11 Postsurgical patient
9. Follow up in 1 week. instructions
● Hyperpigmentation of incision sites is fairly common in SUGGESTED READING

all skin types.
1. Brown S, Cropfield O. The case for a lower dose pill.
● Warn the patients to look for it and treat it early with
Assessing the impact of estrogen dose. ORGYN
hydroquinone (Solage—mequinol 2%, tretinoin .1%)
1995;(2):36–39.
● Guidelines for touch-ups 2. Peverill RE. Hormone therapy and venous throm-
● Minor irregularities even out over time; do not do boembolism. Best Pract Res Clin Endrocrinol Metab
touch-ups before 1 year (or at least 6 months) after 2003;17(1)149–164.
each procedure. 3. Lidegaard O, Edstrom B, Kreiner S. Oral contracep-
● Do not touch up a patient-perceived irregularity that tives and venous thromboembolism: A five-year
you cannot appreciate clinically. national case-control study. Contraception 2002;
65(3):187–196.
● Some asymmetry may be due to some bony struc-
ture that was not evident before the fat was removed
(or was evident but not due to the fat).
CHAPTER 7
0 Fat Transfer
Naomi Lawrence, MD ● Recent large weight loss
● Very low calorie diet (VLCD)
KEY POINTS FOR SUCCESS ● The following may necessitate medical clearance:
● Diabetes
● Prepare the patient for a process of improvement. With
● Cardiac disease
current techniques, only 30% of the graft survives in
most patients. At least three transfers are required for ● Hypertension
full augmentation. ● Chronic disease
● Follow proper technique of laying small pearls of fat in ● Liver disease
multiple tunnels. ● Immunosuppression
● Have three transfer sessions. ● Patient at risk for thromboembolism
● Fat frozen at ⫺20⬚C has been shown to be not viable.
Do all transfers with fresh fat until better techniques
are developed for cryopreservation. PATIENT SELECTION
● The future of fat transfer may be in transfer of adipose
● Patient should be 30–60 years old with moderate
stem cells, which are small and more resilient than
mature adipocytes. (rather than severe) atrophy.
● Atrophy of the temples, lateral jawline, malar and buc-
● These cells can be expended and differentiated in
culture. cal cheek, premarionette, sulcus on chin, and pre-
maxillary upper lip.
● Later on these may be transferred and induced to dif-
● Focal area of fat atrophy on the body (better success if
ferentiate post-transfer. These cells are also used as
adipose filler in patients with inadequate donor area. within scar tissue).
INDICATIONS PREOPERATIVE PLANNING

● Facial lipoatrophy ● Preoperative labs
● SMA20 (general chemistry profile)
CONTRAINDICATIONS ● CBC with differential and platelets—complete blood
count including platelet count and cell differential
● Absolute:
● PT/PTT (protime/prothrombin time)
● Hematologic abnormalities that cannot be corrected
● Hepatitis screening profile
● Abdominal hernia
● HIV screen
● Anticoagulant medication
● Urine pregnancy test (morning of the surgery day)
● Pregnancy
● Pictures—oblique view is important to show depth of
● True allergy to lidocaine (very rare)
atrophy.
● Body dysmorphic disorder
● Stop all medications that interfere with platelet function
● Consider additional discussion or a waiting period in 2 weeks prior to surgery and restart 1 week after pro-
case of: cedure (see Tables 6-1 and 6-2).
● Weight cycling ● These medications include nonsteroidal anti-inflam-
● Unrealistic expectations matory agents, aspirin, and vitamin E.
● Patient should stop smoking 2 days prior to surgery,
through 1 week following the procedure.
● Duricef: 500 mg, on the evening before the procedure
and continued twice daily for 1 week after procedure.
● Acyclovir: 500 mg, on the morning of the procedure
then twice daily for 1 week.
● Lorazepam: 0.5–1 mg, 1 hour before the procedure.
● Take history for drugs interfering with lidocaine metab-
olism (see Table 6-3).
● Liposuction is usually limited to one or two areas.
● A single drug interfering with lidocaine metabolism
would not have to be discontinued.
● In a patient on multiple drugs interfering with lido-
caine metabolism, or a very thin patient, in whom it
is necessary to infuse multiple areas to obtain adi-
pose tissue, it may be necessary to work with the
patient’s internist to see which drugs could be sub-
stituted or discontinued.
INSTRUMENTS
● Infusion pump
● Infusion cannula/tubing
● 11 blade
● Coleman extraction cannula (an open aperture at tip)
FIGURE 7.1 Areas of facial atrophy are marked while
● Coleman (fat) infusion cannulas I and II the patient is seated
● Nokor needle
● Topical mucosal anesthetic
expose the fat to open air, which breaks the sterile

TECHNIQUE
technique.
● Prepare the face and mark the areas of atrophy with ● Once the fat and fluid have separated, the fluid is dis-
the patient in a sitting position (Fig. 7.1). carded and the fat is transferred into 1-cc luer lock
● Prepare and sterile drape the area to be liposuctioned. syringes through a three-way stopcock.
● ● Why are 1-cc syringes important?
Infuse liposuction areas with tumescent anesthesia
0.05–0.1% (see Chapter 6). ● They allow the surgeon to reinject the fat under less
● Suction gently with Coleman extractor on a 3-cc pressure than do syringes with a larger plunger, thus
syringe. minimizing the risk of introducing fat into vascula-
ture (which can have catastrophic complications
● Place syringes in a beaker (plunger up) on a sterile
such as blindness).
field to allow the fat to separate from the fluid.
● Smaller pearls are laid down, which theoretically
● At this point some surgeons centrifuge at 3300 rpm
improves vascularization and survival of the graft.
for 30 seconds to 1 minute to concentrate the fat.
● Recipient site preparation
The disadvantage of this technique is that in order
do this in a typical blood centrifuge, one must ● Pre ice while liposuction is being done.
Chapter 7: Fat Transfer | 71
● Topical mucosal anesthesia followed by infraorbital
and mental (supraorbital if forehead augmentation is
planned) blocks 1.5–2 cc, 2% lidocaine in each area.
● Small bleb of anesthesia below jawline of marionette
fold and at the corner of the mouth allows access to
the chin, the lip, and the cheek area.
TRANSPLANTATION TECHNIQUE
● Stab incision in predetermined entrance sites with
Nokor needle.
● Introduce infusion cannula as deeply as possible to
allow cannula movement.
● Currently, there is a debate in this field that whether fat
should be put in the subcutis or should be placed in
muscle (FAMI technique).
● In the face, muscles insert onto the under surface of
the skin so that in many areas the fat and the mus-
cle are in the same plane.
● Deep placement allows the fat proximity to the mus-
cle, which is more vascular than the fat.
● Small pearls of fat (0.1-mL aliquots) are laid down.
● In the withdrawal phase of cannula movement, multi-
ple tunnels at multiple levels are made in each area,
fanning out from each entrance site (Fig. 7.2).
FIGURE 7.2 During cannula withdrawal, multiple tun-
POSTOPERATIVE CARE nels are made in each area
● Ice for 10 minutes after the procedure, then the

patient can ice for 15 minutes per hour for the first
4–6 hours
● Band-Aids with petroleum jelly or an antibiotic oint-
ment on all entrance sites until healed (1 week).
● Light compression to the liposuctioned area. ● Fat survival is better when amounts are small (1–3
● Continue antibiotic and antiviral medication for 1 week. cc) in each area and small deposits (0.1 mL) are
implanted.
● Most common adverse effects are swelling and bruis-
COMPLICATIONS AND FOLLOW-UP
ing.
● Periorbital area is at greatest risk of developing visible ● With pre- and post-icing this is minimized but warn
clumps of adipose. each patient.
● Get experience in other areas before attempting this ● Fat survival is variable with augmentation, lasting for
area. more than 5 years in some patients and only a year in
● Resist temptation to over-correct or correct completely others. This is most likely due to the handling of graft
in one session. and preparation of the recipient bed.
SUGGESTED READING 3. June KR, Hanke WC, Senglemann RD, Seigel DM.
Surgery of the Skin. Procedural Dermatology. Elsevier
1. Wheeland RG. Cutaneous Surgery, 1st edn. WB Mosby, Philadelphia, PA, 2005.
Saunders, Philadelphia, PA, 1994.
2. Shan RB, Swanson NA. Local flaps in facial recon-
struction, 1st edn. Mosby, St Louis, MO, 1995.
CHAPTER 8
0 Hair Transplantation
Neil Sadick, MD CHOOSING THE RIGHT CANDIDATE
● Age
● Degree of baldness
● Choose the appropriate surgical candidate, i.e., appro- ● Hair shaft diameter
priate donor site density. ● Hair color
● Perform the procedure utilizing “follicular unit” grafting ● Contrast characteristics of skin and hair
in order to present natural hair grouping.
● Donor hair density
● Dissection of the donor strip should be performed
● Patient expectations
under stereoscopic control.
● Perform hair transplantation with an integrated team
including a surgeon, a cosmetic coordinator, and well- PHYSICAL EXAMINATION
trained technicians. ● Key factors
● Look at other family members—the patient’s own
hair loss pattern may mimic in pattern as well as in
INDICATIONS FOR HAIR chronological course, the pattern and rapidity of
TRANSPLANTATION other family members.
● Androgenetic alopecia—male or female. ● Personal history—if hair loss began at a young age it
● Usually hair transplantation is not performed until the most likely will be progressive.
patient is at least 25 years of age. ● Evaluate the degree of hair loss to measure the
● Senescent alopecia—women. degrees of miniaturization on both the donor and the
recipient areas. This can be performed with a hair-
● Scarring alopecia (inactive disease for at least 6 months
magnifying device called a densitometer (Fig. 8.1).
duration), i.e., discoid lupus, lichen planopilaris, burns,
Assessing the degree of miniaturization from various
etc.
areas of the scalp (normally no more than 20%) will
● Congenital defects, i.e., alopecia triangularis. allow predictor insight as to the progression or hair
loss in various anatomic areas as well as the stability
of the donor area, which translates into long-term
CONTRAINDICATIONS FOR HAIR viability of the transplanted hair.
TRANSPLANTATION
● Severe coagulopathy PREOPERATIVE GOALS
● Platelet inhibitors—blood thinners (Coumadin, ● Creation of a natural hairline
NSAIDS, and aspirin), which the patient is unable to ● The most natural hairlines are those that are not
discontinue exact but have a natural feathered appearance. It
● Herbal preparations should be high enough when planned to give a nat-
● Active HIV or hepatitis B (relative) ural tethered appearance of a mature individual so
that it can be functional for the patient’s entire life-
● Poor donor area
time. The general rule is to place the hairline 3–4 fin-
● Unrealistic expectations gerbreadths above the glabellar notch. Discuss the
● Active inflammatory scarring alopecia location with the patient preoperatively.
FIGURE 8.1 Portable hair densitometer may be used to calibrate donor hair density. Large caliber hair shafts
greater than 70 microns yield most optimal results
● Area to be transplanted ● Implantation device for follicular unit based micro- and
● The area to be transplanted should be discussed minigrafts.
with the patient—front, vertex, and crown sites are ● Stereoscopic microscopic dissecting device.
specified. If a limited number of grafts are available,
the transplant surgeon may choose not to treat the
crown area.
MEDICATION
● ● All medications that increase bleeding time should be
Number of sessions
●
stopped two weeks prior to the surgery.
Using follicular unit technology, most patients can
achieve natural coverage in one or two treatment ● NSAIDS
sessions. The standard has been to transplant 30
follicular units/cm2. The recipient area is usually
about 80 cm2.
● Optimizing donor site
● Maximal number of grafts.
● A small linear donor site is the optimal goal in this
region. In order to maximize the number of grafts
as well as to improve cosmesis, it is often helpful
to excise the previous donor site scar as part of
the donor area if a second procedure becomes
necessary.
INSTRUMENTATION (Fig. 8.2)

Instrumentation utilized for hair transplantation is listed
in Table 8.1.
● Appropriate blade device for excision of the donor FIGURE 8.2 Instrumentation tray for performing hair
area. transplantation
Chapter 8: Hair Transplantation | 75
TABLE 8.1 ■
Instrumentation Used in Hair PROCEDURE TECHNIQUES
Transplantation ● Harvesting hair from the donor area.
● 2 Addson forceps with teeth ● Taken from the occipital scalp where donor terminal
● 1 #3 knife handler hair grows for an individual’s lifetime.
● 4 Kelly clamps curved ● Trimming of area with a PANASONIC trimmer.
● 1 Needle holder ● Tumescent donor site formula, “ring block”: approx-
● 1 Curved 5⬙ sharp scissor imately 15 cc of 0.5% lidocaine with 1:200,000 epi-
● 1 Suture scissor nephrine utilizing a 3-cc syringe.
● Followed by instillation of 20–30-cc saline solution to
● 1 Multiblade knife handle
create a tissue turgor so as to minimize the risk of
● 2 Addson forceps smooth
follicular dissection.
● 2 Curved jeweler’s forceps ● Excision of the donor site may be through a long sin-
● 1 metal comb gle elliptical (20 cm ⫻ 7 mm) strip with average
● 1 Elli’s #4 multiblade knife handle donor density (over 1.5 mm) or
● 2 Handle for 91 and 61 blades through a multiblade knife to create multiple thinner
● 1 Dissecting microscope strips. This will yield over 1000 follicular units.
● Factors affecting the amount of donor area excised
● Klein tumescent anesthesia inserter
● Prone-Prop-Pillow Donor tissue laxity
● #15 Personna surgical blade Donor tissue density
Previous scars
● Donor strip is usually excised in a supine position.
● ● An angle to 110–120° will minimize graft dissection
ASA
(Fig. 8.3).
● Warfarin
● With a #10 BP blade, the depth of strip dissection is
● Clopidogrel bisulfate (Plavix)
usually 1–2 mm. The ends of the strip are tapered at
● Herbal preparations Bristol-Myers Squibb the ends with a #11 BP blade.
● Allergies: antibiotics, lidocaine, and epinephrine ● Hemostasis is obtained with electrocautery or more
rarely with ligation of sutures.
PREOPERATIVE BLOOD WORK-UP
● CBC, chemistry profile, PT, PTT (INR), platelet count,
HIV, and hepatitis profile.
PREOPERATIVE ANESTHESIA
● Preanesthesia
● Ativan 1 mg p.o.
● Percocet (7.5-mg Hydrocodone) 500-mg Aceta-
minophen
● Other preanesthetic agents such as nitrous oxide
have been employed in this setting.
● Local ring blocks in the donor and recipient areas FIGURE 8.3 Double-bladed knife allows uniform width
have been employed with lidocaine 1% with epi- of donor site dissection and standardization of depth of
nephrine 1:100,000. dissection
● Donor area is closed using a buried interlocking suture PREPARING THE GRAFTS
of 4–0 Vicryl followed by a surface running 4–0
Monocrylic suture. ● After examination of the donor strip, it is placed in a
● Sutures are removed in 10–14 days leaving a small lin- Petri dish containing chilled isotonic saline.
ear 1- to 2-mm scar. ● A team of trained technicians and the physician super-
vise dissecting the strip into slivers of tissue approxi-
mately 2 mm in width and subsequently these slivers
are dissected into single, double, or triple haired follic-
PEARLS AND PITFALLS IN DONOR
ular unit grafts (Fig. 8.4).
DISSECTION
● A magnifying microscope is used for this purpose.
● Appropriate planning in size of donor site. ● A #10 Personna razor blade in conjunction with a fine
● Prone pillow to assure the patient comfort and relative jeweler’s forceps is used.
immobility. ● Use a transilluminating light source.
● Tumescent anesthesia to produce adequate tissue ● Follicular units should be kept in chilled saline in order
turgor. to retain moisture prior to implantation.
● Double-bladed knife to ensure uniformity of width and
depth of the donor ellipse. PEARLS AND PITFALLS OF GRAFT
● Buried interlocking suturing to decrease wound-healing PREPARATION
tension.
● Use a dissecting microscope with backlighting.
● Re-excision of previous donor scars to ensure a single
● Avoid transection of hair follicles when cutting strips.
scar after multiple hair transplantation sessions.
● Keep cut grafts in a moist cool environment.
● Examine donor site as the strip is being dissected to be
● Remove excess fat and fibrous tissue from the area
sure that a significant transection of follicles is not
occurring. surrounding the grafts.
● Keep the dissection angle at 110–120° in order to min-
imize transection.
PLANTING THE RECIPIENT AREA
● ● Keys:
At repeat procedures, the donor scar can be re-
excised, thus improving cosmetic appearance. ● Try to recapitulate the prebalding hair pattern.
A B C
FIGURE 8.4 Technique for graft dissection involves (A) slivering of tissue into 2 mm sections, (B) followed by
dissecting into follicular units, and then (C) followed by separation into single, double, and triple hair grafts
● A maximum of 40 grafts/cm2 should be implanted in
order to avoid excess packing and vasoocclusive
crushing of grafts.
● Anteriorly, plant with a sharp angle of 20°.
● Posteriorly, plant with greater angle of 20–45°.
● A 19-gauge needle may be used to make all single
hair insertion sites.
● Alternatively a 91-gauge Beaver blade may be used
to create slits for double and triple haired follicular
units (keep distance of 1–2 mm between slits in
order to prevent crushing).
● Jewelry forceps are best to assure meticulous graft
placement.
● Hairs in the grafts must be aligned at the appropri-
FIGURE 8.5 Proposed recipient hairline is usually ate angle and direction to create a snug fit into the
mapped 3–4 fingerbreadths above the mid glabellar recipient sites (Fig. 8.6).
notch with lateral tapering at the temporal fringes
PEARLS AND PITFALLS OF RECIPIENT

PLACEMENT
● Keep hair placement in its naturally growing direc-
● Meticulous technique of insertion markedly improves
tion.
graft survival.
● In the frontal scalp, try to maximize natural facial
● Plant with a back to front pattern to avoid displace-
framing.
ment of grafts, compression, and popping.
● The hairline should be created 3–4 fingerbreadths
● Create a mature frontal hairline with temporal blunting.
above the intraglabellar notch creating curved bell-
shaped hairline tapering at the lateral temporal ● Recreate a whorled pattern in the occipital region to
fringes (Fig. 8.5). recreate the natural pattern of hair growth.
● Recipient anesthesia is accomplished using a ring ● Use a feathered pattern in the anterior hairline to cre-
block with 2% lidocaine. ate a natural graded zone of hair density.
Forces displacing graft when needle is inserted behind the graft
Compression
forces
FIGURE 8.6 Implantation of follicular unit

Displacement force
Resistance grafts into slits is accomplished using a jew-
forces eler’s forceps
● A backward forward direction of graft insertion will help POSTOPERATIVE COURSE
minimize graft pop out.
● Pearls and Pitfalls
TREATMENT PLANS ● Provide adequate postoperative instructions (Table
8.2),
● Majority of patients with Norwood Class V–VI alopecia
● Four to seven days are average for crusts to
require three treatment sessions of approximately
3000 total follicular unit grafts. dissipate.
● In most cases no postoperative bandage is neces-
● Partial alopecia may be addressed with 1 or 2 sessions.
sary.
● Time required for this treatment: 5–6 hours.
● Shampooing may be begun gently within 24 hours.
● Alternatively, larger sessions (mega sessions) of
● Facial edema and forehead swelling, particularly in
1000–1500 grafts may be transplanted over the entire
scalp in a single session. the periorbital area, may begin 24–48 hours after the
procedure and last for 5–7 days.
● Time required: 6–10 hours.
This may be treated with ice packs, upright posi-
● Author’s personal approach
tioning (45°), sleeping on two pillows, or alterna-
● 600–900 grafts: to cover the anterior scalp. tively, a short course of prednisone 20–40 mg/day
● 500–800 grafts: to cover the midvertex scalp. for 3–5 days
● 400–500 grafts: to cover the occiput. ● Full exercise may be resumed in 1 week.
TABLE 8-2 ■ Post-op Hair Transplant Instructions

● Please follow instructions carefully. If you have any questions or concerns during your recovery please call
the office.
● You will receive products from us to be used during your recovery. These consist of treatment shampoo,
post-Biotin spray, and postsurgical gel.
● Keep taking the Propecia as prescribed before, and also keep using the Rogaine.
● You may take a light shower the day after the procedure. Do not get the area of the hair transplant under the
spray. You can PAT the shampoo we give you on the area of the transplant, and rinse by a very gentle spray or by
patting water over the area. DO NOT RUB AREA. This you have to do for 5 days until the grafts attach. After
5 days, you need to start washing the area more aggressively. After 7 days you should be washing your hair
normally. All the scabs should be off the graft area in 10–14 days. After the light shower, you may pat hydrogen
peroxide over the area to cleanse area. Then you may apply the post-Biotin spray and postsurgical gel, very
gently. Be very careful when brushing or combing to avoid the transplant area for the first 5–7 days. This is to
prevent the comb from catching on the grafts/scabs.
● You will have scabs on the area of the transplant. Do not pick at them. They will fall off when you start washing
your hair more aggressively. All scabs should be off your head by day 14. You may pat hydrogen peroxide on the
area twice a day to help cleanse the area and to decrease the scabbing. Also, during the first month there will be
particles that fall from the graft area. This is normal. It does not mean that the grafts are falling out.
● You may resume normal daily activity after the procedure. Do not do vigorous physical activity for one week after
the procedure.
● You will be put on an antibiotic the day you come in to get the hair transplant. You may also need an oral steroid
to help with inflammation a week after the treatment.
● After the procedure is finished you may feel tight in the area of the donor site. You may take acetaminophen for
any discomfort. Refrain from aspirin and ibuprofen.
● You should not expect to see hair growth until 6–8 months after the treatment is complete. This can take up to 18
months to see full growth. You may need additional treatments after the first hair transplantation.
● The author places all males on Finasteride 1 mg/day ● Usually resolves in 6–12 months; most common in
routinely prior and 5% Minoxidil solution twice a day donor occiput area.
in order to decrease posttransplantation telogen ● Telogen effluvium
effluvium and shorten the growth course of trans-
● More common in females and in area where trans-
planted hair.
plants are performed into existing areas of residual hair.
● Arteriovenous fistula formation
PEARLS AND PITFALLS ● May last for 6–12 months
● ● Should be explained during the initial consultation
Provide adequate postoperative instructions (Table
8.2). ● Topical Minoxidil solution 5% applied b.i.d. may
● Cooper peptide dressings such as Graftcyte may be minimize this sequelae
used to promote wound healing and angiogenesis.
● Short courses of prednisone 20–40 mg/day to
decrease postoperative swelling. CONCLUSIONS
● Wait for 6–12 months between transplant sessions in Hair transplantation surgery has evolved with increased
order to assess results and to allow hair to begin to grow. patient satisfaction related to improved cosmetic tech-
niques. Like all other cosmetic surgical procedures, best
results are achieved with careful surgical planning, fas-
COMPLICATIONS tidious technique, and carefully outlined postoperative
Complications following hair transplantation are relatively surgical care.
rare and may include the following:
● Nausea and vomiting caused by medications
● Postoperative bleeding (less than 5%) SUGGESTED READING
● Infection (less than 5%) 1. Tan E, Shapiro J. Hair transplantation update. Cos
● Swelling (5%) Dermatol 2002;13:39–41.
2. Stough DB, Whitworth L, Seage DJ. Hair restoration,
● Temporary headache
In: Techniques in Dermatologic Surgery, Chapter 27,
● Temporary numbness of the scalp 2003, Mosby, St. Louis, pp. 217–232.
● Scarring around the grafts (less than 1%) 3. Bernstein RM, Rossna WR, Szanlanos KIW, Halpern
● Poor growth of grafts AJ. Follicular transplantation. Int J Aesthet Restor
Surg 1995;3:119–132.
● X-factor—vasoconstriction, poor host growth factor,
4. Schiell RC. Modern hair restoration surgery. Clin Der-
and poor operative technique have all been hypoth-
matol 2001;19:179–187.
esized but none proven.
5. Auram MZ. Hair transplantation for men and women.
● Syncope Cos Dermatol 2002;15:23–27.
● Folliculitis 6. Bernstein RM. Rossman WR. The aesthetics of follic-
● Keloid formation ular transplantation. Dermatol Surg 1997;23:
785–789.
● May be secondary to genetic healing tendencies or
7. Eisenberg EL. Avoiding problems in hair transplanta-
increased wound tension secondary to taking too
tion. Cos Dermatol 2003;16:19–23.
large of a donor strip.
8. Bernstein RM, Rossman WR. Follicular transplanta-
● Neuroma tion: Patient evaluation and surgical planning. Derma-
● Paresthesias tol Surg 1997;23:711–784.
Evaluation and Treatment of Varicose
CHAPTER 9
and Telangiectatic Leg Veins
Neil Sadick, MD HISTORY
● Family history
KEY POINTS FOR SUCCESS ● History of venous disease, recurrent throm-
● Correct diagnosis of proximal point of reflux. bophlebitis or pulmonary emboli.
● Mastering duplex ultrasound testing. ● Medical history
● Decision of which modality (endovascular radiofre- ● Same as family history plus history of bruising,
quency or laser technology, ambulatory phlebectomy, bleeding.
sclerotherapy, or external laser) is most effective for the ● Ask if veins are symptomatic, i.e. pain, edema, tired-
treatment of a vessel of given diameter. ness.
● Fastidious technique. ● Surgery
● Choosing the appropriate minimal sclerosant concen- ● Any history of bleeding after surgery.
tration (MSC) for a given diameter vessel.
● Any history of previous ligation or stripping proce-
● Choosing the right grade and duration of compression. dures.
● Allergies/medicine sensitivity: history of allergies to a
given sclerosing agent, i.e., glycerine, sodium
INDICATIONS sotradecol sulfate, or polidocanol should be elicited.
● Functional saphenofemoral/saphenopopliteal incom- ● Medications that prolong bleeding time or interfere
petence (pain, ulcers, stasis dermatitis, lipoder- with platelet function, e.g., Warfarin, clopidogrel bisul-
matosclerosis) fate (Plavix, Bristol-Myers), aspirin, nonsteroidals, are
● Truncal varicosities (symptomatic or cosmetic) contraindicated.
● Cosmetic spider veins or reticular veins (lower extrem- ● Hormones: high-dose estrogen therapy may increase
ities) the risk of thrombotic phenomena or telangiectatic
● Periorbital veins matting after any vein procedure.
● Hand veins
PHYSICAL EXAMINATION
● Lower extremity vessels may be classified according to
CONTRAINDICATIONS size, degree of oxygenated hemoglobin, and connec-
● Absolute tion to the greater or lesser saphenous vein (Table 9.1)
● Look for signs of chronic venous insufficiency, i.e., sta-
● Pregnancy
sis dermatitis, ulcers, hyperpigmentation, lipoder-
● Hypercoagulable states (protein S or C deficiency,
matosclerosis.
antiphospholipid antibody syndrome)
● Recurrent thrombophlebitis or deep venous throm-
INDICATIONS FOR VASCULAR
bosis
TESTING (TABLE 9.2)
● Relative
● Symptomatic veins
● On anticoagulation therapy, ASA, NSAIDS, Plavix,
herbal preparations ● Bulging varicosities: usually greater than 4 mm
TABLE 9.1 ■ Vessel Classification
Type Vessel Class Diameter Color
I Telangiectasis “spider veins” 0.1–0.5 mm Red
II Venulectasia 0.5–2.0 mm Violaceous, cyanotic
III Reticular veins 2–4 mm Cyanotic to blue
IV Nonsaphenous varicose 3–8 mm Blue to blue-green
veins (usually related to
incompetent perforators)
V Saphenous varicose veins 4–8 mm Blue to blue-green
● Duplex examination (Fig. 9. 1) Preoperative set-up (Table 9.3)

● Duplex evaluation of varicose veins depends upon Procedure
the use of a 7.5-mHz gray scale, high-resolution B- ● A 5 Fr catheter is placed over a 0.035-inch diam-
mode scanner, and a 5-mHz Doppler probe. eter J guide wire with intravascular placement
● Suggested manufacturers: documented by Duplex.
Biosound Esoate, 8000 Castleway Drive, Indianapo- ● 400–750-nm bore tip filter is then introduced
lis, IN 46250; model: Mylab 25. through the catheter.
Terason, 77 Terrace Hall Avenue, Burlington, MA ● Vein is subsequently reduced in diameter by
01803; model: Terason 2000. administration of perivenous tumescent anes-
thesia (lidocaine .05% with or without epineph-
rine).
CLINICAL APPROACH TO TREATMENT
● 12–14 W of energy is delivered in a continuous
OF LOWER EXTREMITY VEINS
mode with a pullback rate of 10–20 cm/minute.
● Procedures: Greater/lesser saphenous veins
● Postoperative care
● Options: Endovascular technologies (performed under
● Patients are subsequently placed in a compression
Duplex guidance)
bandage overnight.
● Laser (815, 830, 870, 1320 nm)
● Subsequently then wear Class II 20–30 mm Hg
● Radiofrequency (VNUS procedure) compression for 2 weeks following the procedure.
● Foam sclerotherapy
● Endovascular laser
● EVLT (815-nm laser; Diomed, Andover, MA) (Fig.
9.2) RADIOFREQUENCY CLOSURE
● Procedure (Table 9.4)
● The available catheter sizes 8 Fr/5 Fr allow treatment
of vessels 2–12 mm in diameter
TABLE 9.2 ■ Indications for Vascular Testing
● Catheter insertion is carried out over a guide wire
● Symptoms (pain, fatigue)
followed by similar perivenous tumescent anes-
● Clinical signs of venous insufficiency, stasis dermatitis, thesia.
ulcers, lipodermatosclerosis
● A thermal sensor allows delivery of temperatures of
● Bridging varicosities 80–90ºC (average 85º) heating the targeted greater
● Veins ⬎4 mm in diameter GSV
Chapter 9: Evaluation and Treatment of Varicose and Telangiectatic Leg Veins | 83
LASER
FIGURE 9.2 EVLT: endovascular laser involves inser-

tion of a diode laser fiber 815 nm into the greater
saphenous vein (14–15-W energy)
● Under Duplex guidance a pullback rate of 2–3

cm/minute is carried out (Fig. 9.3)
● Postoperative care: Same as for EVLT
DUPLEX-GUIDED ENDOVASCULAR
SCLEROSING TECHNIQUE
● Alternatively, duplex-guided sclerotherapy with sodium
tetradecyl sulfate (Sotradecol) may be used in this
setting
Table 9.5 presents a comparison of the three endovas-
cular technologies.
TRUNCAL VEINS
Treatment options: Ambulatory phlebectomy and foam
sclerotherapy.
TABLE 9.3 ■ EVLT™ Kit Components

● 600 ␮m EVLT fiber
● 19 gauge entry needle

● 6 Fg 45 cm introducer sheath
● 0.035⬙ J tip guide wire

FIGURE 9.1 Color duplex evaluation of the greater saphe-
● 90 cm ⫻ 90 cm plain drape
nous vein showing reflux manifested by backward flow
TABLE 9.4 ■ VNUS Closure System Components
● VNUS RF Generator
● VNUS Closure Catheter
● CL-504 (5 F)
● CL0–812 (8 F)
● Instrument Cable (not shown)
● Footswitch (optional not shown)
■ Ambulatory Phlebectomy
● Must initially rule out greater or lesser saphenous vein
incompetence or may be done in conjunction with one
of the endovascular techniques. FIGURE 9.3 Radiofrequency closure of the greater
● May also be used to treat periorbital and hand veins. saphenous vein involves insertion of a catheter to pro-
●
duce heat generation of approximately 85⬚C, causing
Preoperative marking (Fig. 9. 4).
thermal absorption of the targeted vessel
● Should be made in the standing position and con-
firmed in the supine position.
● Bulging veins (area of proposed hooking) may be
marked with a surgical pen or permanent marker
(Acculine or vis-à-vis (Sanford Company)). Produces temporary swelling and firmness of soft tis-
● A transillumination device (Vein-Lite, Atlanta, GA) sue aiding vein removal by pressing the vein next to
with the patient in a supine position may document the skin.
vein shifting from the original standing marking. Tourniquet effect on vessels reduces blood loss and
● Anesthesia (Table 9.6) bruising.
● Tumescent anesthesia is given to tumesce and pro- Allows excellent patient comfort for a greater period
duce local anesthesia. Peau d’orange firmness in the of time.
treatment limb is the endpoint of therapy. ● Operative set-up (Table 9.7): Multiple types of hooks
Eliminates multiple needle sticks. are available; however, the Muller hook is an inexpen-
Allows rapid anesthesia of extensive segments of dis- sive effective tool (Fig. 9.5).
eased vein. ● Intraoperative procedure
TABLE 9.5 ■ Endovascular Treatment Options for GSV Incompetence

Approximate
Cost of Time of Clinical Post-operative
Materials Procedure Efficiency Discomfort Complications
Duplex Guided 20–30 30 minutes To be Minimal Risk of arterial injection
Sclerotherapy determined and subsequent necrosis
Endovascular 200 45 minutes ⬎90% Delayed pain at Bruising
Laser 3–5 days
Radiofrequency 750 1 hour ⬎90% Minimal Thermal burns (minimized
Closure 15 minutes with tumescent anesthesia)
TABLE 9.6 ■ Ambulatory Phlebectomy
Tumescent Anesthesia Formula
Tumescent Anesthesia Solution .05%
05% ⫽ 500 mg total
Lidocaine
1000 cc Normal saline .9%
50 cc Lidocaine 1%
1 cc Epinephrine 1/1000
12.5 cc Bicarbonate 8.4%
1 cc Triamcinolone 10 mg/cc
acetonide (optional)
Total 500 mg Lidocaine ⫽ .05%
● Traction and a gentle kneading traction maneuver

allows removal of the longer vein segments (Fig.
9.6).
● The diseased vein segment usually separates from
underlying normal vein segment (Fig. 9.7).
● Excellent functional and cosmetic results.
● Apply absorbent pads and an ace bandage for 24
hours immediately postoperation.
● Then apply Class II, 30–40 mm Hg graduated sup-
port hose worn daily for 3 weeks following waking
hours.
● Continue ambulating immediately postoperation.
TABLE 9.7 ■ Setup and Instrumentation for

Ambulatory Phlebectomy
FIGURE 9.4 Preoperative marking of the planned
avulsed varicosities is carried out with the patient in the #2, 3, 4 Muler hooks
standing position Knife handle
11 blade
16 gauge No-Kor needle
Straight Iris scissor
4-mosquito clamps
● Microincisions are made vertically over marked Towel clip – to wrap foot with towel
areas of bulging with an 11 BP blade or 16-gauge Tumescent infusion tubing
No-Kor needle. 1 or 3 mm infusion cannula
● Vessel is separated from underlying fascia by means Klein pump
of an iris scissor or combined tissue hook dissection. 4 ⫻ 4 opaque sterile sponges
● Vein is hooked and subsequently exteriorized. Maxi pads
●
4⬙ Medi-rip
It is then grasped with a mosquito clamp.
traction technique traction technique
FIGURE 9.6 Traction techniques for ambulatory phle-

bectomy may involve a pulling, pushing, or whirling
technique
● Complications: Complications of this procedure are

FIGURE 9.5 Ambulatory phlebectomy operative set up usually minor and rare; however, these should be rec-
includes Nokor needles, 11⬘⬘ blades, mosquito clamp, ognized and treated appropriately (Table 9.8).
tumescent anesthesia instillation cannula, and set of
ambulatory phlebectomy hooks
■ Foam Sclerotherapy
● May be used as an alternative for treatment of non-
saphenous truncal veins.
A B
FIGURE 9.7 Removal of an entire segment of a vari-

cosity will lead to improved clinical results, decreased
recurrence rate, and a lesser incidence of hyperpig-
C mentation
TABLE 9.8 ■ Complications of Ambulatory
Phlebectomy
Vascular complications:
● Bleeding, seroma
● Superficial thrombophlebitis
● Deep venous thrombosis
● Pulmonary embolism
● Telangiectasias
● Matting
Lymphatic complications:
● Lymphorrhea
● Persisting edema
● Lymphocele
Neurological complications: FIGURE 9.8 Foam sclerotherapy involves the produc-

● Nerve damage around the ankle tion of a microfoam emulsion, which improves endothe-
● Temporary hypesthesia lial-sclerosant interaction yielding more effective results
● Dysesthesia (temporary/permanent) in treatment of large diameter varicose veins
● Traumatic neuroma
Cutaneous complications:
● Bullous detachment or blister
● Pigmentation, transitory or permanent TELANGIECTASIA/RETICULAR VEINS
● Eczema ● Materials on the sclerotherapy tray include
● Keloid formation
● cotton balls soaked with 70% isopropyl alcohol;
● Dimpling
● protective glasses;
● Skin necrosis
● Infection dermatitis ● 3-cc disposable syringes;

● Induration hypo-hyperpigmentation of microincision ● 30-gauge disposable transparent hub needles
● Tattooing
(1/2⬙ length);
Compression bandage complications: ● 32-gauge needles or 33-gauge autoclavable dispos-
● Swelling
able;
● Blisters
● clear light source preferably with a magnifying
● Skin necrosis
source.
● Ischemia
● Basic principles of treatment
● Always treat proximal sites of reflux first.
● Sotradecol of 0.2–1.0% is most commonly used. ● Larger and protruding vessels are treated before
● Hypertonic saline (18% to 30%) also widely used. smaller veins.
● ● An entire varicosity is treated at a given treatment
May at present be prepared manually utilizing a maxi-
mum of 4 parts air with 1 part sclerosant to produce a session.
microbubble emulsion (Fig. 9-8). ● The lowest effective concentration of sclerosant
● Foam agents are more potent and thus have a greater should be used (MSC).
effect down stream from initial injection sites. ● Adequate compression should be applied immedi-
● Caution: Use with care when treating small telangiec- ately after therapy.
tasia as this potent detergent sclerosing effect may be ● Ambulation should begin immediately after treat-
associated with an increased incidence of postscle- ment.
rotherapy hyperpigmentation. ● Choice of sclerosing agent
TABLE 9.9 ■ Suggested Sclerosant/Concentrations for Treatment of Telangiectasias/Reticular Veins
VESSEL TYPE SCLEROSANT CONCENTRATION
Telangiectasias ⬍1 mm Hypertonic saline 11.7%
Sodium tetradecol sulfate 0.2%
Polidocanol (Aethoxysklerol) 0.25%
Chromated glycerin ⬎ 2%
Venulectasia 1–2 mm Sodium tetradecol sulfate 0.25%
Hypertonic saline 23.4%
Hypertonic glucose/saline 200 mg/mL dextrose
100 mg/mL sodium chloride
100 mg/mL propylene glycol
Polidocanol (Aethoxysklerol) 8 mg/mL phenoxyalcohol 0.5%
Reticular veins ⬎ 2 mm Hypertonic saline 1:1 23.4%
Hypertonic glucose/saline
(Sclerodex)
Sodium tetradecyl sulfate 0.25–0.4%
(Sotradecol)
Polidocanol (Aethoxysklerol) 0.5–1.0%
● Only sodium tetradecyl sulfate and sodium morrhu- ● Brisk cannulation of veins causes minimal vascular
ate are FDA approved. trauma and thus less chance for extravasation of
● Use the MSC agent for a given vessel diameter blood.
(Table 9.9). ● Use low injection pressure.
● If a poor response to a given sclerosant occurs, the ● Use a small amount of sclerosant at each injection
sclerotherapist may site (0.1–0.4 cc).
● increase the concentration of sclerosant;
● switch to another sclerosant;
● reexamine the patient under Duplex guidance in
order to find a possible source of occult reflux.
● Injection technique
● Two hand traction keeps the skin tight to ensure pre-
cise vessel cannulation (Fig. 9.9).
● Large vessels are injected before small ones, i.e.,
injection of reticular veins feeding smaller telangiec-
tasias or venules may eradicate larger surface areas
of telangiectasias with lesser numbers of injections
(Fig. 9.10).
● Areas of vascular arborization should be treated
before single vessels are cannulated (Fig. 9.11).
● Preswiping of treatment areas with alcohol, transillu-
mination devices such as the Venoscope or polariza- FIGURE 9.9 Two-hand traction and brisk cannulation
tion devices, i.e., Syris Light (Syris Gray ME) are all with injections of small amounts of sclerosant 0.1–0.3
aids that help in visualization of vessels and thus cc at a given injection site will improve clinical results
improved results. and minimize complication profiles in sclerotherapy
● 7–14-day waking hour compression is recom-
mended following sclerotherapy.
● Following injection of bulging varicose veins the area
is wrapped with a Class 1 stocking (10–20 mm Hg
compression).
● For telangiectasias, fashion hose (15–18 mm Hg).
COMPLICATIONS
Fastidious technique and the choice of appropriate scle-
rosant for a given vessel diameter are the major corner-
stones of limiting the incidence of untoward sequelae.
FIGURE 9.10 The sequence of sclerotherapy should CONCLUSION

always be treatment of larger vessels (areas of higher
reflux) such as reticular veins prior to small telangiecta- A number of new technologies and therapeutic
sia and venulectasia approaches allow the dermasurgeon to treat both med-
ical and cosmetic venous problems.
● Injections are carried out at approximately 3-cm

intervals. SUGGESTED READING
● Treatment sessions are carried out at 4–6 week 1. Weiss RA, Weiss MA. Controlled radiofrequency
intervals to allow time to evaluate results of prior endovenous occlusion using a unique radiofre-
treatment. quency catheter under duplex guidance to eliminate
● Most patients require between 2 and 5 treatment saphenous varicose vein reflux: A 2-year follow-up.
sessions. Dermatol Surg 2002;28:38–42.
● Compression considerations 2. Goldman MP. Closure of the greater saphenous vein
with endoluminal radiofrequency thermal heating of
the vein wall in combination with ambulatory phle-
bectomy: Preliminary 6-month follow-up. Dermatol
Surg 2000;26:452–456.
3. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD.
Endovenous laser treatment of the incompetent
greater saphenous vein. J Vasc Interv Radiol 2001;
12:1167–1171.
4. Navarro L, Min RJ, Boné C. Endovenous Laser: A new
minimally invasive method of treatment for varicose
veins—preliminary observations using an 810-nm
diode laser. Dermatol Surg 2001;27:117–122.
5. Sadick NS. Controlled radiofrequency mediated
endovenous shrinkage and occlusion of the greater
saphenous vein. Cosmet Dermatol 2001;18:14–16.
6. Goldman MP, Weiss RA. Transillumination mapping
prior to ambulatory phlebectomy. Dermatol Surg
FIGURE 9.11 Treatment of arborizing foci as shown 1998;24:447–450.
with single feeding points will minimize the number of 7. Smith SR, Goldman MP. Tumescent anesthesia in
injections necessary to treat a given surface area of ambulatory phlebectomy. Dermatol Surg 1998;24:
vessels 453–456.
8. Sadick NS. Multifocal pull-through endovascular 13. Sadick NS, Li C. Small vein sclerotherapy. Dermatol
cannulation technique of ambulatory phlebectomy. Clin 2001;19:475–481.
Dermatol Surg 2002;28:32–37. 14. Weiss RA, Dover JS. Leg vein management: Scle-
9. Garde C. Ambulatory phlebectomy. Dermatol Surg rotherapy, ambulatory phlebectomy and laser
1995;21:628–630. surgery. Semin Cutan Med Surg 2002;21:76–103.
10. Olivencia JA. Pitfalls in ambulatory phlebectomy. 15. Sadick NS. Foam sclerotherapy. Cosmet Dermatol
Dermatol Surg 1999;25:722–724. 2002;15:81–83.
11. Cohn M, Seiger E, Goldman S. Ambulatory phlebec- 16. Sadick NS. Sclerotherapy. Clin Prob Dermatol 2001;
tomy using the tumescent technique for local anes- 31:37.
thesia. Dermatol Surg 1993;21:315–318. 17. Leach BC, Goldman MP. Comparative trial between
12. Ricci S. Ambulatory phlebectomy: Principles and sodium tetradecyl sulfate and glycerin in the treat-
evolution of the methods. Dermatol Surg 1998;24: ment of telangiectatic leg veins. Dermatol Surg
459–464. 2003;29:612–615.
CHAPTER
CHAPTER10
0 Lasers
Chapter Title
Neil Sadick ● Lipolysis/cellulite
● Stretch marks
KEY POINTS FOR SUCCESS ● Photorejuvenation
● ● Resurfacing
Understanding the appropriate laser/intense pulse
light source for a given clinical indication.
● Adequate cooling technology.
CONTRAINDICATIONS
● Choosing appropriate pulse direction/spot size.
● Infection (viral, bacterial)
● Sun protection measures; do not treat patients with
● Sunburn
lasers who are tanned or sunburned.
● Suntan
● Postoperative wound care.
● Artificial tanners
● Matching patient expectations to technology capability.
● Pregnancy (relative)
● Consider using spot tests when treating darker skin
phenotypes, i.e., Fitzpatrick skin types V–VI.
TREATMENT WITH ABLATIVE LASERS

LASER CLINICAL PARAMETERS
(TABLE 10.1)
● Titan 1100–1800nm 34 J
■ Vascular Lesions
● Fraxel 1520–1580 nm 6.8 J 250 mHz. Available technologies and their wavelengths
● ● KTP laser 532 nm
Wavelength will determine the major chromophore
absorbed and produce a particular tissue effect, i.e., ● PDL laser 585–600 nm
green light targets melanin, yellow light targets hemo- ● Long pulsed Nd:YAG laser 1064 nm
globin, and infrared light may target water as well as
● Diode laser 800–900 nm
hemoglobin.
● Alexandrite laser 755 nm
● Spot size will vary energy deliverance characteristics;
● Intense pulsed light (IPL) 500–1200 nm
smaller spot sizes allow delivery of higher fluences of
energy in a concentrated fashion while larger spot sizes Indications
deliver energy over a larger surface with greater diffusion.
● Port wine stains
● Pulse duration: longer pulses allow deliverance of high
● Hemangiomas
fluences of energy over a longer period of time.
● Actinic telangiectasias
● Cooling technologies: allow the capability for deliver-
● Rosacea/flushing
ance of high energies, which protect epidermis and
surrounding tissue; e.g., simple coupling gels or cooled ● Spider/reticular veins
air devices, static chilled circulating (⫺1 to ⫺4°C) cool- ● Poikiloderma
ing window tips, or dynamic sprayed cooling devices.
● Scars
● Striae distensae
INDICATIONS
● Warts
● Vascular lesions Treatment
● Pigmented lesions ● See Fig. 10.1 for an overview of choosing a course of
● Hair removal clinical treatment for the various types of lesions.
TABLE 10.1 ■ Types of Lasers and Their Cutaneous Application
Laser Type Wavelength Cutaneous Application
Argon (CW) 418/514 nm Vascular lesions
Argon-pumped tunable dye 577/585 nm Vascular lesions
(quasi-CW
Copper vapor/bromide 510/578 nm Pigmented lesions, vascular lesions
(quasi-WC)
Potassium-titanyl-phosphate 532 nm Pigmented lesions, vascular lesions
Nd:YAG, frequency-doubled 532 nm Pigmented lesions, red/orange/yellow tattoos
Pulsed dye 510 nm Pigmented lesions
585–595 nm Vascular lesions, hypertrophic/keloid scars,
striae, verrucae, nonablative dermal remodeling
Ruby 694 nm
QS Pigmented lesions, blue/black/green tattoos
Normal mode Hair removal
Alexandrite 755 nm
QS Pigmented lesions, blue/black/green tattoos
Normal mode Hair removal, leg veins
Diode 800–810 nm Hair removal, leg veins
Nd:YAG 1064 nm
QS Pigmented lesions, blue/black tattoos
Normal mode Hair removal, leg veins, nonablative dermal
remodeling
Nd:YAG, long-pulsed 1320 nm Nonablative dermal remodeling
Diode, long-pulsed 1450 nm Nonablative dermal remodeling, acne
Erbium: glass 1540 nm Nonablative dermal remodeling
Erbium: YAG (pulsed) 2490 nm Ablative skin resurfacing, epidermal lesions
Carbon dioxide (CW) 10,600 nm Actinic cheilitis, verrucae, rhinophyma
Carbon dioxide (pulsed) 10,600 nm Ablative skin resurfacing, epidermal/dermal
lesions
Intense pulsed light source 515–1200 nm Superficial pigmented lesions, vascular lesions,
hair removal, nonablative dermal remodeling
Treatment of Red Facial Lesions
Port wine stains Telangiectasis Flushing

and (Rosacea)
Angiomas Red Blue
Alar vessels
Periorbital vessels
Pulsed dye laser Pulsed dye laser Nd:YAG laser IPL ± RF

595–600 nm 595–600 nm 1064 nm 500–1200 nm
KTP laser
532 nm
FIGURE 10.1 Approach to choosing
IPL ± RF clinical treatment for treatment of vas-
500–1200 nm cular lesions
Chapter 10: Lasers | 93
FIGURE 10.2 Pre- and post-1064 nm Nd:YAG three treatments. Red vessels: 1.5 mm spot size, 150–400 J/cm2,
15–30 ms PD; blue vessels: 3.0 mm spot size, 100–250 J/cm2, 30–50 ms PD
■ Red Facial Lesions ■ Pigmented Lesions and Inflammatory

● PDL is treatment of choice for large discrete vessels on Hyperpigmentations
the face as well as port wine stains. ● Available technologies
● Short pulse duration, i.e., 1–5 ms produce purpura, ● Green light
but are more effective in a single treatment.
510 nm pulsed dye laser
● Extension of the pulse duration to 8–10 ms will
511 nm copper vapor laser
reduce this at 10 J/cm2, but usually requires more
● 532 nm Nd:YAG laser
than one treatment session.
● 1064 Nd:YAG lasers treat deep blue vessels at the alae Q-switched
nasi and periorbital veins; low fluence of 90–110 J/cm2 694 nm ruby
are used in this setting 755 nm alexandrite
● Leg veins up to 4 mm may be treated with the 1064 1064 nm Nd:YAG
nm Nd:YAG laser employing varying pulse widths ● Indications
(Fig. 10.2 and Table 10.2)
● Epidermal
● Smaller spot sizes of 1–2 mm with shorter pulse
directions of 30–40 ms and high fluences of
400–500 J/cm2 are used to treat small red oxy-
genated vessels, while larger spot sizes of 2–6 mm
with larger pulse durations of 50–80 ms and lower TABLE 10.2 ■ Monomodal Approach to Lower
fluences of 150–300 J/cm2 are used to treat larger Extremity Veins (1064 nm Technologies)
diameter blue vessels. Vessel 1 mm Vessel 1–3 mm
● Rosacea responds well to IPL treatments using 590 or (Red) (Blue)
640 nm cut off filters with fluences of 28–32 J/cm2.
Spot size 1–5 mm 3 mm
Combined IPL/RF technologies are also used in this
Fluence 150–400 J/cm2 100–250 J/cm2
setting. Maintenance of treatments is required at 3–6-
Pulse duration 15–30 ms 30–50 ms
month intervals.
Lentigos are unpredictable and often recur if the inciting
Labial melanotic macules event is still present.
● Fractional photothermolysis (Fraxel) is a new tech-
Seborrheic keratoses, dermatosis, papulosis nigra
nology showing promise in this setting (fluence 6–8
Ephelides
J/cm2 250 Microthermal Zones)
Café-au-lait macules
● Tattoos require multiple treatments. Carbon-based
Nevus spilus
particles have under absorption bands blue and
● Epidermal and dermal green ink absorb greatest for wavelengths of
Becker’s nevus 600–800 nm, whereas red ink absorbs best below
Postinflammatory hyperpigmentation 575 nm, tan below 560 nm, flesh-colored pigment
below 535 nm, and yellow below 520 nm.
Melasma
Nevocellular nevi
■ Hair Removal
Junctional melanocytic nevi
● Indications for hair removal by wavelength
Compound melanocytic nevi
● Short wavelength is appropriate for Fitzpatrick skin
Congenital melanocytic nevi
types I-III
Dermal
Ruby (694 nm): thin hair shaft
Nevus of Ota, Ito
Alexandrite: blonde to light brown hair
Mongolia spots
● Intermediate wavelength is appropriate for Fitzpatrick
Blue nevus
skin type II-V
Tattoos (exogenous pigment)
Diode (800–900 nm): intermediate hair shaft
● Anticipated results
IPL ⫾ RF (500–1200 nm): light brown to dark brown
● Good response can be expected for
hair
lentigos
● Long wavelength is appropriate for Fitzpatrick skin
ephilides type IV-VI
tattoos
Nd:YAG (1064): intermediate to coarse hair shaft;
● Moderate response with high recurrence rate can be medium brown to black hair
expected for
● Factors involved in photoepilation
café-au-lait spot
Body site
veins
Hair depth
nevi
Follicle density
● Poor response is seen with
Anagen/telogen duration
seborrheic keratosis
postinflammatory hyperpigmentation Hair color
Becker’s nevus Hair coarseness

● The Q-switched ruby (694 nm), alexandrite (755 Hair is most efficiently targeted in the anagen phase
nm), and Ng:YAG (532/1064 nm) lasers are where the maximal amount of the target chro-
most effective in this setting (fluences 5–10 mophore melanin is present
J/cm2). ● Treatment
● Lentigos and ephilides respond best in a single treat- ● Hair removal may be long term if the entire germi-
ment session. native area of the follicles is destroyed or associated
● Melasma and postinflammatory hyperpigmentation with varied degree and duration of regrowth of this
● Preoperative care
TABLE 10.3 ■ Possible Effects of Photoepilation
Chromophore not targeted No effect Anesthesia EMLA (lidocaine 2.5%, prilocaine 2.5%)
(i.e., light hair telogen) or ELMAX (lidocaine 4%, topical application
Hair shaft destroyed Exogen shedding regrowth 36–60 minutes prior to treatment).
Partial germinative area Regrowth with dystrophic Shaving is acceptable between treatments.
destruction hair Photoprotection/absence of tanning or self-
Total germinative area Long-term (permanent) tanners.
destruction removal ● Treatment regimens
20–100 J/cm2 delivered depending upon particular
technology.
zone is injured but not totally destroyed (Table Expectations are 60–75% mean hair removal effi-
10.3). ciency (MHRE) after three to five treatment
● Usually three to five treatment sessions are per- sessions.
formed at monthly intervals with touch-up treat-
ments performed on an individual basis determined
by the degree of hair regrowth.
● Short wavelength technologies, i.e., ruby, (694 nm)
TREATMENT WITH NONABLATIVE
and alexandrite (755 nm) are most effective in tar-
LIGHT SOURCES
geting thin light hair and light skin phenotypes. Nonablative rejuvenation uses lasers and intense pulsed
● Intermediate wavelength technologies, i.e., diode light sources, which improve aging parameters without
(800 nm) and intense pulsed light (500–1200 nm) disrupting cutaneous integrity, minimal downtime, and
have greatest versatility in treating the largest spec- low-risk profile.
trum of skin phenotypes, varied hair hues, and shaft ● Available Technologies: The available technologies are
diameters (Fig. 10.3). listed in Table 10.4.
● Longer wavelengths, i.e., 1064 nm Nd:YAG lasers ● Indications and Contraindications: A summary of the
allow treatment of darker skin phenotypes and dark, author’s approach to nonablative rejuvenation is as
coarse hair. follows:
FIGURE 10.3 Pre- and post-diode hair removal: 20 months/3 treatments; 22–26 J/cm2, auto
● IPL treatments are gold standard usually performed
Nonablative Technology Effective Technology
in five monthly treatment sessions with single, i.e.,
Skin toning LED photomodulation maintenance treatments at 3–6-month intervals.
Vascular PDL (585–600 nm) ● Fluences of 24–32 J/cm2 are normally employed.
improvement/flushing IPL ⫾ RF (500–1200 nm)
● Combined RF/IPL technologies delivering radiofre-
Nd:YAG/KTP (532 nm)
Pigmentation IPL ⫾ RF (500–1200 nm) quency energy of up to 25 J/cm2 may have additive
Nd:YAG/KTP (532 nm) effects. This treatment is the treatment of choice for
Fractional diffuse redness and idiopathic flushing syndromes.
photothermolysis ● Discrete vessels may require touch-up with a 532
(1520–1580 nm) nm KTP laser.
Skin smoothing IPL ⫾ RF (500–1200 nm) ● Larger blood vessels may require PDL 585–600 nm
Fractional photothermolysis (Fig. 10.4).
(1520–1580 nm)
Wrinkle reduction CoolTouch (1320 nm)
SmoothBeam (1450 nm) ■ Improvement in Pigmentation
Erbium glass laser A diffuse photoaging pigment as well as discrete
(1540 nm) ephilides and lentigo may be addressed by 532 nm KTP
Skin tightening Thermacool (RF) lasers, IPL or RF sources, or more recently the introduc-
Titan (1100–1800 nm) tion of the concept of fractional photothermolysis (Fraxel)
1570–1580 nm at 6–8 J (250 MTZ) have been shown by
● Treatment causing deep microwounding focally to have a beneficial
● Skin toning—LEDS provide indirect biologic effect to effect on diffuse inflammatory hyperpigmentation.
augment skin reflectance and color.
● Improvement in vascular lesions/flushing.
■ Skin Smoothing
● IPL or RF.
TABLE 10.4 ■ Available Nonablative Rejuvenation
● Fractional photothermolysis.
Technologies (Laser/Intense Pulsed Light Sources)a
● IPL technologies may induce skin smoothing effect by
Laser Technologies
temporarily shrinking sebaceous glands and inducing
Yellow Light a small amount of new collagen formation 560/590/
Potassium titanyl phosphate (KTP) laser (532 nm) 640 cut-off filter, 22–34 J/cm2 fluence.
CuBr laser (578 nm) ● Fractional photothermolysis may induced microwound
Pulsed dye laser (PDL) (585–600 nm) zones within the dermis leading to new collagen forma-
N-Lite laser (585 nm) tion 6–8 J with 250 microthermal zone wounding para-
Broadband light (500–1100 nm) meters of MTZ one suggested initial starting parameters.
Intense pulsed light (IPL) (500–1100 nm)
Infrared lasers
Nd:YAG (1064 nm) ■ Rhytid Reduction (Fig. 10.5)
CoolTouch (1320 nm)
● Best achieved by longer wavelength infrared lasers
SmoothBeam (1450 nm diode)
with water as primary chromophore
Aramis (1540-␮m erbium glass laser)
● Available technologies:
Fraxel (1570–1580 nm)
Nonlaser modalities ● 1320 nm Nd:YAG (CoolTouch II) laser (New Star
Radiofrequency technologies (Thermage) laser, Roseville CA) (14–18 J/cm2).
Titan (1500–1800 nm) ● 1450 nm SmoothBeam diode laser (Candela, Way-
a
Intense pulsed light sources (400–1100nm) land, MA); 1540 glass sphere laser (Aramis, Quantel
⫾ radiofrequency (RF). Medical, Bozeman, MT).
FIGURE 10.4 Pre- and post-IPL five treatments: 560 nm, 32 J/cm2, 2.4–4.2 PD; flushing/photoaged skin
● These technologies have been shown to be effec- ● Treatment protocols

tive in treating mild perioral and periorbital ● Three to four monthly treatment sessions.
rhytides, hand rejuvenation, and atrophic acne
● One to two maintenance treatments in a year.
scars.
● 40–60% improvement after initial treatment session
● These technologies are based on dermal remodeling with continued improvement up to a year after each
with stimulation of new collagen. treatment.
FIGURE 10.5 Pre- and post-CoolTouch three treatments: 2␮s macropulse, 30 ms pre/postcooling, 14–18 J/cm2
TABLE 10.5 ■ Comparison of Thermacool and Titan
Thermacool Titan
Unipolar RF Broadband infrared light source
(1100–1800 nm)
Painful (Percocet, Valium, DMG) Relatively painless
1 treatment session 3 treatment sessions
Multiple passes (68–71 settings) Multiple passes 34 J/cm2
Spot size up to 3.0 cm Spot size
Complications including atrophic Mild skin burns reported
panniculitis reported although relatively
uncommon with multipass low energy
regimens
Greatest efficacy in the lower face and neck Greatest efficacy in the lower face
and neck
■ Skin Tightening ● Contraindications

● Recent tissue augmentation
Available technologies (see Table 10.5 for comparison):
● Recent systemic isotretinoin usage (6 months)
● Thermacool (Thermage, Haywood, CA)
● Preoperative care
● Titan (Cutera, Brisbane, CA)
● Bleaching agents (hydroquinone 4%)
● Produce skin tightening by immediate skin contrac-
● Retinoids
tion and long-term collagen remodeling
● Antiviral prophylaxis (Valtrex 500 mg b.i.d. or Famvir
250 mg)
● Technique
TREATMENT WITH RESURFACING
LASERS ● Anesthesia
Treatment with resurfacing lasers has lost popularity Percocet

because of prolonged healing times and relatively high Valium 10 mg ⫾ regional blocks or tumescent
complication profiles; however, this treatment is still anesthesia
effective in severely photodamaged individuals. ● 1–3 passes
● Available technologies (see Table 10.6 for comparison) ● Tissue wiping with CO2 ablation
● CO2 laser 10,500 nm ● End point of ablation skin surface and microbleeding
● Long pulsed erbium laser 2940 nm points with Er YAG laser
TABLE 10.6 ■ Comparison of CO2 and Erbium Laser

CO2 Laser (10,500 nm) Erbium Laser (2940 nm)
Collagen target Water target
c Vaporization c Ablation
Mild erythema lasting 3–6 months Prolonged erythema lasting 1–2 months
Endpoint tissue tightening Endpoint pinpoint bleeding
Delayed hypopigmentation Less delayed hypopigmentation
Greater collagen remodeling Lesser collagen remodeling
● Open approach
● 14% acetic acid compresses ⫹ Aquaphor (Biers-
dorf-Jobst, Norwalk, CT) 3–6 times per day
● Closed technique
● Biologically active semiocclusive dressing, i.e., Silon
TSR (Biosciences, Allentown, PA) (should not be left
on longer than 24–48 hours to prevent secondary
infection with bacteria or yeast.
COMPLICATIONS
● Relatively rare with laser/IPL procedures
● Result from the following predominantly:
● poor technique
● improper setting
● poor patient selection
● lax sun protection measures
● inappropriate pre- and postoperative considerations
● Scarring
● Elicit personal or family history
● Rare, has been most commonly reported after abla-
tive laser resurfacing procedure
● Overzealous fluences and stacking of pulses are the
most common causes
● Persistent erythema crust formation and ulcers are FIGURE 10.6 Postlaser scarring
impending signs
● Predisposing locations—bony prominences of the Montgomeryville, PA) and targeted phototherapy
face, neck, hands, legs, and chest (Fig. 10.6) (UVB, UVA) with the MultiClear (Curelight LTD,
●
Akiva, Israel) are more recently introduced technolo-
Telangiectasias
gies that may be helpful in this setting
● Commonly noted after ablative laser resurfacing pro-
● Demarcation irregularities are common after ablative
cedures
resurfacing particularly around the neck and scalp-
● Wait up to 6 months before instituting therapy as forehead junctions
may correct spontaneously
● Feathering techniques with defocused beams, lower
● Hyper-/hypopigmentation fluences, and combination treatments may be help-
● Commonly secondary to inadequate sun protection ful in this setting
measures ● Milia: Occlusion cysts are common after laser resur-
● May be secondary to inappropriate matching of wave- facing of the face
length with skin phenotype, i.e., utilization of a short
wavelength in a Fitzpatrick Type V or VI individual
●
PEARLS/PITFALLS
Footprinting is the most common sequelae of IPL
procedures ● Pulse stacking should be avoided.
● Hypopigmentation is a long-term sequelae of CO2 ● Laser treatments should never be performed when one
laser ablation. The XTRACTM laser (PhotoMedex, is tanned.
● All lasers and IPLs should be serviced at least one time ● Antiviral prophylaxis is essential with ablative technolo-
per year. gies.
● Conservative expectations and maintenance pro- ● The key to care after ablative resurfacing is careful fol-
grams should be explained with nonablative tech- low-up and fastidious wound care.
nologies. ● In dark skin phenotypes, Type V-VI, spot test sessions
● Decreased hair density after laser hair removal means are recommended for all lasers and intense pulsed
at least 50% of hair has been eradicated. light sources.
CHAPTER
CHAPTER11
0 Lower Lid Blepharoplasty
Ron Moy, MD PREOPERATIVE CONSULTATION
● Explain what can actually be accomplished by moving
fat into the tear trough deformity or injecting in
KEY POINTS FOR SUCCESS hyaluronic acid into the tear trough deformity (Fig. 11.1).
● Patients should understand that looser skin, wrinkled
● Management of patient expectations including
skin, and volume loss around the eye contributes to
● modest improvement and the aged eye.
● the need for combination procedures to manage ● Modest improvement can be accomplished by trans-
wrinkles. posing fat from a transconjunctival blepharoplasty
● Careful anesthesia avoiding globe injury. approach or by injection of fat or hyaluronic acid into
● Careful fat removal the tear trough deformity.
● Wrinkles can only be modestly improved by laser
● with electrocautery for fat that surfaces above the
incision and resurfacing or by a pinch excision of skin near the
lateral ciliary margin of the lower eyelid.
● transposition and not electrocautery for fat in middle
compartment. Swelling and delayed skin tightening with laser
resurfacing can cause an improvement to be
● Creation of a pedicle of fat for successful transposition.
delayed for many months.
The swelling and bruising that can occur must be
INDICATIONS explained to the patient.
● Discussion of available techniques: Older lower ble-
● Protuberant fat below the lower lid.
pharoplasty techniques called the skin-muscle flap
● A loss of fat in the tear trough deformity (loss of fat blepharoplasty where the orbicularis muscle flat was
of the medial canthal side of the infraorbital area) incised to reach the fat weakened the muscle along
(Fig. 11.1). with some skin excision leading to an ectropion and
● Looser skin of the infraorbital area and a loose lower scleral show. Support with some type of anchoring
lid. suture and careful skin excision could prevent this
● Patient complaints of tired eyes or too much fat of problem.
the lower lids, which may be a problem of too little fat ● A transconjunctival blepharoplasty to remove or to
of the tear trough deformity and looser skin with transpose the fat, followed by either a pinch excision of
wrinkles. skin (without violation of the orbicularis oculi muscle)
● Patients complain of dark circles under their eyes, or laser resurfacing to tighten the skin and improve the
which is the loss of fat of the medial side of the infra- wrinkles is believed to be a safer technique than the
orbital area and sometimes pigmentation of the skin. skin muscle flap technique.
● A canthopexy can tighten the slightly loose lower lid
● Patients should be warned that postoperative bleeding
can have terrible complications. and at least prevent ectropion or scleral show from
occurring. This can cause lumpiness or bunching of
● Patients should be informed that avoiding aspirin
skin over the lateral canthus.
products for at least 2 weeks prior to the procedure
can decrease the chance of bleeding.
● Patients should be informed that avoiding a nons-
HOW MUCH FAT TO REMOVE
teroidal anti-inflammatory 2 days prior to the proce- ● Take out less fat because volume loss contributes to
dure will also limit bleeding. the older looking eye.
A C
B D
FIGURE 11.1 A&B Preoperative and C&D postoperative views of a 84-year-old woman with tear trough deformity
(3 month follow-up)
● Patients with previous transconjunctival blepharo- ● A few days of topical tetracaine placed into the eye are
plasty may have less fat protrusion as more fat used necessary to use the Jaegar plate over the eye.
to be removed than is currently done. However they ● The injection of local anesthesia using a 30-guage nee-
may look older in later years from their volume loss. dle maybe the most dangerous part of the procedure
Some of these patients will still improve with some because care must be taken to avoid a needle stick to
fat removal especially on the lateral and medial fat the globe. Pulling the lower lid away from the eye can
compartments. be helpful to avoid globe injury.
● Most patients will benefit from modest fat removal and
more transposition of fat into the medial tear trough
deformity.
INCISION
● There is usually an arcade of blood vessels on the con-
● With the different techniques of fat transposition or
of fat injection not all the fat survives. junctiva that is another marker to help place the incision
(Fig. 11.2). The incision is made anterior to the arcade
● Some older patients may not have enough fat that
of vessel midway between the conjunctival sulcus and
can be transposed in which case a transconjunctival
the lower lid margin on the through the conjunctiva.
blepharoplasty should not be performed.
● The incision is made using a sharp needle type
● Lower lid tightening, volume enhancement with fat or
(Colarado needle) attached to the electrocautery
hyaluronic acid, and skin tightening may be all that is
device or using a laser so that the incision is relatively
required to make the lower eye look younger.
bloodless (Fig. 11.3).
● The incision is made over where fat projects with
ANESTHESIA pressing on the globe with a Jaeger plate (looks like a
shoe horn). A Desmarres retractor pulls the lower lid
● Anesthesia is accomplished using 1% lidocaine with away from the globe (Fig. 11.4).
epinephrine into the
● The incision is usually made midway between the
● lower lid conjunctiva, lower lid tarsus and the conjunctival sulcus.
● the lower lid retractors, and ● The incision is made through the lower lid retractors
● lower lid fat compartments. into the fat compartments (Fig. 11.5).
Chapter 11: Lower Lid Blepharoplasty | 103
Conjunctiva 4 mm
FIGURE 11.2 The incision site for a transconjunctival

blepharoplasty is usually midway between the sulcus
FIGURE 11.4 Pressure on the globe pushes the fat out
and the lid margin where a few horizontal arcades of
so that the incision is easily placed
blood vessels exist on the conjunctival surface. Pres-
sure on the globe helps demonstrate where the fat is
bulging and where the incision should be placed ● Fat will usually surface above the conjunctiva; this fat
should be considered for removal with electrocautery.
● Most of the fat in the medial or middle fat compart-
ments should not be vaporized and should be used to
FAT REMOVAL transpose into the nasojugal groove.
● The fat is exposed by using blunt tenotomy scissors to ● The lateral fat compartment should be vaporized if the
spread through the fascia surrounding the fat com- fat emerges above the surface of the conjunctival
partments. The areas first exposed are those areas that plane. Rarely will it be necessary to dissect deep below
bulge when pressure is applied to the globe with the the conjunctival surface, which then requires avoiding
Jaeger plate. the inferior oblique muscle.
Conjunctiva
Inf. Tarsal M.
Conjunctiva Lid Retractors Capsulopalpebral
Fascia
Inf. Rectus M.
Inf. Oblique M.
CPF
Intraorbital Fat
Orbital Septum
FIGURE 11.5 Cut through lid retractors with an electro-

FIGURE 11.3 The fine point needle on the electrocautery sharp needle and tenotomy scissors to remove
cautery helps make an incision without bleeding fat
● The suture holds the fat pedicle into the tear trough
deformity.
● Two sutures hold the fat pedicle at the tear trough
deformity.
COMBINATION PROCEDURES WITH

LASER RESURFACING, PINCH
EXCISION, AND LID TIGHTENING
■ Laser Resurfacing
Laser resurfacing should be performed prior to the place-
Obicularis
oculi m. ment of fat into the tear trough deformity. Two passes of
Tear
carbon dioxide lasers, erbium, or plasma resurfacing
trough may be necessary to achieve tightening and wrinkle
improvement (Fig. 11.8).
■ Pinch Excision
SOOF
● The pinch excision is performed by pinching the skin
fat
Periosteum with forceps and marking out a narrow ellipse around
the lateral canthal area.
FIGURE 11.6 The tear trough deformity or nasal jugu- ● This narrow ellipse will be
lar groove needs to be filled with fat or a filler
● right below the ciliary eyelid margin;
● start laterally;
FAT TRANSPOSITION
● extend maybe to the middle lower eyelid margin.
● If fat is to be transposed into the nasal jugular groove,
● This pinch excision of skin is done conservatively with
then a pedicle of fat, which allows movement, needs to
minimal tension across the skin edges.
be created (Fig. 11.6).
● Undermining of the entire infraorbital area will decrease
● Tenotomy scissors can be used to dissect around the
the wrinkle lines and help tighten the skin.
pedicle to allow the free movement (Fig. 11.7A, B).
● Closure of the skin edges is accomplished with 6-0 fast
● The area of the tear trough deformity is visualized
absorbing.
from the skin surface.
● More skin will need to be removed if a MACS-Lift (a
● Tenotomy scissors are used to dissect a space above
vertically pulled minimal incision cranial suspension
the orbicularis oculi but below the skin surface of the
facelift) creates more skin in the infra orbital area.
nasojugal tear trough deformity.
Some advocate placing the fat into a subperiosteal
space. This subperiosteal space is harder to create ■ Canthopexy Suture
then separating a space above the orbicularis muscle.
● The canthopexy suture tightening the lower lid can be
● Forceps are used to push the fat pedicle to the nasal placed from a small stab incision or the pinch excision
jugular groove (Fig. 11.7C). opening (Fig. 11.9).
● The other hand is used to hold a needle holder with ● A small stab 1⁄4 inch incision is created over the lat-
a 6-0 fast absorbing gut suture that can grab and eral canthal area so that a suture can be placed
hold the fat pedicle. grabbing a portion of the lateral orbicularis oculi and
● A simple interrupted suture starts at the skin surface tacking it to the lateral orbital rim superior to the lat-
and grabs the fat pedicle. eral canthus.
Chapter 11: Lower Lid Blepharoplasty | 105
tear trough
deformity
FIGURE 11.7 A. Fat pedicles from the central and medial

fat compartments remain attached and B. are moved into
B the tear trough deformity in a sub-orbicularis plane. C. The
central fat pad is displaced into the submuscular plane of
the tear trough deformity-nasojugular groove.
● A skin hook is used first to pull the skin over medi-

COMPLICATIONS
ally to help suture a portion of the lateral orbicularis
oculi and pull the skin hook superiorly to help attach ● Postoperatives not reported by the patient is the worst
a periosteal suture to the lateral orbital rim. complication.
● The result of this canthopexy suture is tightening of ● Retrobulbar hematoma has the potential to damage
the lower lid. the eye.
● The most common complaint after a lower lid ble-
pharoplasty is delayed improvement due to swelling
and delayed skin tightening.
● A pinch excision and canthopexy can result in tempo-
rary bunching of tissue over the excision line.
● This may require steroid injection.
● Or, it will resolve with time.
● Bruising of the conjunctiva and skin are often seen
after a lower lid blepharoplasty. The bruising will
always resolve with time.
● Inadequate fat removal of the lateral fat compartment
FIGURE 11.8 Laser resurfacing is used to tighten the and fat not taking in the tear trough deformity are pos-
skin and improve wrinkles combined with a transcon- sible complications.
junctival blepharoplasty
SUGGESTED READING
1. Hamra ST. The role of orbital fat preservation in
● Postoperative bleeding should be minimized by facial aesthetic surgery: A new concept. Clin Plast
making sure the patient is off any aspirin products Surg 1996;23:17–18.
for 2 weeks prior to surgery. 2. Mendelson BC. Fat preservation technique of lower-lid
● Nonsteroidal anti-inflammatories should be avoided blepharoplasty. Aesthetic Surg J 2001;21:450–459.
for 1 week prior to surgery. 3. Flowers RS. Tear through implants for correction of
tear trough deformity. Clin Plast Surg 1003;20:
● Bleeding vessels should be carefully cauterized.
403–408.
● Patients should report any increase in pain since it 4. Loeb R. Fat pad sliding and fat grafting for leveling
could be caused an expanding hematoma. lid depressions. Clin Plast Surg 1981;8:757.
● Patients are called the night of surgery and usually 5. Codere F, Tucker N. Eyelids - Cosmetic Blepharo-
examined the day after surgery. plasty and Browplasty. Yanoff: Ophthalmology, 1st
edn. Mosby, 1999, Section 7.8.7.
6. Coleman SR. Facial contouring with liposculpture.
Clin Plast Surg 1997;24:347.
7. de la Plaza R., Arroyo JM. A new technique for
treatment of palpebral bags. Plast Reconstr Surg
1988; 81:77.
8. Goldberg RA, Edelstain C, Shorr N. Fat repositioning
in lower blepharoplasty to maintain infraorbital rim
contour. Facial Plast Surg 1999;15(3):225–229.
9. Kawamoto HK, Bradley JP. The tear ‘trough’ proce-
dure: transconjunctival repositioning of orbital uni-
pedicled fat. Plast Reconstr Surg 2003;112:1903–
1907.
10. Goldberg RA, Yuen VH. Restricted ocular move-
ments following lower eyelid fat repositioning. Plast
Reconstr Surg 2002;110(1):302–305.
FIGURE 11.9 A canthopexy with a 5-0 absorbable 11. Goldberg RA. Transconjunctival orbital fat reposition-
suture grabs lateral canthal orbicularis muscle and ing: transposition of orbital fat pedicles into a subpe-
tacks it to superior orbital rim so that there is lower lid riosteal pocket Plast Reconstr Surg 2000;105:
tightening 743–738.
CHAPTER
CHAPTER12
0 Upper
ChapterLid
Title
Blepharoplasty
Ron Moy, MD ● Pre- and postoperative photos should show only a
modest improvement in visualizing the upper eyelid.
● Patients should be warned that postoperative bleeding
can have terrible complications.
KEY POINTS FOR SUCCESS ● Patients should be informed that avoiding aspirin prod-
● Management of patient expectations including ucts for at least 2 weeks prior to the procedure can
● modest results and decrease the chance of bleeding.
● Patients should be informed that avoiding nonsteroidal
● potential complications.
anti-inflammatory 2 days prior to the procedure will
● Avoidance of aspirin and NSAIDs prior to surgery.
also limit bleeding.
● Careful anesthesia, including having additional lido- ● The risks and benefits of an upper eyelid blepharo-
caine readily available for anesthetization of the fat pad
plasty include asymmetry, cyst formation and granulo-
after it has been dissected.
mas, and not being able to close the eye due to excess
● Careful hemostasis. skin removal.
● Avoiding excess tension on closure. ● The patient may require least 2 weeks before the eye
looks presentable.
INDICATIONS
● The upper lid blepharoplasty creates a more visible
younger upper eyelid platform by excising excess
PREOPERATIVE PLANNING AND
crinkly skin and less importantly by removing fat or
MARKINGS
muscle. ● The markings used for an upper eyelid blepharoplasty
● The need for a brow lift can sometime correct the lat- (Fig. 12.2) is determined by
eral hooding that most patients complain about so that ● the amount of skin to be excised,
a brow lift with an upper lid blepharoplasty will give ● the race of the patient, and
maximum correction of the lateral hooding.
● the natural upper lid crease of the patient.
● The main indication for an upper lid blepharoplasty is
● The excised skin is marked as an ellipse with the angle
excess upper eyelid skin especially of the lateral upper
toward the medial canthus being narrow and lateral
eyelid with minimal brow ptosis (Fig. 12.1).
canthal side being a larger angle (Fig. 12.3).
● This skin can be crinkled and thin and so the excess
● The markings are usually made with small dots to
removal may improve the appearance by removing
maximize precision and to minimize smearing of the
the crinkled skin and by allowing more of the upper
markings.
eyelid to be visualized.
● The ellipse is wider on the lateral canthal side to
● Some patients will want a more prominent upper
improve the lateral hooding that usually exists
eyelid crease, especially Asian patients.
(Fig. 12.4).
● The lower incision marking is placed within the natural
PREOPERATIVE CONSULTATION
crease extending up to the medial canthal area out to
● Visualization of the brow ptosis component by the the lateral canthus.
physician pulling up on the lateral brow shows the ● Discuss with the patient that more lateral hooding can
patient what a brow lift will do in combination with an be improved if we extend the incision farther laterally
upper eyelid. into the crow’s feet lines, but that this incision line
● Blepharoplasty complications should be explained. could be slightly visible for months.
A B
FIGURE 12.1 Upper lid blepharoplasty removes excess upper eyelid skin. A. Presurgical photograph. B. Postsurgical
result
● The lower incision marking is usually about 8–10 mm ANESTHESIA

above the upper lid in Caucasian woman (slightly less
● Anesthesia is usually accomplished under local anes-
in men) and 4–5 mm above the lid margin in Asians.
thesia with 1% lidocaine and epinephrine if this is a
● The upper eyelid incision marking is decided by pinch-
solitary procedure.
ing the skin with Adson forceps and making a surgical
● This is a procedure that is easily performed under local
judgment on how much skin can be safely excised and
still allowing the eye to close (Fig. 12.5). anesthesia (although some patients may want con-
scious sedation).
● If there is excess tension on the closure, the brow could
● Anesthetize the entire upper eyelid area via one needle
be pulled down and the patient really needs a brow lift
combined with an upper eyelid blepharoplasty. stick so that bruising is minimized (Fig. 12.6).
A B
FIGURE 12.2 The incision markings are made with small dots in the natural crease
of the upper eyelid. This natural crease is usually about 8–10 mm above the lid
Chapter 12: Upper Lid Blepharoplasty | 109
FIGURE 12.5 The upper eyelid can be pinched with

8–10 mm forceps to help judge how much skin can be excised
● After skin is excised, hemostasis is achieved with

electrocautery.
FIGURE 12.3 The natural crease is marked. An ellipse ● A carbon dioxide laser or electrocautery with a sharp
is drawn with the natural crease as the lower part of needle can be used to remove skin and to minimize
the ellipse bleeding of the skin edges.
● The disadvantage of using these devices is that the
wound healing may be delayed and a hypopig-
● Wait at least 10 minutes so that the lidocaine mented incision line may result.
spreads and the epinephrine can decrease the
● It would be rare to have much scarring with any tech-
amount of bleeding.
nique or device since the eyelid skin is so thin and
● Anesthesia may need to be added within the fat pad thus the results are almost always invisible scars.
and so it is helpful to have some local anesthesia in
a sterile syringe on the surgical tray for lidocaine
administration by the surgeon in a sterile fashion FAT AND/OR MUSCLE REMOVAL
after the excision of skin is accomplished. ● Sometimes fat or muscle need to be removed.
● If the patient has just crinkly excess skin without fat
INCISION bulging and there is no need to define the upper eye-
● The incision is carried out with a sharp Persona #15 lid crease, then the simple blepharoplasty is to remove
blade through the skin down to orbicularis muscle. only the skin.
FIGURE 12.6 Anesthesia via one needle stick will mini-

FIGURE 12.4 Draw ellipse to include lateral hooding mize bruising
● If excess fat or muscle is removed the patient can have scissors to poke a little hole through the underlying
overly sculpted, hollowed look. fascia below the muscle to expose fat (Fig. 12.8).
● There are now many patients who require no fat or The preoperative analysis should determine where
muscle removal, but just skin removal. and how much fat should be removed.
● This type of blepharoplasty will look more natural Many patients will have more fat laterally or medially
with more of the upper eyelid being visible but not so that fat removal will be concentrated in these
the overly sculpted eyelid that has been called the areas.
superior sulcus syndrome. Laterally, the tear gland could be mistaken for fat
● The results may be more modest and natural than although it does not appear as yellow globs, but
when muscle and fat are aggressively removed. less yellowy and firmer (Fig. 12.9).
● Some patients can be helped by a more defined upper The fat will need to be anesthetized prior to removal.
eyelid crease requiring modest muscle and fat There should be very little tugging or pulling on the
removal. fat to decrease the chance of bleeding.
● If orbicularis ocular muscle is removed, it is impor- The fat is usually cauterized away with visible shrink-
tant to remove a thin strip of muscle in the upper half ing of fat seen.
of the wound so that any chance of damage to the
Clamping of fat was taught as a technique of fat
levator aponeurosis is minimized (Fig. 12.7).
removal; however, this may create more pulling on
● A thin conservative strip of orbicularis oculi muscle the fat, which could lead to bleeding and a possi-
should be removed with tenotomy scissors. This ble retro bulbar hematoma.
removal of muscle helps create a more defined eye-
The fat should be removed very gently so that the
lid crease.
chance of bleeding is minimized.
● The amount of muscle and fat removed would be
greater when operating on an Asian eyelid requiring
the creation of a defined crease. CLOSURE
● After the strip of muscle is removed fat may project ● Use a buried 5-0 or 6-0 Vicky or Dixon on the lateral
above the surface of the orbicularis muscle or many canthal side since this is where most of the tension
times the surgeon will need to use Tenotomy type across the wound exists.
A B
FIGURE 12.7 Removing a strip of orbicularis muscle will help recreate the eyelid crease
Chapter 12: Upper Lid Blepharoplasty | 111
FIGURE 12.8 The orbital septum is opened with tenotomy scissors dissecting into the bulging
fat areas. Exposed fat is vaporized with electrocautery
● Use one of these buried sutures to relieve lateral

wound tension.
● Follow the one buried suture by using running 6-0 fast
absorbing gut so that sutures do not have to be
removed.
● Some lagophthalmos (1–2 mm) where the eye does
not close is permissible postoperatively because of the
swelling created by the anesthesia and surgery.
POSTOPERATIVE CONSIDERATIONS
● The main worry for any blepharoplasty patient is to
make sure that bleeding does not occur, which could
lead to a retro bulbar hematoma and eye damage.
FIGURE 12.9 Avoid lacrimal gland in the lateral upper ● Patient should be called the night of surgery to make
opening by looking for prolapsed tissue that is not as sure that there is no complaint of excess pain as that
yellow as fat could be a sign of increased pressure from a hematoma.
● A patient complaining of pain should be examined ● Scarring or milia type bumps of the incision line can be
and the possibility of opening up the wound to find treated with dilute intralesional steroids.
any bleeding vessel be entertained. ● Upper eyelid scarring will always resolve or markedly
● A patient may need to be examined to make sure that improve with time.
any lagophthalmus has resolved. ● Patients complain of not enough skin being excised.
● Swelling can peak at 48 hours after the procedure and This is usually due to brow ptosis requiring a forehead
so the patient should be warned about the possibility lift.
of the lids being swollen shut.
● Asymmetry may be noted; however, it is usually due to SUGGESTED READING
swelling that has occurred greater on one side or
another. 1. Bosniak S. Reconstructive upper lid blepharoplasty.
Ophthalmol Clin North Am 2005;18(2):279–289.
● Place wound closure tape over the fast absorbing gut
2. Collins PS. Upper lid blepharoplasty with skin, muscle
sutures so that the patients do not see the wound since
and fat excision. In: Moy RL, Fincher EF, eds. Ble-
they leave this on until one of their postoperative visits
pharoplasty. Elsevier Press, 2006, Ch 4, pp. 37–52.
around postoperative day 3 to day 7.
3. Gentile R. Upper lid blepharoplasty. Facial Plast Surg
Clin North Am 2005;13(4):511–524.
4. Eremia S, Willoughby MA. Upper lid blepharoplasty
COMPLICATIONS with maximal hooding correction. In: Moy RL, Fincher
● Late complications of an upper lid blepharoplasty are EF, eds. Blepharoplasty. Elsevier Press, 2006, Ch 4,
uncommon. pp. 37–52.
CHAPTER
CHAPTER13
0 Forehead
Chapter Title
Lift
Ron Moy, MD ■ Pretrichial Forehead Lift
● Incision is at the hairline: Ideal in patients with large
forehead since some of the forehead will be excised.
● Second most dramatic forehead lifting results, but car-
KEY POINTS FOR SUCCESS ries risk of visible scar when hair pulled back. This may
be minimized when the incision is beveled so that hair
grow through the hairline.
● moderate results,
● need for a bone screw in temporal brow lifting, and
■ Temporal Brow Lift
● potential complications.
● Minimal incision: Same as endoscopic brow lift, but
● Careful planning of the vector of lift.
without using endoscope.
● Careful and gentle undermining to prevent nerve
● Corrects lateral eyelid heaviness by lifting the lateral
damage.
brow (Fig. 13.1)
● Without endoscope, bleeding is still minimal but with
INDICATIONS
careful dissection and release of forehead-brow
● Temporal brow forehead lift, pretrichial forehead lift, area.
the endoscopic forehead lift or coronal for upper eye- ● With endoscope, blood vessels can be visualized
lid heaviness, which cannot be corrected with upper thus minimizing bleeding.
lid blepharoplasty
● Minimal complications.
● Upper eyelid heaviness caused by brow ptosis.
TYPES OF FOREHEAD LIFT
The main issues are as follows:
Types of forehead lift vary with
● Patient expectations
● placement of the incision,
● modest correction of brow ptosis;
● the plane of dissection, and
● actual results and longevity of results;
● type of fixation.
● placement of a bone screw, which remains in place
for 2 weeks vs. just suture fixation.
■ Coronal Forehead Lift ● Potential complications
● Largest incision ● Damage to the temporal branch of the facial nerve,
● Almost from ear to ear behind the hairline. although this must be a rare event since all under-
● Dissection of the forehead down to the brows and mining is beneath this nerve.
corrugator muscles. ● Slight trauma to the nerve, swelling, or traction on
● Most dramatic lifting results, but carries risk of the nerve could account for a temporary temporal
nerve injury that resolves.
● alopecia,
● Infection
● numbness, and
● Scarring
● unnatural appearance when mid forehead is pulled
● Alopecia
greater than the lateral brows where more ptosis
usually occurs. ● Bleeding
A B
FIGURE 13.1 Temporal browlift can improve the lateral hooding without a upper blepharoplasty and any obvious
incisions on the upper eyelids
INCISION ner of the lateral nose where the melolabial fold inter-
sects through the lateral canthal region to the tempo-
● A 1-cm incision is placed at least 5 mm behind the ral hair area (Fig. 13.2).
temporal hairline to hide the incision. ● The incision can also be placed both perpendicular
● To maximize lifting, the incision is placed in the vector to the vector of pull and parallel to the nasal labial
of pull, which is usually in a line starting from the cor- fold.
A FIGURE 13.2 Temporal browlift incision and vector of lift

Chapter 13: Forehead Lift | 115
Fixation
for radial
incisions
Radial
incision
Tension
14 mm screw
placed at posterior
end of incision
FIGURE 13.3 Bone screw and staple fixation places a screw behind a staple perpendicular to the temporal browlift
so that the incisions are smaller but requires a screw to protrude above the skin surface for a couple of weeks
● A small incision perpendicular to the nasal labial fold UNDERMINING AND RELEASE
in the temple area is necessary when using a
● Undermining occurs from the incision to the periosteal
screw–staple for fixation (Fig. 13.3).
attachments below the eyebrow (Fig. 13.4).
● The bone screw is placed within the incision and the
● The plane of undermining is over the deep temporal
scalp is pulled back.
fascia to the periosteum of the orbit, which can be
● A staple is placed behind the screw to hold the scalp
checked by making a nick over the white glistening
in place.
fascia of the deep temporal fascia and seeing tem-
● The other incision method is a 2-cm parallel incision poralis muscle (Fig. 13.5).
with a small amount of skin excision and sutures to the
● The undermining is carried our carefully under the
temporal fascia is for fixation.
temporal branch of the facial nerve to the periosteal
● Suture placement can be difficult with the 1-cm mini- attachments of the orbit.
mal incision and so the incision may need to be
● Careful and gentle undermining will decrease any
extended.
chance of damage to the nerve (Fig. 13.6).
● The elliptical incision has the advantage of allowing
● A periosteal elevator is helpful especially to gently
more room to place the fixation sutures and allowing
access for the undermining and brow release. release the periosteal attachments.
● This temporal 1.5-inch incision can also be used to ● A Metzenbaum facelift scissor can by used if the
place the Endotine device or to place suture threads periosteal attachments are released gently.
that pull up the mid-cheek fat. ● Undermining across the forehead will include the
● For bone screw–staple fixation and suture fixation an fascial sheath that divides the middle forehead from
“A to T” type incision is created, which allows both an the temporal forehead that needs to be released and
elliptical excision and screw placement. separated.
FIGURE 13.6 A finger protects the glove and helps

facilitate the release of attachments with a periosteal
elevator
● The 1.5-inch incision placed behind the temporal

FIGURE 13.4 The most important part of a temporal hairline can be fixed with sutures to the deep tem-
browlift is the release of fibrous attachments under the poralis fascia pulling in a superior direction.
eyebrow with a periosteal elevator and not the excision
A 0.25-inch small incision perpendicular to this inci-
of skin
sion can be used to use the screw–staple fixation,
which will stay in place for 2 weeks (Fig. 13.3).
Botox is also used to immobilize the area and
achieve better fixation.
● The Endotine device placed at the forehead hairline
FIXATION
can be an effective quick method that allows the
● Fixation of the brow can be accomplished with sutures, skin to be draped superiorly over the device that has
a screw, and a dissolving needle device (Endotine) been fixated to bone.
(Fig. 13.7). The main disadvantage of this device is its cost and
that this palpable device under the skin lasts for
many months.
COMPLICATIONS
● The chance of complications with this procedure is
minimal.
● The most severe complications may be the following:
● Permanent damage to the temporal branch of the
facial nerve, which is rare.
● Alopecia at the incision site is possible.
● Modest results are sometime achieved compared to
the coronal lift, which gives maximum results with a
large incision, and sometimes does not give a natural
FIGURE 13.5 White glistening of deep temporal fascia appearance because the maximum pull can be
above muscle above the middle glabella area.
Chapter 13: Forehead Lift | 117
STF
F
DT TM
DTF STF DTF

“WINDOW”
FIGURE 13.7 Fixation of the elevated brow lifted skin and superficial temporalis fascia
(STF) to the deep temporalis fascia (DTF)
SUGGESTED READING Surg 1996;97(7):1334–1342; Plast Reconstr Surg

2001;108(2):564–567.
1. Langdon RC. Endoscopic Brow Lifting. In: Moy RL, 3. Troilius C. Subperiosteal brow lifts without fixation.
Fincher EF, eds. Blepharoplasty. Elsevier Press, 2006, Past Reconstr Surg 2004;114(6):1595–1603.
Ch 4, pp. 37–52.
2. Knize D. Limited-incision forehead lift for eyebrow ele-
vation to enhance upper blepharoplasty. Plast Reconstr
CHAPTER
CHAPTER14
0 Minimal
Chapter Title
Incision Face-Lift and Face-Lift
Ron Moy, MD ● The neck improvement is not quite as good as the con-
ventional face-lift with the incision behind the ear, but
significant improvement can be achieved.
● The results are always more significant than with any
KEY POINTS FOR SUCCESS of the suture thread lifts.
●
complications and
● Listen to the patient’s wants and concerns and analyze
● with minimal incision face-lift the neck improvement
what can be done for the patient.
is not quite as good as with traditional face-lift.
● Establish a rapport with patients by educating them on
● Maintaining a vertical vector of pull throughout the
the procedures and discussing all the pros and cons.
procedure.
● Photographs of typical face-lift patients may be helpful.
● Careful homeostasis and avoidance of bleeding
● A slight pull of the skin in a vertical vector may also
through the use of tumescent anesthesia and electro-
cautery. simulate the face-lift results.
● Risks and benefits should be described including the
● Use of undermining scissors separated in a vertical,
risks of
rather than horizontal, direction.
● infection
● Careful undermining in the temple region to avoid
● bleeding
nerve damage.
● scarring
● Use of multiple superficial plication sutures.
● nerve damage
● Careful trimming of excess skin that is pulled in the
vertical direction. ● A second consultation is suggested so that good com-
munication can be established between the physician
and the patient. A detailed description of the possible
INDICATIONS complications can be discussed during this time,
including discussion of the actual consent form.
● Jowls and neck sagging (Figs. 14.1 and 14.2)
● Different types of face-lifts can be discussed, including
● Desire to improve appearance of the lower third of the the methods of
face with a minimal incision face-lift or a regular face-
● SMAS (superficial muscular aponeurotic system)
lift (Fig. 14.3).
tightening,
● In a traditional face-lift, the incision is made behind the ● the incisions to be made, and
ear and there is a possibility of scarring, which can be
● alternative procedures.
noticeable for patients with short hair.
● The type of anesthesia, i.e., whether local anesthesia
● In a minimal incision face-lift, the incision begins with
or local anesthesia with twilight sedation (Versed and
a trichophytic temporal incision extending retrotragal
Propafol), should also be discussed.
and ends at the earlobe accomplishing excellent
results for the mid-cheek area, along the jawline and
even the neck if the vector of pull is more vertical INCISION
instead of the sideways pull. ● Incisions can be tailored to a patient’s needs, but the
● This newer face-lift has the advantage of a smaller inci- most common is a temporal incision 2 mm behind the
sion line, more natural result, and not causing the scar hairline so that mid-cheek and neck elevation can be
behind the ear. achieved (Fig. 14.5).
A B
FIGURE 14.1 A. Preoperative and B. postoperative photos show that S-Lift gives jowl improvement and some neck
improvement
A B
FIGURE 14.2 A. Preoperative and B. postoperative photos show improvement of a heavy neck accomplished with a
postauricular incision that extends to the hairline behind the ear. A heavy neck such as in this patient makes
improvement more difficult
Chapter 14: Minimal Incision Face-Lift and Face-Lift | 121
A B
FIGURE 14.3 A. Preoperative and B. postoperative photos show improvement of the jowls and neck with an S-Lift
vertical minimal incision lift. There is less improvement of the neck than a full-face-lift with an incision behind the
ear and into the hairline. Mid-face-lifting of the malar fat pad will improve the eye area, including giving the improve-
ment of the jowls and modest improvement of the neck area
● The advantage of the temporal hairline incision is ● The incision is then carried to the hairline with a
that the hairline is not altered, which can often cause beveled incision, which can allow a vector of pull that
the stigmata of obvious cosmetic surgery. improves the neck region.
● The incision should be beveled in a 45⬚ angle and in ● The other incision that can improve the neck is a small
a zigzag fashion so that any dog-ear and scar is min- submental incision in the submental crease. With this
imized. incision, the platysma separation and banding can be
● A temple zigzag incision will decrease any dog-ear tightened, subplatysmal and platysmal fat can be
formation in the temple area. removed, and the neck skin can be redraped.
● The beveled incision will also allow hair to go through ● An incision near the postauricular sulcus actually over
any scars. the cartilage portion of the ear (so that after suturing
●
the incision scar will fall into the postauricular sulcus)
The incision then is carried down to behind the tragus
and than extending high on the postauricular sulcus
and down to the earlobe without beveling.
and extending down into the neck hairline is used to
● A retrotragal incision hides the incision better, although give more of a neck-lift. This post-auricular incision will
care needs to be taken not to distort the tragus. allow more of a posterior pull to the neck.
● Sometimes the incision is carried behind the ear to
remove a dog-ear; however, if the vector of pull is
more vertical, the dog-ear is minimal and the neck
UNDERMINING
improvement is maximized. ● Undermining needs to be carried out in the best plane
● If the incision is extended to the postauricular area, so that the flap created is of sufficient thickness and
it should be placed onto the back surface of the ear bleeding is minimized (Fig 14.6).
instead of into the postauricular sulcus. ● Bleeding can be minimized with the use of tumescent
● This extension is carried high above the level of the anesthesia so that a natural separation occurs.
auditory canal so that the scar across to the hairline ● This natural separation can also be created by
will not be seen. using undermining scissors separated in a vertical
FIGURE 14.4 Rejuvenation of the face requires eleva-

tion of the SMAS, malar fat, submental tissue, and skin.
A vertical vector provides superior “lifting” compared
with a posterior or horizontal vector
FIGURE 14.5 Vertical minimal incision S-Lift. The inci-

direction instead of the more common horizontal
sion extends around the temporal hairline, the retro-tra-
separation.
gal incision down to the earlobe. Three purse string
● Another method to insure the proper flap thickness is sutures are used to vertically lift the SMAS and the
to shine the overhead light through the flap so as to malar fat pad. Care must be taken so that these purse
insure the flap “possesses” a uniform amount of fat. string plication sutures do not damage the facial nerve
● The incision at the retrotragal area needs to preserve
the cartilage and create a flap of adequate thickness.
● The incised flap than is undermined about 6 cm away
from the incision.
● The amount of undermining needs to extend a dis-
tance away from the skin edge at so that plication
sutures can be placed.
● The undermining can be extended to the nasolabial
fold, although this would be considered an aggressive
procedure.
● Extending the undermining to the nasal labial fold does
not seem to significantly improve the fold as much as
using some type of mid-cheek fat plication or mid face-
lift, which improves the nasal labial fold.
● Undermining in the temple area has to be done with
caution because of the path of the temporal branch of
the facial nerve or prominent blood vessels in this
area. FIGURE 14.6 Undermining should be done with the
● Hemostasis after undermining should be accom- blades of the tenotomy scissors held vertically rather
plished very carefully with bipolar electrocautery or than horizontally
minimal light cautery (Monopolar Hyfrecator) so as not
to damage any branches of the facial nerve.
● Tumescent anesthesia with a concentration of at least
1% lidocaine and epinephrine minimizes significant
bleeding.
PLICATION OF SMAS
The methods of tightening the SMAS include the follow-
ing:
● Imbrications—incising into the flap and suture tighten-
ing.
● Using a technique that pulls up the mid-cheek fat with
a suture or a suture thread will also give nasolabial
improvement.
● Mastectomy—removing a strip of SMAS over the
parotid and suturing the incised edges together.
● A small 1-inch wide strip of the SMAS starting at the
superior parotid and extending to the lateral cheek- FIGURE 14.7 Multiple plication sutures with 3-0
mid face area is removed. Maxon or Vicryl sutures lift and loosen SMAS. These
● The two edges of the separated SMAS are then plication sutures are best fixated on stable tissue near
sutured together. the ear and away from the path of the temporal branch
of the facial nerve
● Deep plane face-lifting—undermining deeply past the
parotid area. Undermining of the SMAS into the mid-
cheek and advancing it in a superior direction consti-
tutes a deep plane face-lift.
● This type of deep-plane face-lift was once thought to
give more and longer lasting improvement of the
nasolabial fold.
● This nasolabial improvement has not been proven to
be better with the deep-plane face-lift techniques
compared to the plication techniques.
● The deep-plane face-lift puts the facial nerve at more
risk.
● Plication of the SMAS, which is suture tightening of the
SMAS without incision into the SMAS.
● The simplest method is to use multiple large inter-
rupted 2-0 or 3-0 suture loops (Maxon, PDS or Ethi-
bond) wherever there is SMAS looseness around the
parotid area (Fig. 14.7).
● The sutures encompass the loose SMAS and can be
fixed to the stable tissue near the superior preauric- FIGURE 14.8 Tightening of the plication sutures may
ular ear above the tragus. tighten the SMAS as well as any deep plane face-lift
● The ideal vector of pull is in a vertical direction, which according to many surgeons and paired comparison
will improve the neck and the jowls (Fig. 14.8). studies
● Multiple plication sutures are the simplest and one of Second suture
the safest methods of plication if the plication bites
are kept superficial. First suture
● Plication has also been described with the S-Lift and Zygoma
the minimal access cranial suspension lift (MACS-lift).
Once continuous purse string suture is placed, taking
small bites starting from a superior pre-auricular position
down to include platysma-SMAS, jowls or cheek fat or
just SMAS and returning to a superior pre-auricular
position and tightened. The suture is fixed to the deep
temporalis fascia anterior, to the ear or below the zygo-
matic arch posterior to the path of temporal branch of
the facial nerve. Three of the plication purse string
sutures are used (Fig. 14.9).
● The first suture improves platysma ptosis.
● The second suture improves the lower jowls.
● The third suture is placed in the mid-cheek area and
extends to a lateral canthal position avoiding the FIGURE 14.10 Purse string plications sutures tighten
temporal branch of the facial nerve. the SMAS of the cheeks and the neck. These purse
string sutures are fixated close to the ear on the zygoma
● This suture is anchored in the temporalis muscle
so that interference of any branches of the facial nerve
fascia, lateral to the lateral orbital rim and anterior
is minimized
to the path of the temporal branch of the facial
nerve.
● This suture or a suture thread provides improvement
of the nasolabial fold and mid cheek areas.
Anchor sutures or suture threads can also be used

to improve this mid-face area.
The use of a position on the inferior mid zygoma has
also been advocated as a point of fixation since
this is also a firm place with only a small chance of
2.0
facial nerve injury (Fig. 14.10).
The disadvantage of using the zygoma periosteum
2.0 1.8
to fixate the plication sutures is that it may more
easily cross the facial nerve path and it is harder
to fixate the suture to the tissue lying over the
zygoma.
● With either of the plication techniques, the path of the
facial should be drawn and the sutures should avoid
the path and depth of the facial nerve that starts within
the parotid gland and extends to the temple forehead
area.
FIGURE 14.9 MACS lift: Two pursestring sutures are ● Once the plication sutures have been placed, there is
used to create a vertical pull on the SMAS and platysma often dimpling of the skin that needs to be corrected
of the neck. A third purse-string suture is used to ele- by separating the skin from the underlying tissue with
vate the malar fat pad to rejuvenate the midface the undermining scissors.
TRIMMING OF EXCESS SKIN
● Trimming of excess skin can be the longest part of the
procedure.
1
● The first step is to pull the skin up in a vertical direc-
tion so that the jowls and neck are improved.
● This upward vector pull gives a more natural look
than a sideways posterior vector pull and it also
improves the neck. 3
● The flap must be incised, trimmed, and finessed so

that the tension across the wound is minimal yet
improved results along the jowl-neck are achieved.
● A few staples can be used across the maximum ten-
sion points.
● The first staple where tension occurs is above the
ear (Fig. 14.11). FIGURE 14.12 Small incisions are followed by trim-
● The skin flap is pulled in a superior direction and ming of the excess skin
small amount of skin is excised to the point where
the skin edges can by stapled with cosmetic
improvement (Fig. 14.12). ● If a dog-ear occurs, it can be repaired or removed
● This suture can have tension across it with the use behind the ear adjacent to the earlobe.
of staples. ● This dog-ear removal of skin behind the ear maybe
● Most face-lifts will relax over the first few months resulting necessary in patients with excessive neck laxity.
in significant tension above the ear. ● It is best to recreate the natural tragal contour by thin-
● Tension should be minimized across the tragus and ning the fat and dermis over the tragal cartilage and
earlobe. anterior to the tragus.
● Buried sutures are used to take tension off the incision ● Skin is rarely excised anterior to the tragus with the
line and the skin edges are closed with 5-0 gut and minimal incision face-lift.
buried with 4-0 sutures.
● The natural earlobe without the “attached earlobe”
● It is best to start suturing at the superior end of the appearance is created by not suturing the earlobe to
incision line (temple area) down to the earlobe area so the cheek skin. This issue should be discussed with the
that any dog-ears are minimized. patient and observed prior to surgery to decide whether
to suture the lobe to cheek skin or to let the earlobe
heal naturally without attachment to the cheek skin.
● If the neck-lift is being added, the skin closure tension
should be minimized using buried sutures.
● The skin flap tolerates less tension across the neck
area than the face area. The flap is usually thinner with
less subcutaneous fat in the postauricular neck area.
● It can be difficult to separate the skin from the under-
lying fascia and muscle in the postauricular area.
ANCILLARY PROCEDURES
● Neck liposuction or platysmal tightening via a sub-
FIGURE 14.11 First tension suture above ear mental incision can create improved results. Platys-
mal plication is indicated in patients with significant COMPLICATIONS
platysmal banding when the face-lift has not improved
● Complications from a face-lift are uncommon and rare.
banding.
● Risks of infection are very unlikely on the face because
● Laser resurfacing can be done at the same time as the
face-lift. of the good blood supply.
● The chance of bleeding creating a hematoma can be
● The most common areas of laser resurfacing include
the eye and lip areas. decreased by making sure the patient has not been on
any blood thinners and appropriate bleeding studies
● The entire face can be resurfaced if resurfacing is
are performed.
done very conservatively, especially toward the
edges of the flap. Careful meticulous hemostasis with minimal cautery
(so that the chance of nerve damage is minimized), care-
● Pinch excision of the lower eyelid can be performed to
ful dissection, and tumescent anesthesia all contribute to
improve infraorbital skin laxity. Pinch excision of the
the least chance of a hematoma.
infraorbital skin may need to be performed when skin
● Careful undermining with plication will have a low
is pulled in a superior upward direction.
probability of any permanent nerve damage.
● Volume replacement is important to give natural-
● Unless the extremely deep bites of tissue are taken
appearing results.
with the purse string plication sutures, the facial
● A tighter face does not always make a patient natu-
nerve will not be damaged.
rally looking younger.
● Fixation of the periosteal suture outside of the path
● Thin patients can benefit from fat or Sculptra injec-
of the motor branches of the facial nerve will
tions into the mid cheeks.
decrease the possibility of nerve damage.
● Volume replacement will also give the mid-cheek ● If a patient is exhibiting unilateral motor nerve weak-
area some lifting and rounding of the cheeks.
ness, placations sutures can be loosened or released.
● Volume replacement prevents any “wind tunnel ● Skin necrosis is minimized with the creation of an ade-
appearance” where it appears the skin has been
quate thickness flap and minimal tension. The full-
pulled too tight or pulled sideways.
face-lift is more likely to give necrosis because the
postauricular flap is thinner and often is subjected to
POSTOPERATIVE CONSIDERATIONS increased tension.
● Considerable swelling and bruising can occur from any
face-lift including a minimal incision face-lift. SUGGESTED READING
● It is hard to predict who will get such swelling. Brandy DA. The Quick lift: a modification of the S-Lift.
● A minimized pressure dressing around the face can Cos Dermatol 2004;17:351–360.
prevent some of this bruising. Nobel A. La Chirurgie Esthétique son Rolle Social. Mason
● Drains are not necessary to prevent hematomas. CIA, Paris, 1926, pp. 62–66.
●
Nobel A. La chirurgie Esthetique. Claremont (Oise), Thiron
It has not been proven that the use of fibrin glues
et Cie, 1928.
decreases the amount of bruising or hematomas.
Tonnard PL, Verpaele AM. The MACS-Lift. Short-Scar
● Patients should be seen after the procedure to look for Rhytidectomy. Quality Medical Publishing, St. Louis,
any postoperative complications, such as hematomas. MO, 2004.
● Facial nerve injuries are always a possibility but Moy RL, Fincher E, eds. Advanced Facelifts. Elsevier,
uncommon. 2006.
SUBJECT INDEX
A temporary dermal fillers, 44
Ablative lasers. See Aids and devices upper lid blepharoplasty, 112
Advancement flaps, 9 Considerations, postoperative. See also Postoperative
Aids and devices course/care
ablative lasers, 91, 93–94 face-lifts, 126
endovascular laser, 83f, 83t upper lid blepharoplasty, 111–12
forceps, 104 Consultations, preoperative. See also Planning,
hair densitometer, 73, 74f preoperative
instrumentation, 74, 75t, 63f face-lifts, 119
tenotomy scissors, 104 forehead lift, 113–14
Ancillary procedures, 125–26 lower lid blepharoplasty, 101, 102f
Anesthesia, 35, 63–65, 75, 102 upper lid blepharoplasty, 107
Contraindications
B fat transfer, 69
Botox, 48 hair transplantation, 73
Brow lift, 49 initial patient consultation, 2, 4t
lasers, 91
C liposuction, 57–58
Candidate selection temporary dermal fillers, 38–39
for fat transfer, 69 varicose and telangiectatic leg vein treatment, 81
for hair transplantation, 73 Coronal forehead lift. See Forehead lift, types of
Cheek defects, 11f, 12, 15–16 Crow’s feet, 51
Chemical peeling, 31–35
Chemical peeling, frequency of, 33, 35 D
Chemical peels, 31–36 Depressor anguli oris/frown, 53–54
Chin defects, 26 Dermal fillers, 37–44
Clinical hyperpigmentation, 32–33 Donor dissection, 76
Closure, 110–11 Drug discontinuance guidelines, 3t
Combination brow lifting, 49 Dysport, 48
Complications
ambulatory phlebectomy, 87t E
botulinum injections, 54–55 Ear defects, 26, 28–30
dermasurgical procedures, 6 Endovascular laser. See Aids and devices
face-lifts, 126 Epidermal melasma, 32–34
fat transfer, 71 Excess skin trimming, 125
forehead lift, 116–17 Eyebrow defects, 10–12 (bis)
hair transplantation, 79 Eyelid defects, 12–15 (bis)
liposuction, 67–68
lower lid blepharoplasty, 105–6 F
resurfacing lasers, 99 Facial lipoatrophy, 38f
telangiectasia/reticular veins, 89 Facial musculature, 48–49, 50f
128 | Index
Fat and/or muscle removal, 103–4, 109–10 Injection sites

Fat transfer, 69–71 botulinum injections, 48–54
Fat transposition, 104 temporary dermal fillers, 40–44
Filler selection, 40 Instrumentation. See Aids and devices
Fixation, 116 Interpolation flaps, 9
Flap types, 9
Forceps. See Aids and devices J
Forehead defects, 10 Jawline restoration, 42–43
Forehead lift, types of, 113
Frown lines, 48
K
Key points for success
G
botulinum injections, 47
Glabellar complex, 44, 48, 51f
chemical peels, 31
Graft preparation, 76
face-lifts, 119
Gum show, 53
facial flaps, 9
fat transfer, 69
H
forehead lift, 113
Hair densitometer. See Aids and devices
hair transplantation, 73
Hair removal, 94–95
initial patient consultation, 1
Hair transplantation, 73–79
lasers, 91
Horizontal forehead lines, 50–51, 52f
liposuction, 57
Hyaluronic acid, 37
lower lid blepharoplasty, 101
Hyaluronidase, 44
temporary dermal fillers, 37
Hydroxy acids, 33
upper lid blepharoplasty, 107
Hypertrophic orbicularis oculi, 51, 53
I L
Incision, 102–3, 109, 114–15, 119, 121 Lasers, 91, 92t
Indications Lip defects, 23–27 (bis)
chemical peeling, 32 Lip enhancement, 41, 43f
face-lifts, 119, 120f Liposuction, 57–68
fat transfer, 69
forehead lift, 113 M
hair removal, 94 Mastectomy, 123
hair transplantation, 73 Medical considerations
lasers, 91 botulinum injections, 47
liposuction, 57 initial patient consultation, 1–2
lower lid blepharoplasty, 101 varicose and telangiectatic leg vein
temporary dermal fillers, 38 treatment, 81
upper lid blepharoplasty, 107 Medications
varicose and telangiectatic leg vein treatment, 81 hair transplantation, 74–75
vascular testing, 81–82 initial patient consultation, 2
Inflammatory hyperpigmentations, 93–94 leg veins, 81
Informed consent temporary dermal fillers, 39
botulinum injections, 47–48 Medicines affecting coagulation, 60t-61t
initial patient consultation, 4, 5f Mentalis, 54
temporary dermal fillers, 39–40 Myobloc, 48
Index | 129
N Preoperative considerations, liposuction, 58–61

Nasalis, 53 Preoperative goals, 73–74
Nasojugal crease, 43 Preoperative labs, 61, 69
Nasolabial folds, 40–41, 42f Preoperative marking, 84, 85t, 107–8
Necrosis, 44 Pretrichial forehead lift. See Forehead lift, types of
Nitroglycerin paste, 44 Psychosocial history
Nonablative rejuvenation technologies, 96t botulinum injections, 47
Nonfacial chemical peeling, 35 initial patient consultation, 4
Nose defects, 15, 17–23 (bis) temporary dermal fillers, 39
O R
Oral commissures, 42 Radiesse, 37
Red facial lesions, 92f, 93
P Reimbursement/Fee structure, 6, 7f
Patient expectations, 4, 6 Repetitive nasal flare, 53
Peel depth, classification of, 32 Rhytids
Peeling agents, 33 face, 38
Periorbital lines, 52 periocular, 43
Pharmacology perioral, 53
botulinum toxin, 47 radial, 53
chemical peeling, 31 reduction of, 96–97
dermal fillers, 38 Rotation flaps, 9
Photography
botulinum injections, 48 S
initial patient consultation, 4, 6f “Smoker’s lines”, 48
temporary dermal fillers, 40 Skin smoothing, 96
Physical examination Skin tightening, 98
hair transplantation candidate, 73 Skin toning, 96
leg vein patients, 81–82 Staphylococcus aureus, 2
liposuction, 59 Staphylococcus epidermides, 2
Pigmented lesions, 93–94 Superficial muscular aponeurotic system (SMAS)
Planning, preoperative. See also Consultations, plication, 123–24
preoperative Surgical considerations, 2, 81
fat transfer, 75–76 Surgical suite setup, 61
temporary fillers, 39–40 Swelling, 44
upper lid blepharoplasty, 107–8
Postoperative course/care. See also Considerations, T
postoperative Technique
botulinum injections, 54 ambulatory phlebectomy, 84–86, 87t
fat transfer, 71 canthopexy suture, 104–5
hair transplantation, 78–79 duplex guided endovascular sclerosing, 83, 84t
initial patient consultation, 6 fanning, 40, 41f
lasers, 99 fat transfer, 70–71
leg vein treatment, 83, 85 foam sclerotherapy, 86–87
liposuction, 66 graft dissection, 76f
temporary dermal fillers, 44 hair transplantation, 75–76
Preoperative blood work-up, 75 injection, 40–41
130 | Index
Technique (continued ) hair removal, 94–95

laser resurfacing, 104 lower extremity veins, 82
liposuction, 61–66 resurfacing lasers, 98–100
nonablative rejuvenation, 95–96 telangiectasia/reticular veins, 87–89
photoepilation, 94, 95t tissue contour defects, 38
pinch excision, 104 truncal veins, 83
radiofrequency closure, 82–83
recipient placement, 76–78 U
serial puncture, 40, 41f Undermining, 115, 116f, 121–23
threading, 40–42
transplantation, 71 V
Temporal Brow lift. See Forehead lift, types of Vascular lesions, 91, 92f
Tenotomy scissors. See Aids and devices Volume selection, 40
Tissue movement principles, 9–30
Transposition flaps, 9 W
Treatment Wrinkling, 33

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CONCISE MANUAL OF

New York Chicago San Francisco Lisbon London Madrid

Want to learn more?

We would like to acknowledge Samuel Stegman, Theodore

Preface . . . . . . . . . . . . . . . . . . . . . . . . ix Chapter 8: Hair Transplantation . . . . . . 73

Chapter 1: Approach to the Chapter 9: Evaluation and Treatment

Chapter 6: Liposuction . . . . . . . . . . . . 57 Chapter 14: Minimal Incision

Medical History (includes system review)

Do you have or have you had any of the following?

Do you need antibiotics before surgical or dental procedures? [ ] [ ]

Information Request (check if you would like more information)

__________________________________________ _______________ _______________ ____________

FIGURE 1.1 Patient medical/surgical history questionnaire

Procedure: _________________________________ Fee: _________________________

CONCLUSION 5. Shiffman MA. Dangers of herbs when performing

■ Advancement Flaps (Table 2.1)

● Within the brow ● Lid wedge advancement

FIGURE 2.7 A. Lower lid defect. B. Lower lid defect.

FIGURE 2.8 A. Inner canthus defect. B. O to Z recon-

FIGURE 2.10 A. Nasal sidewall defect. B. Dorsal

FIGURE 2.17 A. Nasal sidewall defect. B. Dorsal

FIGURE 2.19 A. Nasal defect. B. Island pedicle—

FIGURE 2.20 A. Nasal defect. B. Dorsal nasal—

FIGURE 2.21 (continued) C. Bilobed—2 months

FIGURE 2.22 A. Forehead ﬂap—immediately postsuture. B. Forehead ﬂap—8 months postoperative

FIGURE 2.23 A. Ala defect. B. Rhombic—immediately

● Melolabial ● Nasal ala

FIGURE 2.24 A. Nasal defect. B. Meilolabial—

● Dorsal-nasal ﬂap: Can also be used in tip defects of ■ Lips

FIGURE 2.25 A. Lower lip defect. B. Wedge

FIGURE 2.27 A. Upper lip defect. B. Bilateral advance-

● Lateral upper crease. The cheek advancement blunts the boundary

FIGURE 2.32 A. Presurgery. B. Helix defect. C. Antia-

SUGGESTED READING 3. Robinson JK, Hanke WC, Senglemann RD, Seigel

● Mild to severe dermatoheliosis ● Jessner’s solution (Fig. 3.3)

FIGURE 3.4 Frosting is a sign of self-neutralization of ■ Procedure

FIGURE 4.1. Recommended ﬁller injection depths. (Reprinted with per-

● Direct questions toward specific drugs isotretinoin

TABLE 4.1 ■ Medications and Herbs That Can Affect Hemostasis

Lips (Fig. 4.5)

FIGURE 4.4. A. The linear threading method of injection is

Oral commissures ● In both cases, we use a bent 30-gauge needle

FIGURE 4.5. Technique for lip architecture

TABLE 4.2 ■ Side Effects

Levator labii Zygomaticus

FIGURE 5.1 A. Upper and midfacial musculature

■ Brow Lift—Lateral ■ Brow Lift—Medial

Auricularis superior muscle

Auricularis anterior muscle

Zygomaticus major muscle

Eyebrow—special considerations Eyebrows—cautions

FIGURE 5.2 A & B. Injection sites for glabellarfrown

FIGURE 5.3 A. Injection sites for horizontal forehead

FIGURE 5.4 A. Injection sites for periorbital lines.

■ Hypertrophic Orbicularis Oculi

■ Upper Gum Show

● Examine bulk—anterior thigh, calves, upper back ● Oxygen

Body Habitus: Thin Normal Mild obese Morbid obesity

Extent of suctionable adiposity: Mild Moderate Extensive

Skin Quality – Elasticity: Poor Adequate Good

__________________________________ _ _ ____

Procedure: _________ Fee: _