Cosmetic Bootcamp Primer: Comprehensive Aesthetic Management

Cosmetic Bootcamp Primer

SERIES IN COSMETIC AND LASER THERAPY Series Editors David J. Goldberg, Nicholas J. Lowe, and Gary P. Lask Published in association with the Journal of Cosmetic and Laser Therapy

David J. Goldberg, Fillers in Cosmetic Dermatology, ISBN 9781841845098 Philippe Deprez, Textbook of Chemical Peels, ISBN 9781841842954 C. William Hanke, Gerhard Sattler, Boris Sommer, Textbook of Liposuction, ISBN 9781841845326 Paul J. Carniol, Neil S. Sadick, Clinical Procedures in Laser Skin Rejuvenation, ISBN 9780415414135 David J. Goldberg, Laser Hair Removal, Second Edition, ISBN 9780415414128 Benjamin Ascher, Marina Landau, Bernard Rossi, Injection Treatments in Cosmetic Surgery, ISBN 9780415386517 Avi Shai, Robert Baran, Howard I. Maibach, Handbook of Cosmetic Skin Care, Second Edition, ISBN 9780415467186 Jenny Kim, Gary Lask, Comprehensive Aesthetic Rejuvenation: A Regional Approach, ISBN 9780415458948 Neil Sadick, Paul Carniol, Deborshi Roy, Luitgard Wiest, Illustrated Manual of Injectable Fillers, ISBN 9780415476447 Paul Carniol, Gary Monheit, Aesthetic Rejuvenation Challenges and Solutions: A Global Perspective, ISBN 9780415475600 Neil Sadick, Diane Berson, Mary P. Lupo, Zoe Diana Draelos, Cosmeceutical Science in Clinical Practice, ISBN 9780415471145 Anthony Benedetto, Botulinum Toxins in Clinical Aesthetic Practice, Second Edition, ISBN 9780415476362 Robert Baran, Howard I. Maibach, Textbook of Cosmetic Dermatology, Fourth Edition, ISBN 9781841847009 David J. Goldberg, Alexander L. Berlin, Disorders of Fat and Cellulite, ISBN 9780415477000 Kenneth Beer, Mary P. Lupo, Vic A. Narurkar, Cosmetic Bootcamp Primer : Comprehensive Aesthetic Management, ISBN 9781841846989

Cosmetic Bootcamp Primer Comprehensive Aesthetic Management With DVD Edited by Kenneth Beer MD PA Founding Director Cosmetic Bootcamp West Palm Beach, Florida, USA

Mary P. Lupo MD FAAD Founding Director Lupo Center and Cosmetic Bootcamp and Clinical Professor of Dermatology Tulane Medical School New Orleans, Louisiana, USA

Vic A. Narurkar MD FAAD Founding Director Bay Area Laser Institute and Founding Director Cosmetic Bootcamp San Francisco, California, USA

Disclaimer: This eBook does not include ancillary media that was packaged with the printed version of the book. First published in 2011 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK. Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th Floor, New York, NY 10017, USA. Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: 37–41 Mortimer Street, London W1T 3JH, UK. Registered in England and Wales number 1072954. © 2011 Informa Healthcare, except as otherwise indicated No claim to original U.S. Government works Reprinted material is quoted with permission. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, unless with the prior written permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP, UK, or the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA (http://www.copyright.com/ or telephone 978-750-8400). Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. This book contains information from reputable sources and although reasonable efforts have been made to publish accurate information, the publisher makes no warranties (either express or implied) as to the accuracy or fitness for a particular purpose of the information or advice contained herein. The publisher wishes to make it clear that any views or opinions expressed in this book by individual authors or contributors are their personal views and opinions and do not necessarily reflect the views/opinions of the publisher. Any information or guidance contained in this book is intended for use solely by medical professionals strictly as a supplement to the medical professional’s own judgement, knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be independently verified. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as appropriately to advise and treat patients. Save for death or personal injury caused by the publisher’s negligence and to the fullest extent otherwise permitted by law, neither the publisher nor any person engaged or employed by the publisher shall be responsible or liable for any loss, injury or damage caused to any person or property arising in any way from the use of this book. A CIP record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data available on application ISBN-13: 9781841846989 Orders may be sent to: Informa Healthcare, Sheepen Place, Colchester, Essex CO3 3LP, UK Telephone: +44 (0)20 7017 5540 Email: [email protected] Website: http://informahealthcarebooks.com/ For corporate sales please contact: [email protected] For foreign rights please contact: [email protected] For reprint permissions please contact: [email protected]

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Contents

Contributors

vii

Preface

ix

Part I

Marketing and Management

1 The role of the aesthetic specialist

1

Kenneth Beer

2 The size and scope of the aesthetic marketplace

2

Neil S. Sadick

3 Aesthetic marketplace economics: Trends and performance of the top performing aesthetic medical procedures

9

Page S. Piland

4 Photography for the aesthetic patient

18

Holly P. Smith

5 Ergonomics for an aesthetic office

36

Steven K. Cordonnier

6 Interviewing the cosmetic patient

39

Susan H. Weinkle and Harriet Lin Hall

7 Red flag patients

43

Timothy Corcoran Flynn

8 Internal marketing

46

Amy Derick

9 Financial benchmarking for the aesthetic medical practice

50

Page S. Piland

10 Form, forms, forms

60

Kenneth Beer

Part II Clinical Cosmetic Patient Care 11 Skin type classification systems: Cosmetic consideration and planning for procedures

79

Wendy E. Roberts

12 When non-invasive is not enough: Limits to individual treatments

85

Roxanne J. Guy

13 Complications A to Z

98

Vince Bertucci

14 Botulinum toxins type A: Advanced techniques

106

Andreas Boker and Fredric S. Brandt

15 Botulinum toxin in the management of focal hyperhidrosis

115

Dee Anna Glaser

Fillers Advanced Techniques 16 One syringe wonder

130

Mary P. Lupo

v

vi

CONTENTS

17 Hyaluronic acid fillers

135

Mary P. Lupo

18 Calcium hydroxylapatite dermal filler for aesthetic correction of face and hands

141

Roberta D. Sengelmann

19 PLLA (Sculptra)

151

Cheryl M. Burgess

20 Permanent fillers

161

Derek Jones

21 Liposuction my way

165

Patricia Wexler

22 Chemical peeling

172

Sue Ellen Cox

Surgical Procedures 23 Aesthetic considerations in facial enhancement: A plastic surgery perspective

184

Julius Few

24 Periorbital rejuvenation utilizing blepharoplasty and adjunctive surgical techniques

189

Craig N. Czyz, Brian S. Biesman, and Jill A. Foster

25 Breast augmentation

209

Clark F. Schierle and Laurie A. Casas

26 Surgical rejuvenation of the neck

215

Anthony P. Sclafani, E. Ashlie Darr, and Ameet Kamat

Lasers and Lights 27 Intense pulsed light

225

Andreas Boker, David H. Ciocon, and David J. Goldberg

28 Fat melting devices

232

Kimberly Finder

29 Ablative fractional laser resurfacing

238

Vic A. Narurkar

30 Non-ablative devices

241

Vic A. Narurkar

31 Cosmeceuticals

245

Jeanine Downie

32 Diverse populations in aesthetics: Young patients

251

Ava Shamban

33 Diverse populations in aesthetics: Male patients

259

Toral Patel and Murad Alam

34 Diverse populations in aesthetics: Ethnic patients

265

Ava Shamban

Index

275

Contributors

Murad Alam Northwestern Medical Faculty Foundation, Chicago, Illinois, USA Kenneth Beer Cosmetic Bootcamp, West Palm Beach, Florida, USA Vince Bertucci Bertucci MedSpa, Woodbridge, Ontario, and University of Toronto, Toronto, Ontario, Canada Brian S. Biesman Vanderbilt University Medical Center, Nashville, Tennessee, USA Andreas Boker University of California San Francisco, San Francisco, California, USA Fredric S. Brandt PA and Dermatology Research Institute, Coral Gables, Florida, USA Cheryl M. Burgess Georgetown University, and Center for Dermatology and Dermatologic Surgery, Washington, DC, USA Laurie A. Casas University of Chicago Medical Center, Chicago, Illinois, USA David H. Ciocon Skin Laser and Surgery Specialists of New York and New Jersey, New York, New York, USA Steven K. Cordonnier Midmark Corporation, Versailles, Ohio, USA Sue Ellen Cox Aesthetic Solutions and University of North Carolina, Chapel Hill, and Duke University, Durham, North Carolina, USA Craig N. Czyz Ohio University College of Osteopathic Medicine, and OhioHealth Doctors Hospital, Columbus, Ohio, USA

Timothy Corcoran Flynn University of North Carolina, Chapel Hill, and Cary Skin Center, Cary, North Carolina, USA Jill A. Foster The Ohio State University, and Eye Center of Columbus, Columbus, Ohio, USA Dee Anna Glaser Saint Louis University School of Medicine, St. Louis, Missouri, USA David J. Goldberg Skin Laser and Surgery Specialists of New York and New Jersey, New York, New York; Sanctuary Medical Aesthetic Center, Boca Raton, Florida; and Mount Sinai School of Medicine, New York, New York, USA Roxanne J. Guy Brevard Plastic Surgery & Skin Treatment Center, Melbourne, Florida, USA Harriet Lin Hall Private Practice of Susan H. Weinkle, Bradenton, Florida, USA Derek Jones Skin Care and Laser Physicians of Beverly Hills, Beverly Hills, and David Geffen School of Medicine, University of California, Los Angeles, California, USA Ameet Kamat The New York Eye and Ear Infirmary, New York, New York, USA Mary P. Lupo Lupo Center, Cosmetic Bootcamp, and Tulane Medical School, New Orleans, Louisiana, USA Vic A. Narurkar California Pacific Medical Center, San Francisco; Bay Area Laser Institute, San Francisco; and University of California Davis School of Medicine, Sacramento, California, USA

E. Ashlie Darr The New York Eye and Ear Infirmary, New York, New York, USA

Toral Patel Chicago Lake Shore Medical Associates, Chicago, Illinois, USA

Amy Derick Derick Dermatology, LLC, Barrington, Illinois, USA

Page S. Piland Core Healthcare Consulting, Windermere, Florida, USA

Jeanine Downie Image Dermatology, P.C., Montclair, New Jersey, USA

Wendy E. Roberts Rancho Mirage, California, USA

Julius Few The Few Institute for Aesthetic Plastic Surgery, and Clinical Associate, University of Chicago, Division of Plastic Surgery, Chicago, Illinois, USA

Neil S. Sadick Weill Cornell Medical College, Cornell University, New York, New York, USA

Kimberly Finder The LipoSurgery Clinic, San Antonio, Texas, USA

Clark F. Schierle Northwestern Plastic Surgery Associates, Chicago, Illinois, USA

vii

viii

CONTRIBUTORS

Anthony P. Sclafani The New York Eye and Ear Infirmary, New York, New York, USA Roberta D. Sengelmann Mohs & Cosmetic Dermatologic Surgery, Santa Barbara, California, USA Ava Shamban Laser Institute for Dermatology and European Skin Care, Santa Monica; Ava MD, Beverly Hills; and UCLA School of Medicine, Los Angeles, California, USA

Holly P. Smith MedPhoto Group, Dallas, Texas, USA

Susan H. Weinkle University of South Florida, Tampa, Florida, USA

Patricia Wexler Wexler Dermatology, P.C., New York, New York, USA

Preface

The Cosmetic Bootcamp Meetings began as a way for colleagues in dermatology, plastic surgery, ophthalmology, and otorhinolaryngology to teach each other in a collegial environment. Cosmetic Bootcamp meetings are designed to provide core physicians (those in the specialties listed above) a forum to exchange ideas, explore new technologies and techniques, and discuss ways to improve patient care. In short, the focus is on advancing the science and outcomes using a multidisciplinary approach. We include each of the core aesthetic specialties at our meetings in addition to this book since we believe that one specialty does not hold all the answers. Moreover, the most interesting courses at each of our meetings are those that include physicians from different specialties to provide their perspective on a single patient issue or aesthetic technique. This book attempts to capture the flavor of these interactions Each chapter has what the editors consider essential information as well as a few “pearls”. The goal of this is to provide the framework to

understand the topic being discussed as well as the most salient, practical aspects of the chapter. While the book cannot provide the interaction that we see in our meetings, it does have an instructional DVD that helps bridge this gap. Following each meeting, the audience gathers to interact and ask questions about each lecture. Unfortunately, this is not possible with a textbook but most of the authors are participants at many meetings throughout the year and the reader is encouraged to ask him or her questions. Future versions of this text will include internet-based interactions that will foster these discussions. For those interested in a more direct interaction, please visit www. cosmeticbootcamp.com to see dates for upcoming meetings.

Kenneth Beer MD PA Mary P. Lupo MD FAAD Vic A. Narurkar MD FAAD

ix

1

The role of the aesthetic specialist Kenneth Beer

The Cosmetic Bootcamp arose from a simple concept asked at a lecture that I was delivering to a group of people attending a cosmetic meeting. An audience member responded to a statement that I made to the effect that the techniques I was discussing were best reserved for those individuals trained during a residency or fellowship to understand the anatomy and technical considerations involved. On the podium, I was asked, “If people can not learn these techniques at a meeting like this, where then should they learn them and what mechanism exists to train esthetic physicians?” Taken slightly aback, I responded that the mechanism, as I understood it, for training cosmetic physicians exists and is known as the residency or fellowship in an appropriate specialty. However, the question made me think about the role of specialists in aesthetic medicine and surgery. Ultimately it was the impetus to create a meeting where we could have an audience comprised of people that had a common level of education and skills and whom we could expose to new ideas that would enable them to advance. Specialists in medicine have traditionally been individuals who have advanced skills and/or training in a particular discipline. As medicine evolved and broader fields became more refined, some of the practitioners were “grandfathered” in as specialists. In dermatology, there are several examples of this, including those dermatologists who became certified as specialists in dermatopathology without taking the certification exam. Plastic surgery, head and neck surgery, and ophthalmology have each branched into several subspecialties whose practitioners have additional training and skills beyond the scope of the daily activities of most of the generalists in the field. In each of these areas, the specialists drive a great deal of the research and advancements in the field. There are now several physicians as well as several more nonphysicians performing cosmetic procedures far different from anything they trained in during their residency. Many of these physicians can perform basic cosmetic procedures such as injecting the glabella with botulinum toxins or spackling the nasolabial creases with soft tissue augmentation products. Some will perform enough procedures and attain the education to excel in these procedures. However, some of these physicians are also delivering babies or taking care of hypertension. While they may perform fundoscopic and otologic examinations, they typically lack the advanced skills of someone trained specifically to deal with these areas. So it is with the specialists in aesthetic medicine. What are the effects of non-specialists treating patients in this field? Usually, the consequences of the treatments are negligible and there should be no implication that specialists are all particularly gifted and free from cosmetic fiascos. One advantage that specialists have is that they typically understand advanced techniques, anatomy, and methods of combining treatments to optimize patient outcomes. Another is that they have frequently worked with other related specialties during the course of their training as well as in practice so that they are able to recognize the limitations of their own specialty and refer to a colleague when appropriate. The role of the dermatologist, ophthalmologist, otorhinolaryngologist, and plastic surgeon should be to assess the various components of aging and provide a roadmap of options for the patient and to

advance the specialties through research and educational activities. In the office, these specialists can help patients discuss the range of treatments available from lasers to intense pulsed lights, chemical peels, botulinum toxins, fillers, volumizers, cosmeceuticals, and surgery. Specialists should be able to discuss these alone and in combinations that are beyond the scope of those not trained during a formal residency or fellowship. Some of these specialists have broad areas of overlap but others do not—for instance, not all of these specialists will perform a facelift or consider themselves experts at injecting. These specialists have a responsibility to help the patient find the right person for their particular need. Specialists also have the responsibility to tell patients what they should not do. For some this means that no amount of botulinum toxins are going to make them look like they did when they were 20; for others, it is the reality that using a cream may be enough to accomplish some of their goals in a gradual, cost-efficient manner. Patients with unrealistic expectations or body dysmorphic disease should be assessed and should not be treated. There are times when they will mask their symptoms and get treated with unfortunate results for all concerned. For physicians who have participated as faculty or authors, the role of specialists in advancing the fields they are in as well as training the next generation of physicians and physician extenders is also a vital facet of their specialty. The leaders in the fields spend countless hours writing and preparing lectures to facilitate the education of their colleagues. One question that arises during any discussion of the role of aesthetic specialists is a salient one: Why bother with aesthetic specialists at all? This is asked by other physicians, medical economists, and patients concerned by the lack of “seriousness” of aesthetic medicine. My own belief is that there are three primary reasons. The first is that, since the beginning of time, man has always sought to improve his or her appearance and aesthetic medicine and surgery is a natural evolution of this process and one that will continue irrespective of what some may think. A second reason is the unintended consequences of the aesthetic technologies that evolve. Lasers once used to treat wrinkles on the face are now routinely used to treat debilitating and disfiguring burns. Fillers may be used to reconstruct areas damaged by trauma, and botulinum toxins are used to treat headaches, myofascial pain, prostate hypertrophy, spasticity associated with cerebral palsy and a host of other medical conditions. The third reason is that many patients that have an aesthetic procedure not only look better but feel better about themselves and have higher self-esteem and job performance. From botulinum toxins to lasers to fillers to breast augmentation, the properly performed procedure in the properly selected patient may significantly improve the quality of that person’s life. Specialists have the obligation to provide treatments better than poseurs. They need to contour the face instead of spackling lines. Perhaps as important is their role in education and advancing the various specialties. This includes training other specialists and students interested in the fields. The goal of any physician is to help patients and advance the field. I would hope that this book encourages readers to take the best care of their patients and educates those who need to be trained.

1

2

The size and scope of the aesthetic marketplace Neil S. Sadick

THE AESTHETIC MARKETPLACE

Aesthetics is a broad field, with physicians and trained clinical professionals of many different interests and areas of expertise. The spectrum ranges from plastic surgeons that perform reconstructive surgery and invasive procedures with lengthy recovery to dermatologists, skilled in non-invasive body contouring, laser/light rejuvenation, and injectables, to aestheticians addressing topical skin concerns and facilitating maintenance. The shared goal of aesthetics professionals is to create beauty and repair damage. However, their diverse education backgrounds and range of expertise create a vast assortment of procedures that are offered for aesthetic purposes. There is a growing demand on the part of the cosmetic consumer for holistic, aesthetic care—that is the integration of surgical and nonsurgical procedures at a medical aesthetic center. At such facilities, often termed medical spas, physicians and aestheticians can align their services into a synergistic platform to satisfy their patients’ desire for a continuum of care.

supervised by a physician, the organization and operation of an aesthetic medical center differs significantly from a typical doctor’s office. Figure 2.1 illustrates the primary difference between a traditional medical practice and an aesthetic practice—the flow and retention of patients. In a traditional model, patients flow into the office via insurance accepted by the physician. In the aesthetic model, patients are selfreferred or referred by friends and family. As such, patients/clients can come through various channels and the practice should promote itself to expand its footprint. The variety of services offered at an aesthetic medical center provides an opportunity for current patients to move up the cosmetic pyramid to more advanced procedures. The goal of any marketing program is to engage patients into the aesthetic practice at the basic level of care (facials, chemical peels, and low risk treatments) when topical and maintenance services are the patients’ primary need (due to age or financial restrictions) and migrate them into other physician administered services including surgery as they require them.

BACKGROUND

The medical spa is a term applied to aesthetic centers that offer services intended to be administered by a medical professional. The designation of “medical spa” attempts to differentiate the facility as more efficacious and therapeutic than commonplace “day spas.” There are several types of medical spas that include those that are run and owned by a physician (typically a specialist in plastic surgery or dermatology) and those that are owned by an entrepreneur with physician as medical director (either on- or off-site). Typical core services offered at most medical spas include microdermabrasion, chemical peels, medical facials, botulinum toxin, injectable fillers, hair removal, and photorejuvenation with laser and light sources. In addition, many medical spas commonly provide body contouring treatments such as cellulite reduction and skin tightening, injection lipolysis, acne treatment, tattoo removal, laser resurfacing, sclerotherapy, and leg vein removal. A few medical spas are also able to offer on-site cosmetic surgery (e.g., rhinoplasty, blephroplasty, brow, and facelifts), liposuction, and laser-assisted lipoplasty (Table 2.1). The Cosmetic Medicine Task Force (1) developed a classification system to educate the public on the outcomes and relative risks of various cosmetic procedures (Table 2.2). For example, “non-invasive” procedures do not penetrate the dermis and pose virtually no risk to health, while “minimally invasive” procedures do penetrate the skin and are associated with a slight health risk. In general, the closer the on-site involvement with a physician, the more likely “aggressive,” or “invasive” procedures are offered. The services offered by medical spas continue to evolve as novel technologies for aesthetic indications continue to be developed. The trend in demand has been toward nonsurgical procedures, and the top 10 patient-requested procedures in 2008 are shown in Table 2.3. It is interesting to note that many of the most popular procedures performed today did not exist 15 years ago or existed in a very early developmental state. For those contemplating expanding their aesthetic menu of services, it is important to stay within the top 10 most requested procedures to stay profitable as well as foresee the emergence of more powerful and efficacious approaches and invest accordingly. The aesthetic industry is projected to increase by 9% a year (2,3) and offers a lucrative and stable opportunity for expansion. Although the aesthetic services in a medical spa are often administered or closely

2

CORE SERVICES

Microdermabrasion Microdermabrasion is an exceedingly popular procedure for superficial skin resurfacing. It achieves improvement in scars, roughness, mottled pigmentation, and overall appearance, but not rhytids. The procedure involves the deposition of microcrystals, usually aluminum oxide (sodium chloride, magnesium oxide, and sodium bicarbonate are other options), on the surface of the skin with rapid strokes of the handpiece (4). Meanwhile, an aspiration tube attached to the handpiece vacuums the crystals and skin debris. The skin depth of the procedure is established by the strength of crystal flow, speed of handpiece movement, and the number of passes of the target region (4). Histology studies of microdermabrasion revealed the following changes: thickening of the epidermis and dermis, flattening of the rete pegs, vascular ectasia and perivascular inflammation, and hyalinization of the papillary dermis with newly deposited collagen and elastic fibers (5). It has been suggested that microdermabrasion produces clinical improvement by inducing molecular changes within the dermis that trigger dermal collagen remodeling and repair. Recent studies have reported that treatment activates the expression of cytokines AP-1, NF-κB, TNF-α, and IL-1β, which collectively serve to upregulate the expression of various connective tissue degrading enzymes (6). There are hundreds of different microdermabrasion machines on the market. In general, a comprehensive listing of available technology can be found in the Aesthetic Buyers Guide, a bi-monthly trade publication. The Food and Drug Administration (FDA) classifies microdermabrasion units as class 1 medical devices. As such, the machines can be sold without demonstration of clinical efficacy and operated without any medical supervision, as long as the procedure only removes the stratum corneum (7). There is a wide variation in the training of providers for this procedure and it is important to be aware that aggressive treatment can cause excesses in exfoliation, increased redness and rosacea, and dermatitis flares. Microdermabrasion is projected to remain a mainstay of “aesthetician-based” adjunctive care. The demand and increasing popularity of the procedure has resulted in the development of at-home microdermabrasion kits, although not as powerful as the technology available in professional aesthetic settings.

THE SIZE AND SCOPE OF THE AESTHETIC MARKETPLACE

Table 2.1 Procedures Offered in Medical Spas Core services

Common procedures

Microdermabrasion Chemical peels Medical facials Botulinum toxin Injectable fillers Hair removal Photorejuvenation

Cellulite reduction Tissue tightening Laser resurfacing Injection lipolysis

Less common medical procedures Sclerotherapy Laser leg vein removal Photodynamic therapy Tattoo removal Cosmetic surgery Liposuction Laser-assisted lipoplasy

Table 2.2 Classification System for Cosmetic Procedures Non-invasive

Minimally invasive

Body wraps Facials Deep-tissue massage

IPL Microdermabrasion Laser hair removal Laser leg vein removal Non-invasive fat reduction (e.g., High-intensity focused ultrasound or low level light therapy) Cellulite reduction

Moderately invasive

Invasive (surgical)

Botulinum toxin Injectable fillers Laser skin resurfacing Chemical peels

Face lifts Rhinoplasty Liposuction Abdominoplasty

Skin tightening (radiofrequency and infrared)

Breast lifts, augmentation, reduction, and reconstruction

Injection lipolysis

Arm and thigh lifts

3

A variety of mild chemical peels are available including glycolic acid, trichloroacetic (TCA) acid, salicylic acid, pyruvic acid, resorcinol, and Jessner’s solution (14% lactic acid, 14% resorcinol, and 14% salicylic acid) (8). Several proprietary peels are available including systems from Obagi and Theraplex (Melbourne, Australia). The indications for chemical peels are similar to microdermabrasion, but with considerable variation in efficacy and improvement based on depth of peel. Mild chemical peels are effective options for treating melasma in type IV-VI skin (9) and are considerably safer for this group than laser chromophore targeting. Moderate-to-deep peels are possible treatment options for patients wishing to target rhytids and achieve some degree of tightening. Medical Facials A facial is the most basic aesthetic service, typically comprising a deep cleaning, skin analysis (via a magnifying loupe), exfoliation (often with steam), extractions, massage, a mask to tighten pores, and moisturizer application. Medical facials could be defined as facials whose primary goal is to effect an improvement on the condition of the skin rather than deep cleaning and relaxation. Medical facials often focus on specific problems such as aging skin, large pores or acne, maintenance for rosacea, reduction of lines or wrinkles, reduction in hyperpigmentation, hydration, or combination of these conditions. The use of physiciandispensed products and a method of penetration that allows ingredients to penetrate more deeply in the dermis are commonly employed. Various methods to improve penetration are stratum corenum removal with chemical agents or microdermabrasion, ultrasonic devices, and heat or suction. Medical facials are mild treatments that do not claim lasting results but are appropriate adjuncts to other procedures and maintain and improve daily skin care regimens.

Sclerotherapy

Table 2.3 Top 10 Requested Procedures in 2008 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Botulinum toxin Laser hair removal Injectable fillers Chemical peels Laser resurfacing Microdermabrasion IPL Sclerotherapy Breast augmentation Liposuction

Chemical Peels Chemical peels are typically used for treatment of acne and enlarged pores, melasma, anti-aging, and to enhance the results of other aesthetic interventions, most commonly laser treatments. Three types of peels are readily available and classified based on the depth of the peel: superficial/mild, medium, and deep. Chemical peels performed in the medical spa are usually of the superficial or “lunchtime” variety without excessive post-procedure downtime. Most medical spas use aestheticians or nurses for the administration of mild chemical peels. The more moderate-to-deep chemical peels should be administered by a physician or under the direct supervision of a physician due to higher potential for adverse events and skin sensitivity.

Botulinum Toxin Botulinum toxin type A or BTX-A (BOTOX, Allergan, Irvine, California, USA; Dysport, Medicis, Scottsdale, Arizona, USA) is a purified complex of the neurotoxin, produced from the bacterium Clostridium botulinum. Originally approved for the treatment of blepharospasm and strabismus, off-label use began to produce reports of cosmetic improvement. Injections of botulinum toxins are frequently the entry point for patients into procedural aesthetic medicine. In 1992, the first published cosmetic study reported that 16 out of 17 subjects had market improvement in glabellar wrinkles after BTX-A injections into the corrugators with results lasting for 3 to 11 months (10). Since then there have been multiple studies validating these effects and establishing optimum dosing guidelines and injection points, as well as demonstrating the prophylactic and anti-aging effects of this treatment (11–14). In April 2002, BOTOX Cosmetic received FDA approval for the treatment of moderate-to-severe frown lines of the glabella. In 2009, Dysport followed receiving the safe FDA approval. Both formulations are used off-label in other areas of the face/neck for aesthetic benefit and have become the most commonly performed cosmetic procedure. With several other formulations of BTX-A currently in development and undergoing FDA approval (e.g., Purogen, Xeotox) including a topical formulation (Reloxin), the market for BTX-A injections is only projected to grow (15). Performing BTX-A injections requires a strong knowledge of anatomy, muscle function, and toxin diffusion patterns in the treatment area. Only dynamic wrinkles that are caused or worsened by muscle movement can be expected to improve with treatment. The most common treatment area is the upper third of the face including periorbital lines, frown lines in the glabella, and transverse lines across the forehead. With experience, providers can also treat vertical lines of the upper lip, jowl contour and platysmal bands, chin dimpling caused by

4

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Insurance

Appointment scheduled

Office visit

Billing

Retained patients

(A) Advertising

Appt. scheduled

Office visit

Consultation

Promotions No Website

Yes Word of mouth Billing PR

Retained patients

Insurance (B) Figure 2.1 Business models of traditional medicine and aesthetics. (A) Traditional model; (B) Aesthetic medical spa model—yellow diamond indicates the decision to purchase by the patient and the opportunity to convert to billing.

mentalis, muscles exacerbating marionette lines, and other areas of the lower face and neck. Unwanted local effects of BTX-A injection are generally transient. As with any injection, pain, bruising, and infection can occur. The most adverse events—aside from bruising—include asymmetry, headache, and pronounced lateral elevation of the brow. Brow and eyelid ptosis are more severe side effects, which occur in less than 1% of injections and are usually related to technique (16). Injectable Fillers Injectable dermal fillers have experienced a vast surge in popularity since the debut of injectable bovine collagen (Zyderm, Zyplast, Allergan, Irvine, California, USA) in the 1980s. Since then the demand and variety of products offered have only continued to grow with no signs of abatement. The advent of safer, longer lasting agents, as well as the increasing acceptance of and recognition of the significant enhancements that are able to be realized with these procedures strongly contribute to their popularity with both practitioners and consumers. Fillers are frequently the second procedure that cosmetic patients undergo after they have been treated with botulinum toxins and the two procedures are frequently utilized concurrently. Initially intended for the correction of localized and fine facial lines, the current arsenal of products is able to address numerous aesthetic concerns both on and off the face. FDA-approved fillers fall into several classes: hyaluronic acids, collagen-based materials, calcium hydroxylapatite (CaHA), poly-l-lactic acid (PLLA), and polymethylmethacrylate

(PMMA). All fillers are approved for nasolabial fold enhancement; however, many are widely used off-label for other procedures such as lip augmentation, brow elevation, marionette line correction, cheek and tear trough enhancement, and overall volume correction. Developed at the outset as a passive and resorbable correction, fillers have augmented their offerings to provide a biostimulatory and even in some cases permanent response. Biostimulatory fillers include Radiesse (BioForm Medical, San Mateo, California, USA) composed of CaHA microspheres in an aqueous carboxymethylcellulose gel carrier, and Sculptra (Dermik Laboratories, Berwyn, Pennsylvania, USA) composed of PLLA microparticles in a sodium carboxymethylcellulose gel. Both CaHA and PLLA particles are phagocytosed and become surrounded in a capsule of connective tissue cells, macrophages, lymphocytes, mast cells, and foreign body cells (17). As time passes, there is a fibrous-tissue response with collagen deposition providing sustained correction (18). The injection of fillers requires an artistic aesthetic sensibility, excellent eye-hand coordination, and an intimate knowledge of facial anatomy, as necrosis due to vessel occlusion is possible. The necessary skills are difficult to obtain and require much experience. Injectable fillers are recommended for use by experienced dermasurgeons or by physician assistants or nurse practitioners who are under close supervision of a derma-surgeon. Combination treatments with several fillers classes as well as lasers have brought about the nonsurgical or “liquid” facelift—a treatment algorithm focused on global volume enhancement and age-prophylaxis. This sector of aesthetics is projected to experience heavy growth as new products and indications are continuously being developed.

THE SIZE AND SCOPE OF THE AESTHETIC MARKETPLACE Hair Removal Lasers are a popular option in aesthetics for permanent hair reduction. The FDA defines this as “long-term stable reduction in the number of hairs regrowing after a treatment regime” (19). Laser hair removal first became available in the mid-1990s. As with almost all laser technologies, laser hair removal is based on the principle of selective photothermolysis (20). In the case of hair removal, the goal is to heat and destroy the follicular unit without damaging the surrounding tissue. The target chromophore is melanin in the hair follicle. The amount of melanin in hair and skin varies widely between individuals. Therefore, it is crucial to select the appropriate wavelength, spot size, and pulse duration based on the patient’s skin type and hair color for safety and efficacy. The first lasers were only effective in light-skinned and dark-haired patients. Advances in technology have allowed for safe treatments in darker-skinned patients and those with lighter colored hair. There are several different wavelengths and types of devices available, some of the most common offering are:

• •

•

•

• •

Ruby—The ruby laser (694 nm) was the first laser widely used for hair removal (21,22). Although it was effective in lighter skinned patients, it is not used frequently today. Alexandrite—The alexandrite laser (755 nm) was introduced shortly after the ruby and is still used frequently today. Its longer wavelength allowed for deeper penetration and it could cautiously treat some darker skinned patients (23). Studies have reported a reduction up to 50% after only single treatment; and up to 95% hair reduction after multiple treatments, depending upon the number of treatments and body location (24,25). Diode—Treatment of unwanted hair with the diode laser (810 nm) has been demonstrated as comparable to those of the ruby or alexandrite lasers. After a single treatment, hair reduction of about 30% have been reported; and up to 84% reduction with multiple treatments (26). The diode should also be used with caution on darker phenotypes. Nd:YAG—The Nd:YAG laser (1064 nm) is the safest type to treat unwanted hair on patients with dark skin, but the laser does not provide an optimal wavelength for hair removal. Results can be achieved, but higher energies are necessary to achieve results due to lesser affinity with melanin. Reports have shown an improvement of about 50%, depending on the number of treatments administered and body location (27). Intense pulsed light (IPL)—IPL systems have a wavelength range from 550 to 1200 nm. Filters are used to cut off certain wavelengths depending on treatment indications. Bedewi reported a mean hair reduction of 80% after five IPL treatments (28). Intense pulsed light and radiofrequency—The combination of IPL/diode laser with bipolar radiofrequency (RF) is a recently developed dual energy treatment. The hair follicle is pre-heated by light or laser and then RF causes further injury. Because RF does not require a target chromophore, this was the first technology to effectively treat light-colored hair, including white (29,30), albeit at a lower efficacy.

The number of treatments necessary and the interval between treatments are important considerations of laser hair removal and depend on the body area being treated. Only hair in the anagen or growth phase can be effectively treated. Hair in the telogen or catagen phases of rest does not have a mature enough follicle to be treated. The length of time spent in each phase depends on the location of the hair. On the scalp, hair follicles spend up to 10 years in anagen, but on the trunk, brow, and limbs, anagen lasts no longer than 6 months. This variability in hair cycling explains the need for multiple treatments, the correct timing of treatments, and the inability to remove hair 100%.

5

Recently consumer demand has contributed to emergence of at-home hair removal technologies. These technologies are in their infancy and deliver significantly lower energy levels than their professional counterparts. Nonetheless, they present an important evolution of this aesthetic concern and can provide an “entry-level” service for clients who may not be ready for a professional treatment. Photorejuvenation Photorejuvenation refers to the use of lasers and light sources to remove unwanted epidermal pigmentation and reduce upper dermal telangiectasia to improve the texture and tone of the skin. These modalities utilize the principle of photothermolysis with the target chromophores of melanin for pigmentation and hemoglobin for telangiectasia. Several devices in this category have also been reported to improve superficial wrinkles and cause some skin smoothing. IPL is the modality utilized most often for photorejuvenation and nonablative treatment of superficial damage. IPL uses non-coherent polychromatic light (500–1200 nm) to effectively target both melanin and hemoglobin. The minimal risk and virtually no downtime associated with this procedure have contributed to its success. A key IPL study by Bitter (31) showed that serial treatment with IPL visibly improved wrinkling, irregular pigmentation, skin coarseness, pore size, and telangictasias in more than 90% of patients. A newer technology that combines IPL with bipolar RF (electro-optical synergy or el s) was evaluated by Sadick et al. (32) and found to be as efficacious for pigmentation and vascularity but potentially more advantageous for pore size, superficial rhytids, and texture. This difference was caused by the addition of RF, which can penetrate more deeply into the dermis and stimulate collagen remodeling. Other modalities used for photorejuvenation are the pulsed dye laser (PDT 585 nm) and the potassium titanyl phosphate (KTP 532 nm) laser. Both wavelengths effectively target oxyhemoglobin and melanin making them effective at treating red and brown discoloraiton. In a controlled, split face study, Hsu et al. (33) investigated PDT for the treatment of rhytids and reported improvements of surface topography of 9.8% (one treatment) and 15% (two treatments) supported by histologic evidence of collagen remodeling. COMMON SERVICES

Cellulite Reduction Treatment of cellulite can be divided into four main categories: attenuation of aggravating factors, physical and mechanical methods, pharmacologic agents, and laser treatments. Many technologies employed today attempt to improve lymphatic circulation and drainage via negative pressure massage, increase connective tissue to remodel the epidermal–dermal interface, and reduce the size of adipose cells that herniate into the dermal layers. Popular approaches include the use of multi-modality devices to achieve the above aims. The use of bipolar RF, infrared light, and vacuum massage is combined by the VelaShape system (Syneron, Yokneam, Israel). Studies with device have demonstrated the improvement of surface texture, skin tightening as well reduction of circumference of thighs or abdomen (34,35). Other devices that claim to reduce the appearance of cellulite are TriActive (Cynosure, Westford, Massachusetts, USA), a combination of diode laser and massage and SmoothShapes (Eleme Medical, Merrimack, New Hampshire, USA.), a dual wavelength laser with vacuum massage. Recent studies have introduced extracorporeal pulse activation therapy (EPAT) to improve skin elasticity in cellulite. EPAT aims to induce tissue damage through the delivery of high-pressure acoustic energy; this process is followed by dermal remodeling involving recruitment of chemical mediators and neocollagenesis (36).

6

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Overall the devices for cellulite reduction require multiple treatments (8–16) and ongoing maintenance treatments to maintain effect. The results can be modest with some improvement in contour, reduction of rippling, and slight circumferential reduction. Patients need to be properly informed about procedure timing and maintenance as well as realistic expectations to successfully incorporate this procedure into an aesthetic practice. Tissue Tightening Tissue tightening has been a major force in the aesthetic marketplace since the FDA approval of the first non-invasive treatment for rhytids in 2002. The promise to lift and firm the tissues of the face and body without surgery is an important component of nonsurgical aesthetic rejuvenation. With increasing desire on behalf of the cosmetic consumer for earlier and effective nonsurgical intervention, this sector of aesthetics will see prolific growth and development to become a core aesthetic offering in the near future. Monopolar RF devices designed to uniformly heat the dermis utilizing the tissue’s inherent resistance to current flow initiated the field of tissue tightening. This technology facilitated the creation of thermal zones within the dermis while leaving the epidermis undamaged. Results were associated with a wound-healing response by way of recruitment of heat-shock proteins and inflammatory mediators such as TNF-α, IL-β, and TGF-β (37). Histologic analysis revealed new collagen deposition at 10 weeks post-treatment characterized by increased cellularity and hyaluronic deposits (37–39). Early results with RF were promising but inconsistent and shortcomings led to the development of combination therapy using electrical and optical energies. Today the device offerings have extended to monopolar and bipolar RF, broadband infrared light, bipolar RF with broadband light, and ultrasound. Monopolar RF continues to maintain dominance in this aesthetic indication with the ThermaCool (Thermage, Inc., Hayward, California, USA) being the pacesetter. Thermage has expanded its arsenal of heating tips and products to treat the delicate thinner skin areas of the eyelids and hands, as well originate tips with deeper penetration for targeting the subcutaneous layer and treating the abdomen, flanks, thighs, buttock, and arms. Off-face applications of tissue tightening technologies are commonly employed for post-partum abdomen and laxity after sudden weight loss as well as an adjunct to liposuction. Ultrasound is an emerging modality for tissue tightening. Ultrasound delivers heat to the dermis through the absorption of acoustic energy and the cellular response is thermal damage and subsequent recruitment of specific cytokines and inflammatory mediators similar to RF (40). The Ulthera system (Ulthera, Mesa, Arizona, USA) received FDA clearance for non-invasive tissue tightening in 2009. A study by Alam et al. (41) of patients treated with a single pass at 4.5 mm focal depth and energies of 0.4 to 1.2 J demonstrated at least 0.5 cm improvement in brow elevation in 89% of evaluated subjects. Laser Resurfacing Laser technology is a rapidly growing area of skin rejuvenation and aesthetic improvement. Through different mechanisms, all laser therapies utilize thermal energy to reform and homogenize connective tissue. Initially there is a localized coagulation of collagen fibers for 14 days post-treatment, and this process is followed by new connective tissue synthesis from the thermally altered matrix (42). Histologically fibroblasts may be observed migrating to the affected regions and initiating new collagen formation (43). The entire process is mediated various inflammatory cytokines and culminates in increased elasticity and improved aesthetic appearance of the skin (44). Laser resurfacing began with the ablative devices (CO2 and erbium:YAG) that completely eliminate the epidermis and the upper

layers of the dermis, inducing the formation of a wound. This lesion subsequently reconstitutes an epithelium in approximately 7 to 14 days (45). Although ablative treatment demonstrated unparalleled effectiveness in ability treat sun-induced skin damage, it was associated with significant side effects including delayed erythema and edema, pigmentation abnormalities, significant scarring, and increased risk of infection (46,47). Furthermore, the reepithelization period constituted significant downtime. These challenges lead to the emergence of fractional lasers. Fractional photothermolysis (FP) produces distinct lesions of thermal damage surrounded by larger zones of undisturbed normal skin (48). The combination of lesions and adjacent viable tissue allows for complete reepithelization within 24 to 48 hours and creates an annular configuration of thermal coagulation which enhances tissue tightening because collagen shortening is a three-dimensional mechanism (49,50). The stratum corneum remains undamaged, which greatly reduces the risk of developing an infection and serves to function in exfoliating underlying coagulated tissue, referred to as microepidermal necrotic debris (MEND) (48). Complete regeneration and full clinical benefits of using FP takes approximately three months. The emergence of fractional resurfacing or FP has significantly advanced laser therapy. The potential therapeutic benefits of this revolutionary technology device are only beginning to unravel and many more devices and applications are expected in the near future. Injection Lipolysis Injection lipolysis, also sometimes referred to as mesotherapy, denotes the intradermal injection of multiple chemical substances and lipolytic agents for the purposes of circumferential reduction. The active ingredient appears to be deoxycholate, a detergent that saponifies fat and leads to fat’s absorption by the body. Most of the time the injection cocktail is formulated as a phosphotidylcholine/deoxycholate mixture in various proportions. The mixture is then injected—during multiple sessions—in the target area for fat reduction. While very popular, especially in Europe and South America, this technique is not standardized with most practitioners employing a proprietary mixture to which vitamins and other agents are added. A heavy criticism of this procedure has been a paucity of controlled, double-blind clinical trials supporting the results. This technique is not FDA approved and is performed by practitioners with great variability in experience and education making it a risky course of action without researching the provider. CONCLUSION

In recent years, much progress has been made in technological approaches for aesthetic indications. At the same time, the desire for holistic aesthetic care on behalf of the consumer has driven the emergence of medical spas and aesthetic medical centers offering primary services administered or closely supervised by a physician. Core services such as microdermabrasion, medical facials, photorejuvenation, laser hair removal, and injectables are fixtures at most medical spas, with cellulite reduction, tissue tightening and laser resurfacing becoming increasingly common. The growing demand for safer devices with less downtime as well as less invasive and nonsurgical approaches has led to the development of some innovative therapies. In particular novel devices able to induce thermal damage while sparring the epidermis, either for laser resurfacing or tissue tightening indications, as well as advanced injectables are posed to lead the way in nonsurgical and age-prophylactic aesthetic indications. The trend toward non-invasive approaches assures that further advances in science and technology will serve to create superior services for the aesthetic marketplace.

THE SIZE AND SCOPE OF THE AESTHETIC MARKETPLACE

REFERENCES

1. D’Amico R, Saltz R, Rohrich R, et al. Risks and opportunities for plastic surgeons in a widening cosmetic medicine market: future demand, consumer preferences, and trends in practitioners’ service. Plast Reconst Surg 2008; 121: 1787. 2. Singer N. More doctors turning to the business of beauty. New York Times, Section A, page 2. November 30, 2006. 3. Freedonia Group, Inc. Cleveland, Ohio. Cosmetic Surgery Products (Executive Summary). September 2008. 4. Grimes PE. Microdemabrasion. Dermatol Surg 2006; 31: 1160. 5. Freedman BM, Rueda-Pedraza E, Waddell SP. The epidermal and dermal changes associated with microdemabrasion. Dermatol Surg 2001; 27: 1031. 6. Karimipour DJ, Kang S, Johnson TM, et al. Microdermabrasion with and without aluminum oxide crystal abrasion: a comparative molecular analysis of dermal remodeling. J Am Acad Dematol 2006; 54: 405. 7. Food and Drug Administration. Medical device: regulation and guidance. [Available from: http://www.fda.gov/medicaldevices/ deviceregulationandguidance/default.htm] Accessed January 31, 2010. 8. Zakopoulou N, Kontochristopoulos G. Superficial chemical peels. J Cosmet Dermatol 2006; 5: 246. 9. Sarkar R, Kaur C, Bhalla M, Kanwar AJ. The combination of glycolic acid peels with a topical regimen in the treatment of melasma in dark-skinned patients: a comparative study. Dermatol Surg 2002; 28: 828–32; discussion 832. 10. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 1992; 18: 17. 11. Flynn TC, Carruthers J, Carruthers A. Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye. Dermatol Surg 2001; 27: 703. 12. Von Lindern JJ, Niederhagen B, Appel T, et al. Type A botulinum toxin for the treatment of hypertrophy of the masseter and temporal muscle: an alternative treatment. Plast Reconst Surg 2001; 54: 197. 13. Park MY, Ahn KY, Jung DS. Application of botulinum toxin A for the treatment of facial contouring in the lower face. Dermatol Surg 2003; 29: 477. 14. Liew S, Dart A. Nonsurgical reshaping of the lower face. Aesthet Surg J 2008; 28: 251. 15. Carruthers J, Carruthers A. Botulinum toxin in facial rejuvenation: an update. Dermatol Clin 2009; 27: 417. 16. Klein AW. Complications, adverse reactions, and insights with the use of botulinum toxin. Dermtol Surg 2003; 29: 549. 17. Coleman KM, Voights R, DeVore D, et al. Neocollagenesis after injection of calcium hydroxylapatite composition in a canine model. Dermatol Surg 2008; 34: S53. 18. Lacombe V. Sculptra: a stimulatory filler. Facial Plast Surg 2009; 25: 95. 19. Food and Drug Administration. Laser dacts—hair removal. [Available from: http://www.fda.gov/Radiation-EmittingProducts/ ResourcesforYouRadiationEmittingProducts/Consumers/ ucm142607.htm] (Accessed January 31, 2010). 20. Dierickx C, Alora MB, Dover JS. A clinical overview of hair removal using lasers and light sources. Dermatol Clin 1999; 134: 837. 21. Grossman M, Dierickx C, Farinelli W, et al. Damage to hair follicles by normal-mode ruby laser. J Am Acad Dermatol 1996; 35: 889. 22. Dierickx C, Grossman M, Farinelli W, et al. Permanent hair removal by ruby laser. Arch Dermatol 1998; 134: 889.

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23. Garcia C, Alamoudi H, Nakib M, et al. Alexandrite laser hair removal is safe for Fitzpatrick skin types IV-VI. Dermatol Surg 2000; 26: 130. 24. McDaniel DH, Lord J, Ash K, et al. Laser hair removal: a review and report on the use of the long-pulsed alexandrite laser for hair reduction of the upper lip, leg, back, and bikini region. Dermatol Surg 1999; 25: 425. 25. Bouzari N, Nouri K, Tabatabai H, et al. The role of the number of treatments in laser-assisted hair removal using a 755 nm alexandrite laser. J Drugs Dermatol 2005; 4: 573. 26. Lou WW, Quintana AT, Geronemus RG, et al. Prospective study of hair reduction by diode laser (800 nm) with long-term follow up. Dermatol Surg 2000; 26: 428. 27. Tanzi EL, Alster TS. Long-pulsed 1065 nm Nd:YAG laser-assisted hair removal in all skin types. Dermatol Surg 2004; 30: 13. 28. Bedewi AF. Hair removal with intense pulsed light. Lasers Med Sci. 2004; 19: 48. 29. Goldberg DS, Marmur ES, Hussain M. Treatment of terminal and vellus non-pigmented hairs with an optical/bipolar radiofrequency energy source with and without pre-treatment using topical aminolevulinic acid. J Cosmet Laser Ther 2005; 7: 25. 30. Sadick NS, Laughlin SA. Effective epilation of white and blond hair using combined radiofrequency and optical energy. J Cosmet Laser Ther 2004; 6: 27. 31. Bitter P. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg 2000; 2: 59. 32. Sadick NS, Alexiades-Armenakas M, Bitter P, et al. Enhanced fullface skin rejuvenation using synchronous intense pulsed optical and conducted bipolar radiofrequency energy (ELOS): introducing selective photothermolysis. J Drugs Dermatol 2005; 4: 181. 33. Hsu T, Zelickson B, Dover J, et al. Multicenter study of the safety and efficacy of a 585 nm pulsed-dye laser for the nonablative treatment of facial rhytids. Dermatol Surg 2005; 31: 1. 34. Waniphakdeedecha R, Manuskiatti W. Treatment of cellulite with bipoal radiofrequency, infrared heat, and pulsatile suction device: a pilot study. J Cosmet Dermatol 2006; 5: 284. 35. Sadick N, Magro C. A study evaluating the safety and efficacy of the velasmooth system for the treatment of cellulite. J Cosmet Laser Ther 2007; 9: 15. 36. Christ C, Brenke R, Sattler G, et al. Improvement in the skin elasticity in the treatment of cellulite and connective tissue weakness by means of extracorporeal pulse activation therapy. Aesthet Surg J 2008; 28: 538. 37. Zelickson B, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency based nonablative dermal remodeling device. Arch Dermatol 2004; 140: 204. 38. Hantash B, Ubeid A, Chang H, et al. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Laser Surg Med 2009; 41: 1. 39. Hodgkinson D. Clinical application of radiofrequency: nonsurgical skin tightening. Clin Plast Surg 2009; 36: 261. 40. Laubach HJ, Makin AR, Barthe PR, et al. Intense focused ultrasound: evaluation of a new treatment modality for precise microcirculation within the skin. Dermatol Surg 2008; 34: 727. 41. Alam M, White L, Martin N, et al. Ultrasound tightening of facial skin: a rater-blinded prospective cohort study. J Am Acad Dermatol 2010; 62: 262. 42. Alster TS. Cutaneous resurfacing with CO2 and erbium:YAG lasers: preoperative, intraoperative, and postoperative considerations. Plast Reconst Surg 1999; 103: 619.

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43. Alster TS. Increased smooth muscle actin, factor XIIIa, and vimentin-positive cells in the papillary dermis of carbon dioxide laser-debrided porcine skin. Dermatol Surg 1998; 24: 155. 44. Sarradet M, Hussain M, Goldberg D. Electosurgical resurfacing: a clinical, histologic, and electron microscope evaluation. Laser Surg Med 2003; 32: 46. 45. Bodendorf M, Grunewald S, Wetzig T, et al. Fractional laser therapy. J Dtsch Dermatol Ges 2009; 7: 301. 46. Teikemeier G, Goldberg DJ. Skin resurfacing with the erbium: YAG laser. Dermatol Surg 1997; 23: 685.

47. Sriprachya_anunt S, Fitzpatrick RE, Goldman MP, et al. Infections complicating pulsed carbon dioxide laser resurfacing for photoaged facial skin. Dermal Surg 1997; 23: 587. 48. Hantash BM, Mahmood MB. Fractional photothermolysis: a novel aesthetic laser surgery modality. Dermatol Surg 2007; 33: 525. 49. Hantash BM, Bedi VP, Chan KF, et al. Ex vivo histological characterization of a novel ablative fractional resurfacing device. Lasers Surg Med 2007; 39: 87. 50. Goerge T, Peukert N, Bayer H, et al. Ablative fractional photothermolysis—a novel step in skin resurfacing. Med Laser Appl 2008; 23: 93.

3

Aesthetic marketplace economics: Trends and performance of the top performing aesthetic medical procedures Page S. Piland

The year 2008 marked the beginning of a challenging economic time for many aesthetic medical practices in respect of productivity and income. These economic challenges continued through 2009 and are still persistent at the time of this publication. During this challenging economic time, many practices were forced to reevaluate their strategies and make modifications to existing business plans. A major part of this process involved identifying underperforming areas and refocusing marketing activities. Frequently, this led to a shift from large surgical procedures to smaller nonsurgical procedures. This was not a welcome shift for surgeons, but many recognized the need to make a change for the short term. Many physicians initially believed that patients were deferring higher priced surgical procedures until the economy improved. Many patients opted to have nonsurgical procedures performed in the interim. These lower priced nonsurgical alternatives were viewed as a way to meet present patient demand. It also represents a way for the practice to remain engaged with its patient base and generate revenue. Cosmeceutical sales are also viewed in a similar manner and can help retain a patient’s bonds with a practice. OBJECTIVE ECONOMIC DATA: PARSING THE ASAPS COSMETIC SURGERY NATIONAL DATA BANK STATISTICS

All the data in this section have been gathered by the American Society for Aesthetic Plastic Surgery (ASAPS). ASAPS has conducted a multispecialty survey for 12 years in order to collect this information. These data are useful in analyzing the aesthetic market and measuring individual practice performance. Methodology A paper-based questionnaire was mailed to 16,000 board-certified physicians (6000 dermatologists, 6000 otolaryngologists, and 4000 plastic surgeons). A total of 894 completed and valid responses (461 plastic surgeons, 277 dermatologists, and 156 otolaryngologists) were received. Final figures have been projected to reflect nationwide statistics and are based exclusively on the board-certified plastic surgeons, otolaryngologists, and dermatologists. The findings have been aggregated and extrapolated to the known population of 23,600 physicians who are board certified in these specialties. Though the confidence intervals change by procedure, depending on the grouping’s sample size and the response variance, the overall survey portion of this research has a standard error of ±3.21% at a 95% level of confidence. The Survey on Cosmetic Procedures Performed in 2008 was compiled, tabulated, and analyzed by Industry Insights, Inc. (www.industry insights.com), an independent research firm based in Columbus, Ohio. Market Overview and Assessment There were 10,258,556 surgical and nonsurgical procedures performed in 2008. The 2008 market performance was down by 12.33% or 1,442,478 procedures compared to the number of procedures in 2007 which was 11,701,031. This reduction in the number of procedures resulted in a revenue loss of $1.37 billion. To help put this number into perspective and demonstrate the growth of the market over the last 10 years, it is important to recognize that the 2008 market loss represents half of the entire market just

10 years previously. In the 1998 market, 2,772,924 procedures were performed. In the years since that time, there have been only two other market declines. The first was in 2002 with a loss of 18.66% and the second in 2005 with a loss of 3.6% of the total market volume over the previous year. With the exceptions of 2002 and 2005, the years between1998 and 2004 were years of exceptional growth ranging from a low of 19.78% in 2003 to the peak performing year 1999 which experienced 66.14% growth. Since 1997 there has been over a 162% increase in the total number of cosmetic procedures performed. Nonsurgical procedures have led in the percentage growth category, coming in at over 233%, while surgical procedures have grown by almost 80% since 1997. In 2008, women accounted for almost 92% of the procedures. The age of patients with the highest number of cosmetic procedures in 2008 ranged between 35 and 50 years, representing 44.6% of the total market volume. Breaking Down the Economics of Surgical and Nonsurgical Proceduresa In order to organize the data for increased comprehension and ease of use, the top five surgical and the top five nonsurgical procedures will be reviewed and analyzed (Fig. 3.1A and B). The complete data set is available at the ASAPS website: http://www.surgery.org/. Surgical Procedures: The Top Five Surgical Procedures The top five surgical procedures are ranked by total expenditure or revenue generated (Fig. 3.2A and B). Figures are for physician/surgeon fees only and do not include fees for the surgical facility, anesthesia, medical tests, prescriptions, surgical garments, or other miscellaneous costs related to surgery. Figures for procedures often performed on more than one site in the same session reflect typical fees for one site. Breast Augmentationb Breast augmentation held the first position among the cosmetic surgery procedures in the years 2006, 2007, and 2008. This procedure accounted for 11.3% of the total revenue generated in 2008 within the aesthetic market (Fig. 3.3). It generated $1,327,566,071 in revenue, which was down from 2007 by 13.6% or $208,925,578. The national average physician/surgeon fee per surgery in 2008 was $3744, which was a decrease by $144 per surgery (Fig. 3.4). This procedure was performed 355,671 times in 2008, which was a decrease of 10.96% resulting in 43,769 fewer surgeries. The average number of breast augmentations in 2008 per ASAPS member was 62.6, resulting in 15.5 fewer procedures. Silicone Gel Vs. Saline Implants. Saline implants were the first choice of implant 52% of the time in 2008. The use of silicone gel implants continued to increase obtaining a 48% market share. For the last 3 years, saline implant usage has decreased significantly while silicone gel implants demonstrated a consistent growth.

a b

The American Society for Aesthetic Plastic Surgery. The American Society for Aesthetic Plastic Surgery.

9

10

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 0 2006

2007

2008

Surgical procedures

1,922,788

2,079,032

1,766,695

Nonsurgical procedures

9,533,980

9,621,999

8,491,861

2006

2007

2008

Surgical procedures

$7,632,270,642

$8,395,851,754

$7,222,233,062

Nonsurgical procedures

$4,542,014,327

$4,752,340,323

$4,559,075,462

(A) $9,000,000,000 $8,000,000,000 $7,000,000,000 $6,000,000,000 $5,000,000,000 $4,000,000,000 $3,000,000,000 $2,000,000,000 $1,000,000,000 $0

(B) Figure 3.1 Market volume for surgical vs. nonsurgical procedures: (A) total number of procedures; (B) total expenditure. Source : The American Society for Aesthetic Plastic Surgery.

The national average physician/surgeon fee per procedure for silicone gel implants in 2008 was $3885 and $3603 for saline implants. Silicone gel implants generated $637,177,252 and saline implants generated $690,338,819 in revenue. Lipoplastyc Lipoplasty was the second among the top five cosmetic surgery procedures in 2008. This procedure accounted for 8.43% of the total revenue generated in 2008 within the aesthetic market (Fig. 3.5). It generated $984,028,900 in revenue, which was down from 2007 by 26.45% or $353,867,291. The national average physician/surgeon fee per surgery in 2008 was $2903, which was a decrease of $38 per surgery (Fig. 3.6). This procedure was performed 341,144 times in 2008, which was a decrease of 25.32%, resulting in the largest procedure decline in 2008 of 115,684 fewer surgeries. The average number of procedures in 2008 per ASAPS member was 55.1, resulting in 17 fewer procedures.

c

The American Society for Aesthetic Plastic Surgery.

Suction-assisted Vs. Ultrasound-assisted Lipoplasty. Suction-assisted lipoplasty was still the first choice 81.7% of the time in 2008. Ultrasoundassisted lipoplasty lost market share from 20.4% in 2007 to 18.3% in 2008. For the last 3 years, suction-assisted lipoplasty has been the first choice by a significant margin. The national average physician/surgeon fee per procedure for suctionassisted lipoplasty in 2008 was $2874 and $2933 for ultrasound-assisted lipoplasty. Suction-assisted lipoplasty generated $804,268,214 and ultrasound-assisted lipoplasty generated $179,760,686 in revenue. Faceliftd Facelift was the third among the top five cosmetic surgery procedures in 2008. This procedure accounted for 7.6% of the total revenue generated in 2008 within the aesthetic market. It generated $891,524,394 in revenue, which was down from 2007 by 4.99% or $46,807,663. The national average physician/surgeon fee per surgery in 2008 was the highest fee for a surgery or procedure at $6728. This was a decrease of $64 per surgery.

d

The American Society for Aesthetic Plastic Surgery.

11

AESTHETIC MARKETPLACE ECONOMICS $1,800,000,000 $1,600,000,000 $1,400,000,000 $1,200,000,000 $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000,000 $0 2006

2007

2008

$907,651,429

$991,544,589

$806,185,765

$1,379,731,684

$1,536,491,649

$1,327,566,071

$791,678,946

$829,274,709

$787,844,501

$903,002,712

$938,332,057

$891,524,394

$1,162,407,264

$1,337,896,191

$984,028,900

Abdominoplasty Breast augmentation Breast reduction Facelift Lipoplasty (A) $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0

2006

2007

2008

Abdominoplasty

$5,263

$5,350

$5,470

Breast augmentation

$3,678

$3,888

$3,744

Breast reduction

$5,429

$5,417

$5,630

Facelift

$6,532

$6,792

$6,728

Lipoplasty

$2,902

$2,941

$2,903

(B) Figure 3.2 (A) Total expenditure or revenue generated per procedure and (B) national average for physician/surgeon fees per procedure for the top five surgical procedures. Source : The American Society for Aesthetic Plastic Surgery.

$1,200,000,000

This procedure was performed 132,504 times in 2008, which was a decrease of 4.09%, resulting in the smallest procedure decline in 2008 of 5649 fewer surgeries. The average number of procedures in 2008 per ASAPS member was 16.1, resulting in 3.4 fewer procedures.

80.3%

58.1%

$1,000,000,000

$800,000,000

52%

$600,000,000 48% $400,000,000 41.9% $200,000,000 19.7% $0 2006

2007

Silicone gel implants

2008 Saline implants

Figure 3.3 Total expenditures with percentage of market share for breast augmentation using silicone gel implants vs. saline implants. Source : The American Society for Aesthetic Plastic Surgery.

Abdominoplastye Abdominoplasty was the fourth among the top five cosmetic surgery procedures in 2008. This procedure accounted for 6.8% of the total revenue generated in 2008 within the aesthetic market. It generated $806,185,765 in revenue, which was down from 2007 by 18.69% or $185,358,824. The national average physician/surgeon fee per surgery in 2008 was $5470, which was one of only two surgery fee increases in 2008. This was an increase of $120 per surgery. This procedure was performed 147,392 times in 2008, which was a decrease of 20.47%, resulting in the second highest surgical procedure percentage decrease in 2008. There were 37,943 fewer surgeries in 2008. The average number of procedures in 2008 per ASAPS member was 22, resulting in 8.3 fewer procedures per ASAPS member.

e

The American Society for Aesthetic Plastic Surgery.

12

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT $4,200 $4,100 $4,000 $3,900 $3,800 $3,700 $3,600 $3,500 $3,400 $3,300 $3,200 2006

2007

2008

Silicone gel implants

$3,813

$4,087

$3,885

Saline implants

$3,544

$3,690

$3,603

Figure 3.4 National average for physician/surgeon fees per procedure for breast augmentation using silicone gel implants vs. saline implants. Source : The American Society for Aesthetic Plastic Surgery.

This procedure was performed 139,926 times in 2008, which was a decrease of 8.60%. There were 13,161 fewer surgeries in 2008. The average number of procedures in 2008 per ASAPS member was 16.6, resulting in 3.8 fewer procedures per ASAPS member.

$1,200,000,000

$1,000,000,000

Nonsurgical Procedures: The Top Five Nonsurgical Procedures The top five nonsurgical procedures are ranked by total expenditure or revenue generated (Fig. 3.7A and B).

$800,000,000

$600,000,000 79.6% 82.3% 81.7%

$400,000,000

$200,000,000 17.7%

20.4% 18.3%

$0 2006 Suction-assisted

2007

2008

Ultrasound-assisted

Figure 3.5 Total expenditures for suction-assisted vs. ultrasound-assisted lipoplasty. Source : The American Society for Aesthetic Plastic Surgery.

Breast Reduction (Women) Breast reduction for women was the fifth among the top five cosmetic surgery procedures in 2008. This procedure accounted for 6.7% of the total revenue generated in 2008 within the aesthetic market. It generated $787,844,501 in revenue, which was down from 2007 by 5% or $41,430,208. The national average physician/surgeon fee per surgery in 2008 was $5630, which was the highest increase in surgery fees in 2008. This was an increase of $213 per surgery.

Botoxf Botox held the first position among nonsurgical cosmetic surgery procedures in the years 2006, 2007, and 2008. This procedure accounted for 9.3% of the total revenue generated in 2008 within the aesthetic market. It generated $1,090,374,483 in revenue, which was up from 2007 by 3.4% or $35,807,747. The national average physician/surgeon fee per procedure for Botox in 2008 was $443, which was an increase of $63 per procedure. This procedure was performed 2,464,123 times in 2008, which was a decrease of 11.21%, resulting in 311,053 fewer procedures. The average number of procedures in 2008 per ASAPS member was the highest at 222.5, accounting for 24% of the market. The procedure decrease resulted in 129.9 fewer procedures performed per ASAPS member. Laser Skin Resurfacing Laser skin resurfacing was the second among the top five nonsurgical cosmetic procedures in 2008. This procedure accounted for 6.4% of the total revenue generated in 2008 within the aesthetic market (Fig. 3.8). It generated $751,926,177 in revenue, which was up from 2007 by 70.94% and was the highest growth percentage of all surgeries and procedures on this list. Laser skin resurfacing grew by $312,039,521 over 2007. The national average physician/surgeon fee per surgery in 2008 was $1619, which was an increase of $120 per procedure (Fig. 3.9). This procedure was performed 570,880 times in 2008. This was the largest procedure percentage increase at 11.96% in 2008, resulting in 60,979 more procedures. The average number of procedures in 2008 per ASAPS member was 20.1, resulting in 2.1 more procedures.

f

The American Society for Aesthetic Plastic Surgery.

13

AESTHETIC MARKETPLACE ECONOMICS $2,980 $2,960 $2,940 $2,920 $2,900 $2,880 $2,860 $2,840 $2,820 2006

2007

2008

Suction-assisted

$2,868

$2,920

$2,874

Ultrasound-assisted

$2,936

$2,963

$2,933

Figure 3.6 National average for physician/surgeon fees per procedure for suction-assisted vs. ultrasound-assisted lipoplasty. Source : The American Society for Aesthetic Plastic Surgery.

$1,400,000,000 $1,200,000,000 $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000,000 $0 2006

2007

2008

$1,326,367,287

$1,054,566,736

$1,090,374,483

Laser skin resurfacing

$546,256,262

$439,886,656

$751,926,177

Hyaluronic acid

$848,191,987

$834,460,585

$714,165,690

Laser hair removal

$550,344,982

$546,698,426

$417,299,496

Chemical peel

$485,958,315

$412,907,539

$416,573,762

2006

2007

2008

$417

$380

$443

$1,593

$1,499

$1,619

Hyaluronic acid

$532

$576

$566

Laser hair removal

$373

$387

$326

Chemical peel

$870

$718

$704

Botox

(A) $1,800 $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 Botox Laser skin resurfacing

(B) Figure 3.7 (A) Total expenditure or revenue generated per procedure and (B) national average for physician/surgeon fees per procedure for the top five nonsurgical procedures. Source : The American Society for Aesthetic Plastic Surgery.

14

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Ablative Vs. Nonablative Resurfacing. Nonablative resurfacing was still the first choice 71.2% of the time in 2008. Ablative resurfacing lost market share from 43.1% in 2007 to 28.8% in 2008. The national average physician/surgeon fee per procedure for nonablative resurfacing in 2008 increased by $565 to $1145. Ablative resurfacing decreased by $324 to $2094 in 2008. Nonablative resurfacing generated $535,467,810 and ablative resurfacing generated $216,458,367 in revenue. Hyaluronic Acid (Injectible)g Injectible hyaluronic acid was the third among the top five nonsurgical cosmetic surgery procedures in 2008. This procedure accounted for 6.1% of the total revenue generated in 2008 within the aesthetic market. It generated $714,165,690 in revenue, which was down from 2007 by14.42% or $120,294,895. The national average physician/surgeon fee per procedure in 2008 was $566, which was a decrease of $10 per procedure. This procedure was performed 1,262,848 times in 2008, which was a decrease of 12.83%, resulting in 185,868 fewer procedures. The average $600,000,000 $500,000,000

71.2% 83.1%

$400,000,000 $300,000,000

56.9%

$200,000,000

number of procedures in 2008 per ASAPS member was 81.5, resulting in 26.5 fewer procedures performed per ASAPS member. Laser Hair Removalh Laser hair removal was the fourth among the top five nonsurgical cosmetic surgery procedures in 2008. This procedure accounted for 3.5% of the total revenue generated in 2008 within the aesthetic market. It generated $417,299,496 in revenue, which was down from 2007 by23.67% or $129,398,930. The national average physician/surgeon fee per procedure in 2008 was $326, which was a decrease of $61 per procedure. This procedure was performed 1,280,964 times in 2008, which was a decrease of 9.32%, resulting in 131,693 fewer procedures. The average number of procedures in 2008 per ASAPS member was 90.4, resulting in 38.7 fewer procedures performed per ASAPS member. Chemical Peel Chemical peels were the fifth among the top five nonsurgical cosmetic surgery procedures in 2008. This procedure accounted for 3.5% of the total revenue generated in 2008 within the aesthetic market. It generated $416,573,762 in revenue, which was up from 2007 by 0.89% or $3,666,223. The national average physician/surgeon fee per procedure in 2008 was $704, which was a decrease of $14 per procedure. This procedure was performed 591,808 times in 2008, which was an increase of 2.91%, resulting in 16,728 more procedures. The average number of procedures in 2008 per ASAPS member was 39.7, resulting in 3.5 more procedures performed per ASAPS member. CONCLUSION

$100,000,000

28.8%

43.1% 16.9%

$0 2006

2007 Ablative

2008

Nonablative

Figure 3.8 Total expenditures with percentage of market share for ablative vs. nonablative laser skin resurfacing.

The economics of the aesthetic marketplace have grown and contracted dramatically over the past few years. Some of this growth is due to the fact that the procedures have gotten so much better than the ones that preceded them. Contractions in the aesthetic marketplace have typically been due to economic downturns or from news-related blips. During contractions, practices that have coherent marketing plans can alter their strategies and try to convert to less invasive, less expensive procedures. During periods of expansion, practices that can scale with the growth have an opportunity to grow. During either, it is essential to have an understanding of economics as it pertains to an aesthetic practice.

$3,000 $2,500 $2,000 $1,500 $1,000 $500 $0

Ablative Nonablative

2006

2007

2008

$2,341

$2,418

$2,094

$845

$580

$1,145

Figure 3.9 National average for physician/surgeon fees per procedure for ablative vs. nonablative laser skin resurfacing. g h

The American Society for Aesthetic Plastic Surgery. The American Society for Aesthetic Plastic Surgery.

15

AESTHETIC MARKETPLACE ECONOMICS

APPENDIX

500,000 450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 2006

2007

2008

Abdominoplasty

172,457

185,335

147,392

Breast augmentation

383,886

399,440

355,671

Breast reduction

145,822

153,087

139,926

Facelift

138,245

138,153

132,504

Lipoplasty

403,684

456,828

341,144

2006

2007

2008

Abdominoplasty

1.5%

1.6%

1.4%

Breast augmentation

3.4%

3.4%

3.5%

Breast reduction

1.3%

1.3%

1.4%

Facelift

1.2%

1.2%

1.3%

Lipoplasty

3.5%

3.9%

3.3%

(A) 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0%

(B) Figure 3.A1 (A) Number of procedures, (B) percentage of total procedures. (Continued)

16

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT 90 80 70 60 50 40 30 20 10 0 2006

2007

2008

Abdominoplasty

31

30.3

22

Breast augmentation

73

78.1

62.6

Breast reduction

23

20.4

16.6

Facelift

20.7

19.5

16.1

Lipoplasty

72.7

72.1

55.1

(C) Figure 3.A1 (Continued) (C) Average number of procedure per ASAPS member for the top five surgical procedures. Source : The American Society for Aesthetic Plastic Surgery.

3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2006

2007

2008

3,181,592

2,775,176

2,464,123

576,509

509,901

570,880

Hyaluronic acid

1,593,554

1,448,716

1,262,848

Laser hair removal

1,475,296

1,412,657

1,280,964

558,432

575,080

591,808

2006

2007

2008

Botox

27.8%

23.7%

24.0%

Laser skin resurfacing

5.0%

4.4%

5.6%

Hyaluronic acid

13.9%

12.4%

12.3%

Laser hair removal

12.9%

12.1%

12.5%

Chemical peel

4.9%

4.9%

5.8%

Botox Laser skin resurfacing

Chemical peel (A) 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%

(B) Figure 3.A2 (A) Number of procedures, (B) percentage of total procedures. (Continued)

17

AESTHETIC MARKETPLACE ECONOMICS 400 350 300 250 200 150 100 50 0 2006

2007

2008

183.1

352.4

222.5

Laser skin resurfacing

17.4

18

20.1

Hyaluronic acid

78.3

108

81.5

Laser hair removal

62.8

129.1

90.4

Chemical peel

25.5

36.2

39.7

Botox

(C) Figure 3.A2 (Continued) (C) Average number of procedure per ASAPS member for the top five nonsurgical procedures. Source : The American Society for Aesthetic Plastic Surgery.

4

Photography for the aesthetic patient Holly P. Smith

Photography serves a multitude of purposes in medicine; research, medical–legal reasons, comparative studies, and publication as well as for marketing purposes. All of these reasons depend on accurate photographic documentation. The majority of physicians and office staff are not properly trained in existing photographic standards for good patient photography. It is important to implement these standards into your practice because aesthetics is all about aesthetics. It is about being able to visually show an aesthetic improvement and if your photography is not good, it can often depict inaccurate results or more often, no results at all. In a cosmetic or aesthetic practice, the practice of photography can be extremely beneficial especially for communicating what your goals are to your patient. This can be performed through simulated imaging and pre-operative/treatment analysis of your patients’ photographs. Providing photography in your practice is providing a service to your patients. It is one of the most valuable tools that can assist your practice in many ways. For example, photographing your patient’s result throughout different time intervals can reinforce your patient’s perception of treatment success, which leads them to experience a greater level of satisfaction with your products and services. Another example is by providing samples of your work rather than using stock imagery. This helps gain trust with your patients by showing them that you get results. You can explain a procedure or treatment process to a patient but nothing is going to compare to showing a patient the “before and after” photographic result of an outcome you performed. Photography sets the foundation for how your work will be evaluated and presented. Setting high standards in photography and using existing protocols will ensure that your talent is properly represented. PRINCIPLES OF PHOTOGRAPHY

Staff and physicians who may not have a background in photography perform most patients’ photography. Knowing photographic basics will help improve patient photography when photographing in the operating room or clinical setting. The following are the fundamental principles of photography. Aperture Aperture refers to the size of the adjustable opening in the iris in a lens that determines the amount of light falling onto the film or sensor. The size of the opening is measured using an f-number or “f-stop” (f8, f11, etc.). Because f-numbers are fractions of the focal length, “higher” f-numbers represent smaller apertures (1). The smaller the aperture, the greater the depth of field. This means that if you use a smaller aperture, you will have the forefront, middle, and background in sharp focus. For patient photography, it is important to use a small aperture, as you want all areas to be in focus. An aperture between f11 and f22 is suitable for patient photography. Shutter Speed The shutter speed determines how long the iris of the camera is open exposing the film or sensor to light. For instance, a shutter speed of 1/125 s will expose the sensor for 1/125th of a second. Electronic shutters act in a similar way by switching on the light sensitive photodiodes of the sensor as long as requested by the shutter speed (2). For patient photography, it is important to use a shutter speed faster than 1/60.

18

Anything under a 60th of a second can produce blurring if the patient or photography moves even slightly. Depth of Field Depth of field refers to the distance between the closest and farthest in-focus area of a photograph (also called the focal range). Depth of field is affected by the aperture, subject distance, focal length, and film or sensor format. The smaller the aperture, the greater the depth of field meaning that objects within a certain range behind or in front of the main focus point will appear sharp (3). Focal Length The focal length of a lens is defined as the distance in mm from the optical center of the lens to the focal point, which is located on the sensor or film. The focal length establishes the field of view. The longer the focal length the narrower and compressed the field of view becomes. The shorter the focal length, the larger the field of view becomes (4). Camera lenses are categorized by normal, telephoto, and wide angle, according to the focal length and film size.

•

• •

Normal—When the focal length of a lens is in a range close to the diagonal measurement of the film/sensor’s format, the lens is said to be “normal.” For example, 43.27 mm is the exact distance of the diagonal of a 35 mm (35 × 24) film plane; therefore, the closest equivalent lens would be 50 mm. The 50 mm lens has a field of view of 46°. Wide—When the focal length is shorter than the film/sensor’s diagonal; it’s a “short” or wide-angle lens. For example, a 20 mm lens on a 35 mm (35 × 24) film plane would be considered a wide angle. The 20 mm lens has a field of view of 94°. Telephoto—When the focal length of a lens is longer than the film/sensor’s diagonal; it’s a “long” or telephoto lens. For example, a 105 mm lens on a 35 mm (35 × 24) film plane would be considered telephoto. The 105 mm lens has a field of view of 23°.

Single Lens Reflex (SLR) It is a camera in which a system of mirrors shows the user the image precisely as the lens renders it. This is the recommended camera type to use for patient photography. Through the Lens (TTL) Refers to a metering system in which a light sensitive mechanism within the camera body measures exposure from the image light passing through the lens. ISO How sensitive the camera’s sensor is to the amount of light falling on it. Raising the ISO of a camera makes the sensor more sensitive to light. This can be useful when photographing in low light situations where you don’t want to use a flash. The disadvantage to raising your ISO is that you increase camera noise. DIGITAL CAMERA MODES AND WHAT THEY REPRESENT

Digital cameras offer many shooting modes for photographing in various settings. Professional digital single lens reflex (DSLR) cameras primarily have the basic modes while prosumer or consumer digital cameras may

PHOTOGRAPHY FOR THE AESTHETIC PATIENT offer some of the basics but also include some predetermined settings that are represented by icons. Some of these modes may and may not be useful for patient photography. Below is a list of some of the basic modes and icons found on digital cameras and what they represent. Aperture Priority Aperture priority mode if generally represented by an AV or A depending on your camera. This is the preferred mode for photographing patients. This allows the user to choose the aperture and the camera selects the shutter speed to accommodate correct exposure. It is important to have a small aperture when photographing patients because you want all areas to be in focus-greater depth of field. Shutter Priority Mode Shutter priority mode is represented by TV or S. This mode allows users to choose the shutter speed. This mode would be important if you were trying to capture a fast moving object without blur, but it is typically not used in patient photography. Manual Mode Manual mode is represented by an M. Manual mode allows the user to choose both the shutter and aperture. This is the preferred method when photographing with studio lights in a clinical setting as it gives you complete control over the exposure of the scene. Program Mode Program mode is represented by a P. The program mode allows the user partial control over both the aperture and shutter. This mode is not necessary for patient photography. Symbol of Person Running This mode is typically used for fast moving subjects. It sets your shutter speed to a fast setting and raises your ISO. This mode is not necessary for patient photography. Symbol of Mountains Depending on your camera, this mode typically sets your aperture to the smallest setting possible given the available light, and can raise your ISO. Although it may seem unlikely, this mode can be used for capturing subjects in greater depth of field than in other modes. Symbol of a Person’s Profile This mode represents portrait mode. Although it may seem like a good mode for capturing the face of a subject, it is not recommended to use this mode as it widens the aperture putting the background out of focus. For patient photography, it is best to use a small aperture so that all features are in focus. Symbol of Flower (Macro Mode) This mode represents macro mode. It is important to know about macro mode because it can be useful to use in some situations but it does have its disadvantages. With digital photography, the term largely refers to the camera’s closest focusing distance. The macro mode generally has a flower icon. When this icon is chosen, it tells your camera that you want to focus on a subject closer to your lens (5). Typically the macro mode in patient photography is used when the camera needs to be 6 inches or less in distance to the subject being photographed. The disadvantage when photographing in macro mode for patient photography is that it typically tells your camera to use a large aperture, which decreases your depth of field. WHAT TO LOOK FOR IN A DIGITAL CAMERA

There are many objectives to look for when shopping for a digital camera.

19

One of them is the capability of the camera’s zoom. There are typically two types: digital and optical zoom. The digital zoom takes a part of the scene and interpolates data to fit on the CCD sensor plane. It mimics a greater zoom without actually gaining any additional image detail. It often results in a blurry and pixilated image. The optical zoom changes the amount of the scene falling on to the CCD sensor. It is preferable to have an optical zoom because the information is not interpolated and can be enlarged and cropped with higher quality results (6). A 3× optical zoom will give you a focal length of 35 to 105 mm, which is the minimum necessary for photographing the face and body. There are different types of viewfinders available on digital cameras. The viewfinder is the window you look through to compose the scene (7). The following are examples of the different types of viewfinders. Optical Viewfinder on a Digital Compact Camera The optical viewfinder on the digital compact camera is positioned above the camera lens so what you see through the optical viewfinder is different from what the lens projects onto the sensor. This type of sensor has parallax error, which can make framing inaccurate when photographing close-up. Optical Viewfinder on a Digital SLR Camera (TTL) The optical viewfinder of a digital SLR shows what the lens will project on the sensor via a mirror and a prism. It does not have parallax errors and shows information at the bottom of the LCD viewfinder that has a camera and exposure settings. LCD on a Digital Compact Camera (TTL) The LCD on a digital compact camera shows in real time what is projected onto the sensor by the lens. This is also called “through-the-lens” (TTL) viewing. The LCD does not have parallax errors but does shorten battery life and can be difficult to see LCD screen in bright sunlight conditions. Electronic Viewfinder (EVF) on a Digital Compact Camera (TTL) The electronic viewfinder shows in real time what is projected onto the sensor by the lens. It simulates in an electronic way the effect of the (superior) optical TTL viewfinders found on digital SLRs and doesn’t suffer from parallax errors. EVF allows more accurate framing but can shorten the battery life. Video Capability Another important feature to look for when purchasing a digital camera is whether or not it has video capability. Many consumer cameras come with digital video capability but some do not. Having the capability to shoot digital video on your camera is useful for relaying important information between physicians, patients, and for media presentations. Flash Options There are many options for flash capability on digital cameras. If you are using studio lights with your digital camera, it is important that you purchase a digital SLR that has either a hot shoe or an external flash input connection on the camera. These types of connections allow the user more flash and remote flash synchronization options. CONSIDER THE PATIENT

Your patient photography should be performed in a private location, even if it only consists of photographs of the face. Public areas such as open rooms or hallways should be avoided when photographing your patient. Many patients may feel intimidated and embarrassed about being photographed so ensuring privacy will make the experience

20

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Figure 4.1 Watermark of doctor’s name shown on top of an image.

more comfortable. Being aware of how your patient feels about the experience and discussing the reasons for taking the photographs with your patient will help make them more at ease, especially when documenting more sensitive areas of the body. Allow them to express any concerns they may have and discuss them with your patient prior to photographing them. The person responsible for photographing should always inform the subject what areas are being recorded in the camera’s field of view. To provide anonymity, the head should never be recorded in the same field of view with the breasts or body. Although a chaperone is not typically used when photographing, patients should be offered the opportunity for a chaperone if they would like one. If the patient is under 18, a parent or legal guardian must be present during the photography session. PATIENT PREPARATION

Photographic Consent The practice of photography should be included in the Health Insurance Portability and Accountability Act (HIPAA) mandated notice of information signed on admission (8). This should cover photographing and ownership of photographs for treatment purposes only. Below is an example of what is typically incorporated into the informed consent. Sample Paragraph for HIPAA Mandated Notice of Information Signed on Admission that Covers Photography for Treatment Purposes I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that [organization name] will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law or outlined in [organization name]’s policy. Images that identify me will be released and/or used outside the institution only upon written authorization from my legal representative or me. If you want to use your patient’s photographs for non-treatment purposes; education, publication, marketing, Internet, discuss this with your patient and request that they sign a consent for non-treatment purposes, which lists the possible uses of the images. This should be a separate consent form and should be made as a request only.

Sample Photography for Non-treatment Purposes Consent I hereby authorize ______________ to make audio recordings or to take photographs, videotape, or digital images of me (“Images”). I understand that ______________ may use and release my images to the general public for the following purposes: (1) educational lectures and presentations for health care professionals; (2) scientific publications such as journals or books; (3) patient education materials; (4) broadcast, print or Internet media for educational or public interest purposes. I understand that after release of my images to the general public, they may be subject to redisclosure. I understand this authorization is voluntary and I may refuse to sign. There are different state laws that govern the use of photographs so always review your consent form with an attorney prior to using. If the patient is under 18, a parent or legal guardian should be requested to sign the photographic consent form for non-treatment purposes and use. Make a point to discuss the release for the Internet. Because of the nature of the web, any image can be downloaded and repurposed so make sure your patient understands this possibility. To deter others from taking your work, embed a watermark with your name/practice name on top of the image (Fig. 4.1). In the past, masking the eyes was used to de-identify a subject. Today the stance that the International Committee for Medical Journal Editors takes is that “Identifying details should be omitted if they are not essential, but patient data should never be altered or falsified in an attempt to attain anonymity. Complete anonymity is difficult to achieve, and informed consent should be obtained if there is any doubt. For example, masking of the eye region in photographs of patients is inadequate protection of anonymity” (Fig. 4.2) (8). Attention to Detail After the proper consents have been obtained, the patient can be photographed. Attention to detail is an important aspect of medical photography. You want your photographs to be generic and neutral to best depict the anatomy. This can be achieved by having the subject remove any jewelry (including navel rings) from the camera’s field of view as this can often distract the viewer from seeing what is intended. Personal undergarments can be another distraction and disposable undergarments should be supplied for patients to wear to achieve consistency throughout a series of photographs taken at different time intervals and to keep the patients generic looking.

PHOTOGRAPHY FOR THE AESTHETIC PATIENT

(A)

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(B) Figure 4.2 (A, B) Techniques used in the past to de-identify a subject.

Make-up should be removed prior to photographing as it can camouflage the skin’s condition and texture. Having cleaners readily available for your patients to use can speed up the process of make-up removal. After your subject has washed their face, wait until the skin has returned to its normal moisture level before photographing. This will ensure that it is in its most natural state. Requesting the patient to come in without make-up prior to their consultation is the best way to ensure accurate documentation. Hair should be pulled back with hair-colored headbands. If the bangs are too short to be pulled back, have hair-colored bobby pins available for use. Long hair should be pushed off the shoulders. People have been trained to smile when being photographed but this should be avoided for patient photography as it can distort facial features. Unless a particular series calls for animation, careful attention should be paid to not animating the face. Having someone completely relax his or her face is not typically a natural feeling. Request your patient to relax their brow, eyes, and jaw rather than requesting them to just relax their face. This approach can be more successful as often patients don’t realize these areas are animated until they are specifically pointed out. If a series calls for repose and animated views, ensure that the repose views are photographed prior to the animated ones as it is often difficult for the subject to completely relax the facial muscles after animation. These small nuances can often make extreme differences in comparative photographs, especially in non- and minimally invasive procedures such as botulinum toxin injections. If a patient is having difficulty with keeping their eyes open during the flash, have the subject close their eyes and then take the photograph right as they open them. The goal of clinical cosmetic photography is to provide accurate photographic representations from clinical results. This documentation relies on standardizing photographic variables. These variables can be categorized in five components: Standardized views, positioning and alignment, lighting, focal length and camera-to-subject distance, and simplifying the background. Standardized Views Different staff members often perform photography in a clinical practice so it is helpful to use a standardized series. A standardized series is a

predetermined set of photographs per procedure that ensures that the patient will have the same views photographed each time they come in. The series is built for each specific treatment and the patient is generally photographed either 180° or 360° in 45° increments, depending on the procedure and treatment. It is recommended to have the series readily available for whoever is performing the photography. The following are standardized series for some of the cosmetic and aesthetic procedures (Figs. 4.3–4.11). These series not only ensure that the same views are photographed, but they also help define reference points for accurate positioning. There are variables that exist in each face series depending on the surgical procedure or treatment being performed. These variables are noted in each section.a POSITIONING AND ALIGNMENT

Proper anatomical positioning and alignment are important. Identifying reference points and using positioning devices can be helpful in achieving this. For example, placing a target on the wall for the patient to view in the lateral position can help with standardizing the head alignment. Head Positioning: The Frankfort Plane vs. the Natural Horizontal Facial Line The Frankfort plane is used as a reference line for correct head positioning in an X-ray film and has also been used by physicians as a standard for head alignment when photographing the face. Some physicians choose to use the natural horizontal facial plane for alignment (9,10).

a

Author’s note : The focal length information supplied is assuming a 35 mm format of film and/or equivalent CCD/CMOS size of 24 × 36 mm. On some digital cameras, an equivalent lens will have a much smaller focal length because image sensors are much smaller than 35 mm film. For example, while 35 mm has an area of 36 × 24 mm, a 2/3-inch image sensor is only 8.8 by 6.6 mm (11 mm diagonal). For cameras with smaller sensors, a focal length modifier is necessary for achieving the same focal length as with the 35 mm lens.

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(A)

(D)

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Figure 4.3 (A–F) Standardized face/neck series. Camera orientation: Focal length lens/distance: Landmarks: Reference points:

Key points:

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(F) Optional views showing subject with teeth gritting on the left and head down on the right. These views help to depict platysmal banding and submental fat.

Vertical 80 mm at 1 m full face 80 mm at 0.6 close up views Hairline to clavicle Anterior—Align naturally as if subject were looking into a mirror Obliques—Medial part of the eye to the dorsum Laterals—Align brow to chin Make sure that the head is in the standard anatomical position and that the patient is sitting straight and not slumping. Any degree of neck flexion or head retraction can greatly enhance the effect of submental fat/jowl line or conversely neck extension can improve the jowl line.

The Frankfort Plane (Fig. 4.12A) Horizontal plane that transverses the top of the tragus (external auditory canal) across the infraorbital rim (11). Can cause noticeable changes in jaw definition and submental soft tissue (12).

• •

The Natural Horizontal Facial Plane (Fig. 4.12B) Achieved when the patient looks straight ahead as if looking into a mirror at eye level (10). Preferred for use in plastic surgery photography. Used in patients that have low-set ears (10).

• • •

Lateral Face Alignment Having the subject open their mouth and checking commissure alignment can perform proper alignment of the lateral side of the face. This

helps to prevent over or under side-to-side rotation of the head. To help correct the up and down orientation of the head, vertically align the brow with the chin. Consistency in head alignment from photographs taken during different time intervals is important. Placing a sticker on each wall at eye level height and asking the subject to point their nose at it can achieve this (Fig. 4.13). LIGHTING

Lighting is one of the most important variables to standardize in cosmetic photography because it can dramatically change the appearance of the patient with even slight changes. All light has color depending on its wavelength. Our eyes have the ability to correct for color differences in light; the camera however, does not. This can be easily demonstrated by taking a photograph in ambient light without the use of a flash. Your photograph will have an orange colorcast.

PHOTOGRAPHY FOR THE AESTHETIC PATIENT

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(E) Figure 4.4 (A–E) Standardized eye/brow series. (Photographs below are to be taken in addition to the face series.) Focal length lens/distance: 80 mm at 1 m full face 80 mm at 0.6 close up views Camera orientation: Horizontal Landmarks: Eyes—Slightly above eyebrows to slightly below lower orbital rim. Brow—Just above hairline to just below eyebrows Eyes looking into camera with pupils aligned horizontally Eyes looking up (shows submental lower eyelid fat and any upper eyelid hooding) Eyes looking down (shows submental lower eyelid fat and excess upper eyelid skin) Brow (shows detail of horizontal lines and close up of glabellar muscle) Key points: Make sure that the brow is not raised in the photograph with the eyes looking up. Have the subject relax their brow while simultaneously looking up with their eyes.

Using a daylight balanced flash in your photography will help prevent this so you can depict more accurate color for your patient’s skin (Fig. 4.14). Not only do you want to use a flash, you want to use multiple flashes. Using a single on camera flash can produce harsh contrasting of the shadows and highlights.

There is not one lighting technique that can produce the proper lighting for all procedures, so decisions need to be made before setting up your lights. The size of the area, the clinic workflow, and the staff experience are all factors that should be addressed prior to choosing lighting techniques for your photography.

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Generalized Lighting The typical studio lighting setup has two flashes (strobes) positioned at 45° angles and 3 to 6 feet away from the subject (Fig. 4.15). This studio lighting produces an overall even distribution of light, is easily reproducible, and works well for most face and body procedures.

(A)

It also provides an efficient clinic workflow. This lighting setup is best used in a clinical setting where multiple staff members are assigned to photograph. This ensures that lighting variables are controlled because the lights are stationary not repositioned per different procedures.

(B)

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(G) Figure 4.5 (A–I) Standardized laser/skin series. (Photographs below are to be taken in addition to the face series.) (Continued ).

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PHOTOGRAPHY FOR THE AESTHETIC PATIENT

(H) Figure 4.5 (Continued) Camera orientation: Focal length lens/distance: Landmarks:

Key points:

(A)

(I) Vertical and horizontal 80 mm at 1 m full face 80 mm at 0.6 close up views Main thirds of the face Top—Just above hairline to just below eyebrows Middle—Just above the eyebrows to just below the nose Bottom—Just above nostrils to just below chin Cheeks—Just above the eyebrow to just below the jawline Lateral to neck—Ensure consistent rotation by aligning corners of subject’s mouth when mouth is opened. This view is intended to show tonal changes of the skin, if any, from the cheek to the jaw to the neck. Position slightly above eyebrow to collarbone. Make sure that all make-up has been removed prior to photographing.

(B)

(E)

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(F) Figure 4.6 (A–K) Standardized botulinum toxin series. (Continued ).

(D)

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(G)

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(K) Figure 4.6 (Continued) Camera orientation: Focal length lens/distance: Landmarks:

Key points:

Vertical and horizontal 80 mm at 1 m full face 80 mm at 0.6 close up views Glabellar (top third of face)—Just above hairline to just below eyebrows. Horizontal brow lines (top third of face)—Just above hairline to just below eyebrows Crow’s feet (middle third of face)—Just above the eyebrows to just below the nose Vermillion border (bottom third of face)—Just above nostrils to just below chin. Ensure that repose views are photographed prior to animated views. It can be difficult to fully relax facial muscles after having animated them. Photograph a full face view animated and repose in addition to the close up views. The close-up view alone can sometimes be difficult to determine if post injection if the patient is animated or not.

Facial Lighting The preferred lighting technique especially for rhinoplasty, facial fillers, and other cosmetic procedures, produces more three-dimentional effect of the facial structure (Fig. 4.16). This lighting technique is performed similar to the generalized lighting technique except the lights

are positioned above and closer to the subject. This causes shadows to be created by the dorsum, nasolabial folds, and jawline. The disadvantage of this technique is that it is more prone to produce inconsistencies between comparative photographs because the slightest change in flash positioning can produce a dramatically different result rendered

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PHOTOGRAPHY FOR THE AESTHETIC PATIENT

(G)

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Figure 4.7 (A–J) Standardized filler series. Camera orientation: Vertical Focal length lens/distance: 80 mm at 1 m full face 80 mm at 0.6 close up views Landmarks: Just above the hairline to just below the chin. Align like face series. Key points: Make sure that repose views are photographed prior to animated views. It can be difficult to fully relax the face after having animated it.

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Figure 4.8 (A–H) Standardized lip augmentation series. Camera orientation: Landmarks: Key points:

Vertical and horizontal Just above the hairline to just below the chin. Make sure that repose views are photographed prior to animated views. It can be difficult to fully relax the face after having animated it. Photograph lips slightly parted so the full volume of the lips can be shown in the photographs. Remove lip liners and lipstick prior to photographing.

PHOTOGRAPHY FOR THE AESTHETIC PATIENT

(A)

(B)

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(E) Figure 4.9 (A–D) Standardized rhinoplasty series. (Photographs below are to be taken in addition to the face series.) Camera orientation: Horizontal Focal length lens/distance: 80 mm at 1 m full face 80 mm at 0.6 close up views Landmarks: Basal view (Worm’s eye) Head tilted all the way back with top of nose between eyebrows. Shows contour and asymmetries of the nostrils and alar, tip defining points, width of alar and any deviation. (May require adjustment if subject has extremely low tip projection or large lips that block the alar area) Half basal view—Head tilted back with tip of nose just below eyes. Shows dorsal hump and/or deviation of nose. Cephalic view (Bird’s eye)—Head tilted down and photographed from front of subject. Shows cephalic shape, tip defining points, subtle depressions in the dorsum and deviation and/or existing facial fractures. Oblique variables—The oblique can be photographed different ways depending on personal choice. The first way aligns the tip of the nose to the cheek and the second way aligns the dorsum to the inner eye. Key points: The subject should look straight ahead in all views. Place a dot on both sidewalls and ask the patient to point their nose at the dot. This often helps with being consistent with alignment. Supplemental views: (E) If a depressor-septi release s to be performed, additional views of the patient smiling are often taken to show the muscle pulling the nose downward.

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Figure 4.10 Standardized breast augmentation series. Camera orientation: Horizontal Focal length lens/distance: 50 mm at 3 m Breast alignment: The breasts are photographed with the head and feet in alignment. Again, a positioning mat and tripod will help to keep the height consistent and lens parallel with the subject. Care should be taken to ensure that a proper lateral is taken. This can be identified by two ways. First, if the subject has their shoulders relaxed and arms positioned to the side, a reference point can be established by seeing how much of the back is shown. If no back is seen then the patient is turned too far towards the camera. If both sides of the back are seen then subject is over rotated. Using the back rather than the breasts to identify correct lateral views is more dependable. If the breasts were used instead, for example, both breasts were shown in the lateral view, can be often undependable because of the natural asymmetry of the breasts. Landmarks: Just above the inframammary fold to just below the naval. This shows the proportion of the breasts to the rest of the body. Key points: A foot placement mat is helpful for correct alignment. Have subject relax shoulders prior to photographing. For the obliques, when arms are relaxed to the sides of the body, the upper arm should touch the top of the breast.

PHOTOGRAPHY FOR THE AESTHETIC PATIENT by the shadows. This technique would be recommended for clinics that have a person trained in medical photographic techniques, a clinic that provides more space for different photographic setups, and one that is limited to photographing just a few different types of procedures. Cellulite Lighting However, there are some procedures that are better depicted with different studio lighting set-ups. These setups can become more time

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consuming and more apt to inconsistency and reproducibility because the lights are being repositioned for specific procedures. The advantage is more definition of the skin, contour, and facial features. One lighting technique is for cellulite. This lighting emphasizes the skin’s tone and texture and is accomplished by placing the flash above and about 1 to 2 feet in front of the subject. This produces harsher shadows but gives the skin more definition. An additional light placed behind the subject and pointed at the backdrop can reduce the background shadows (Fig. 4.17).

(A) Figure 4.11 (A–D) Standardized body contouring series. (Continued ).

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(B) Photograph on the left shows the patient with the legs too close together. Middle figure shows correct stance for a patient. Knees should not extend passed the hips. Photograph on the right shows patient with legs to far extended.

(C) Figure depicts distorted view of patient when camera is not kept parallel to subject. These photographs were taken seconds apart and are of the same subject. The left figure shows camera at a downward angle, the right an upward angle. Distortion can greatly affect comparative photographs as shown by the comparison of the waist in these two photographs.

(D) Figure shows optional body contouring view called the divers view and is used to depict skin laxity. Figure 4.11 (Continued) Camera orientation: Focal length lens/distance: Body alignment:

Landmarks: Key points: Supplemental view:

Vertical 50 mm at 3 m The body should be aligned from head to toe. The legs should be separated at hip width as shown in the middle photograph in (B). Feet should remain parallel to each other. Twists of the torso should be avoided as they can greatly distort the body and make consistency between photographs taken during different times difficult to compare. To achieve consistent results, a foot-positioning mat should be used to ensure that correct positioning is maintained. Using a tripod is necessary to ensure the camera lens is parallel to the subject and positioned at the midpoint of the body. Distortion can occur if the lens is tilted up or down towards the subject as shown in (C). Just above the inframammary fold to just below the knees. A foot placement mat is helpful for correct alignment. Arms should be bent and held out of the field of view at breast height only. Weight should be distributed evenly and feet should be parallel to each other. The distance between the feet should not extend the knees past the hips. (D) A “diver’s” view is often taken for patients to demonstrate skin laxity and fat.

PHOTOGRAPHY FOR THE AESTHETIC PATIENT

(A)

(B) Figure 4.12 (A) Frankfort plane vs. (B) natural horizontal facial plane.

Figure 4.13 Lateral face alignment. Left depicts over rotation, middle photograph is correct lateral rotation and the photograph on the right is under rotated.

Figure 4.14 Example of with and without flash.

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FOCAL LENGTH AND CAMERA TO SUBJECT DISTANCE

Figure 4.15 Studio example of two 45° flashes.

Figure 4.16 Preferred lighting technique.

Photography has changed dramatically in the past 10 years and the use of digital over 35 mm is commonplace in healthcare. These changes have called for changes in standardizing photography for patient photography. This is most evident in the control of focal length and distance. Proper focal length and subject to camera distance need to be controlled for patient photography to avoid unwanted distortion. Before digital cameras, using a fixed focal length lens in manual focus mode performed proper focal length. The photographer would move back and forth to the patient in order to achieve focus rather than using auto focus. This technique ensured that the correct distance and focal length were used for the area being photographed (9). With the advent of digital cameras, this technique can be reproduced but often consumer zoom lenses are used making it more difficult. The photographer should be aware of the focal length being used and place identifying markers on the floor so that he or she stands the same distance from the subject each time. It is important to control the focal length and distance to prevent unwanted distortion as shown in Figure 4.18. The Cardiff/Westminster scales of reproduction, that was the magnification of the 35 mm film plane for patient photography, decided the focal length. For example, the breasts were photographed with a normal 50 mm lens at a distance of 1/10 while the face was photographed using a long 100 mm at a distance of 1 m (13). All depended on the film plane to be a set size 24 × 36. Then came digital cameras with variable sized sensors making the focal length more difficult to determine per camera. The focal lengths and distances of lenses built for the 35 mm would need to take into account the smaller sensor sizes. For example, the 50 mm lens would now be the equivalent to a 30 mm lens on a digital camera with a 2/3 sensor size. This was determined by using the following formula now known as the FLM—focal length modifier. By taking the diagonal of the sensor and multiplying it by 1.5. Simplify Background with Backdrop Using a backdrop will help simplify your photographs, eliminates distracting objects, helps to produce a contour of the patient and maintains consistency between photographs taken during different timed intervals. The choice of a background color is important. Medium blue is often used and was carried over for the same reasons that laps and

Figure 4.17 Studio example showing difference in lighting techniques used to photograph cellulite.

PHOTOGRAPHY FOR THE AESTHETIC PATIENT

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Figure 4.18 Proper focal length of the face is shown on the left and distorted facial features from improper focal length on the right.

drapes are blue and green in the operating room, to counter the amount of red seen to prevent eyestrain as well as offering contrast to the red seen in medical subjects (9). Naturally it carried over into the clinical setting to make the backdrop colors in operative and clinical photographs consistent. Medium blue also contrasts well with a variety of skin tones. A white background should be avoided because it reflects light and can make subjects appear washed out. It is also not as aesthetically pleasing and does not work well to provide enough contrast to provide contour definition. Black is often used but can absorb a lot of light. It may not work well with dark-skinned people but has been used successfully with additional background or rim lights to highlight the subject’s contour from behind (11). If a room has been dedicated for photography, the wall can be painted blue. A flat-based paint should be used instead of a gloss to prevent reflections from the flashes. If material is used, make sure it is a wrinkle-free material that does not have a lot of sheen to it. Polyester works well for most cases. Rolled paper backdrops can be used with stands and are available at professional photography stores. CONCLUSION

The value of photography in a clinical practice is often underestimated. Staff members are regularly used to perform the practice of patient photography and are often not properly trained in photographic standards. Using these guidelines you can improve the quality of your photography, which in turn improves the documentation of your talent and can create better communication and trust with your clients and patients. REFERENCES

1. Bockaert V. Aperture. [Available from: www.dpreview.com/learn/?/ Glossary/Exposure/Aperture_01.htm] (accessed May 6, 2010).

2. Bockaert V. Shutterspeed. [Available from: www.dpreview.com/ learn/?/Glossary/Exposure/Shutterspeed_01.htm] (accessed May 6, 2010). 3. Bockaert V. Depth of field. [Available from: www.dpreview.com/ learn/?/key=depth+of+field] (accessed May 6, 2010). 4. Bockaert V. Focal length. [Available from: www.dpreview.com/ learn/?/Glossary/Optical/Focal_Length_01.htm] (accessed May 6, 2010). 5. Rowse D. Macro photography tips for point and shoot cameras. [Available from: www. digital-photography-school.com/macrophotography-tips-for-compact-digital-camera-users] (accessed May 6, 2010). 6. Bockaert V. Digital zoom. [Available from: www.dpreview.com/ learn/?/Glossary/Digital_Imaging/Digital_zoom_01.htm] (accessed May 6, 2010). 7. Bockaert V. Viewfinder. [Available from: www.dpreview.com/ learn/?/Glossary/Camera_System/viewfinder_01.htm] (accessed May 6, 2010). 8. International Committee of Medical Journal Editors. Protection of patients’ rights to privacy. Br Med J 1995; 311: 1272. 9. Williams AR, Nieuwenhuis G. Clinical and operating room photography. In: Vetter JP, ed. Biomedical Photography. Boston: Focal Press, 1992:: 251–301. 10. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg 2002; 109: 1421–34. 11. Williams AR. Positioning and lighting for patient photography. J Biol Phot 1985; 53: 131–43. 12. Sommer D. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast Reconstr Surg 2004; 114: 10–14. 13. Young S. Maintaining standard scales of reproduction in patient photography using digital cameras. J Audiov Media Med 2001; 24(4): 162–5.

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Ergonomics for an aesthetic office Steven K. Cordonnier

INTRODUCTION

Ergonomics plays an extremely vital role in an aesthetic office. It can often mean the difference between a very successful and growing practice and one that is barely surviving. This is why it should be an important component during the design and layout of any examination or procedure room and aesthetic office. It should also be a consideration during any equipment purchases and staff training. Unfortunately, ergonomics is often an overlooked area that many times is not given serious attention. When it comes to healthcare facilities, ergonomic principles are just as important for patients as it is for physicians and staff. For patients, the issue is also one of accessibility, which can often be tied to ergonomic principles. When implemented correctly, ergonomic principles can help the healthcare facility owner achieve the highest levels of comfort and safety for patients, physicians, and staff. The foundation for any efficient and successful practice is the level of comfort and safety provided by the facility, especially its exam and procedure rooms. BENEFITS OF ERGONOMIC PRINCIPLES

The benefits of implementing good ergonomic principles in the aesthetic office are many. And these benefits are felt by patients, physicians, and staff. As we mentioned earlier, the two most significant benefits of ergonomic principles are that the office and exam rooms will be more comfortable and safe for everyone. These two factors alone can directly influence the quality level of the physician/patient relationship during a visit. Following are the benefits, including comfort and safety, that can be realized when ergonomic principles are implemented in an aesthetic office. Comfort Comfort is one of those basic human needs, that when met, can help put someone at ease, foster efficient performance, and help facilitate a pleasant experience. These results are especially important in a healthcare environment. For patients, the level of comfort can directly influence their level of anxiety and help ease “white-coat syndrome.” Meanwhile, physicians need to be comfortable in their environment in order to provide efficient and effective patient care. For instance, the inability to easily maneuver in the examination or procedure room can often cause physicians to alter their work style over time, which can result in repetitive motion injuries. Simple comfort considerations in design and equipment can play a significant role in helping physicians conduct a more thorough and accurate exam or procedure and increase the overall satisfaction level of the patient.

procedure table. In many facilities, the burden falls on staff to lift or assist the patient. This sort of patient/staff interaction has a high potential for serious injury to one or both of the parties involved. At the very least, it could result in back injuries for staff, which is a serious issue in the healthcare industry. The National Institute for Occupational Safety and Health (NIOSH) estimates that direct and indirect costs associated with back injuries in the healthcare industry are about $20 billion annually. Accessibility As the healthcare industry evolves, equal access healthcare is an increasingly important issue affecting our healthcare system across the country. It basically pertains to a practice’s ability and willingness to ensure that healthcare is accessible and inviting for elderly patients, as well as those with other mobility concerns, such as patients with disabilities or obesity issues. Quality of Care/Efficiency of Procedures Implementing ergonomic and accessibility principles in a healthcare facility, and in particular the exam/procedure room, will raise the level of the quality of care being provided and increase the efficiency of the procedures being conducted. The basic fact is that the less physicians and staff are forced to strain to move patients or endure uncomfortable positions, the more they will be able to focus on the patient and provide the best quality care possible. Reputation and Perception From a business standpoint, the perception of the patient and the reputation of the healthcare practice are very important. The more pleasant the patient experience, the more likely it is that they will not only return for other procedures; they may even recommend these services to a friend or family member. In any medical practice, especially a cosmetic one, the appearance of your exam tables, lighting, etc. immediately tells a patient whether you are using the best and staying current or whether you are a poseur. GROWING IMPORTANCE OF ACCESSIBILITY

Too many facilities and clinics still lack total architectural and programmatic accessibility. By providing an accessible healthcare environment that works for everyone, providers improve the quality of patient care as well as the quality of their patients’ lives. Full accessibility is closely tied to many ergonomic principles. As a result, it can greatly improve patient safety and patient outcomes, as well as productivity and profitability for the practice. CONSIDERATIONS FOR THE AESTHETIC OFFICE

Safety It is important that patients and staff feel safe when they are in the office and exam/procedure room. A safe environment is conducive to a pleasant experience for everyone. If a patient does not feel safe, they may become agitated and decide not to visit this office in the future. Staff who do not feel safe may become dissatisfied and decide to look for different employment. And if an accident does occur, a safety concern can quickly lead to a liability issue. For example, with the average age of patients on the rise, it is more likely that patients may need assistance in accessing an exam or

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To fully understand the significant role ergonomic and accessibility principles can play in an aesthetic office, it is important to look individually at specific areas and equipment found inside the facility. Entrance and Lobby For patients, ergonomic and accessibility principles can have an effect on them before they ever step foot inside the exam or procedure room. Simple considerations such as accessible parking, wheelchair accessibility, and power door operators can make the office more inviting and create a more safe and comfortable environment. Additionally, it

ERGONOMICS FOR AN AESTHETIC OFFICE is important to have adequate and comfortable seating for patients and any staff. Another ergonomic issue often found in entrance and lobby areas is the potential for trips and falls caused from environmental hazards such as slippery or wet floors, uneven surfaces, cluttered or obstructed passageways, inadequate lighting, or poorly maintained walkways. Exam and Procedure Rooms Since physicians spend most of their time with patients in exam and procedure rooms, it makes sense that these areas are where ergonomic and accessibility principles can have the greatest impact on the quality level of the healthcare environment and care provided. The design and layout of the exam/procedure room can have a significant effect on the quality of patient care and comfort and safety of the facility. The size of the room is very important. It needs to be large enough to comfortably accommodate the patient, physician, and staff and allow procedures to be properly performed. The industry standard for an exam room is approximately 8 ft × 8 ft; however, increasing the room to 10 ft × 10 ft—or larger, if possible—provides a 60-inch diameter area to accommodate wheelchair turnaround for disabled patients, as recommended in guidelines of the Americans with Disabilities Act (ADA). Procedure rooms can be 12 ft × 12 ft, depending on procedure equipment, and patient positioning required. The slightly larger room allows the door to be reverse-hinged to increase patient privacy. If a staff member enters the room to assist the physician, the patient is not exposed to other patients in the corridor. Larger rooms will also accommodate newer equipment, such as lasers, and will allow for versatility down the road if one needs to add new in-office procedures. For most aesthetic procedures, the work of the physician and staff is concentrated around the head section of the table. However, there are other procedures that occur at the foot and midsection of the table, so access around the entire table is critical. To facilitate this access, the procedure table should be positioned either in the middle of the room or at an angle, allowing the physician and staff to work at the head end of the table, and as much as possible in a neutral position, without too much overreaching or bending and twisting of the back and head. And adequate room space will mean that the physician can easily move about while seated on a stool, minimizing any aches that might be caused by continually sitting and standing during an exam or procedure. Procedure tables must be able to afford the physician an opportunity to inject, laser or otherwise treat without having too much neck flexion. It is also a good idea to include side chairs in the room. These chairs can have multiple uses. Two chairs are commonly used for the patient and potentially an accompanying family member to sit together during any sort of consultation. Typically, the patient would sit on the procedure table and a family member would be seated across the room. This is less desirable because the physician must consult the patient and answer questions from all people, wherever they are located. The two chairs, positioned side by side, allow the physician to consult with both individuals simultaneously and maintain eye contact without constantly moving the head or torso, thereby decreasing the stress on the neck and back. As with the lobby and entrance, the exam and procedure room is another area where trips, slips, and falls often occur. Along with slippery and uneven surfaces, other hazards include cords from all the equipment in the room that stretch across the floor. By using floor outlets, the power cord of the procedures table can be shortened and kept from stretching across the floor. Additionally, outlets located on the procedures table enable the physician to plug equipment into the table and keep the associated cords from stretching

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across the floor. Lastly, using wireless controls can completely eliminate the control cords going to the equipment and allow staff to position the controls where they make the best ergonomic sense. An emerging trend that certainly helps the ergonomics of the office is to incorporate a consultation area in the procedure room. This has the benefit of reducing room changes for both the physician and the patient. The doctor can then stay seated and simply turn around when they want to go from the consultation to the procedure. This setup certainly requires a very aesthetically pleasing and friendly, warm environment. The placement of surfaces, instruments, equipment, and access to equipment all require a well thought out plan to make this setup a success but when it is done correctly it can be a very ergonomic solution Lighting It is important to have medical lighting in the exam/procedure room that provides a large pattern size with an even distribution of light throughout that eliminates shadows. It should also remain safe and cool to the touch. The lighting should be counterbalanced to provide precise positioning without drifting and without any undue spring or frictional force that would cause the user to overly push or pull in order to position the light. Thus, it should be easy to maneuver, eliminating any strain on physicians. Physician Stool For a physician, the ergonomic properties of the stool are very important. The ideal stool should feature a contoured seat that molds to the shape of the body and provides maximum comfort and support for the buttocks, feet, and torso. It should also feature a strong base structure that offers stability and minimizes the chances of tipping. Padding is essential in order to avoid compression during consultations. The stool should be easily adjustable and maneuverable, to allow physicians to find the most comfortable working height and effortlessly interface with the patient. The adjustable height will allow physicians to maintain neutral postures and keep shoulders relaxed and the head balanced and looking essentially straight ahead, while minimizing overreaching and sustained bending, and twisting. Stools with armrests should be avoided, as these often limit access to the patient and interfere with other items in the room. Procedure Table or Chair The procedure table or chair is the one piece of equipment in a practice that touches nearly every patient. It can be the most valuable asset of a successful practice. The right procedure table can increase the level of efficiency, comfort, and safety, and enhance the delivery of care. For example, being able to easily get onto a procedure table can increase a patient’s comfort during the visit. In addition to patient and physician comfort, the right procedure table can mitigate risk by preventing injuries and falls. The most important feature of the table is that it should be barrierfree and be able to lower to a height of 19 inches or less so patients are able to get on it with little or no assistance. Being able to easily get onto a procedure table can increase a patient’s comfort, help the physician conduct a more thorough and accurate exam or procedure, decrease potential for staff ’s back injuries and increase the satisfaction level of the overall patient experience. Barrier-free tables also reduce the likelihood of distress and injury to patients who are elderly, disabled, obese, or even pregnant who may have difficulty in accessing a standard procedure table. The tables and chairs should be fully adjustable and feature power height, back, foot, and tilt. This will enable the patient to remain relatively still during the entire procedure. This will also enable easy access and flexibility during examinations and procedures, saving the

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physician from overreaching, twisting or bending the back or torso too much resulting in awkward postures. According to Occupational Safety and Healthy Administration (OSHA), “‘awkward postures’ means working with various parts of the body in bent, extended or flexed positions rather than in a straight or neutral position. Working in awkward postures increases the exertion and muscle force that employees must apply to complete a task and compresses tendons, nerves and blood vessels.” In addition, the federal agency points out that “twisting the torso creates an asymmetry which stretches some sets of muscles while compressing others forcing smaller, isolated groups of muscles to provide the needed force for the task. Twisting the spine creates nonsymmetrical forces on the fibers of the disc which weakens the structure making it more susceptible to bulging and rupture … .” It is clear from OSHA that to minimize the risk of injury, the physician and staff should minimize awkward postures as much as possible. Of special importance to the aesthetic medicine physician is the ability to have close access to the patient. Having close access enables the physician and staff to stand upright without unnecessary bending or twisting while still performing the procedure. Since much of the aesthetic medicine work is performed on the face, neck, and upper body, having a procedure table with a small headrest and a very narrow back section is vital in providing this close access. And because many physicians or staff work from a seated position, it is important to have a thin headrest and back section without obstructions. This gives physician the ability to roll in close to the procedure table’s back section or headrest without bumping their legs or knees on the table components. All of this facilitates proper posture and will reduce strains and injury to the physician. Powered height, from 19 inches up to 40 inches, is crucial to keep the physician and staff from bending over the patient. This large height range adjustment allows both shorter and taller physicians and staff to work at the most appropriate height and limits the amount of neck and back flexion. OSHA studies have found that the work site should be such that the forearm and upper arm should be at 90° angles because it helps keep the strain off of the shoulder muscles. Rotation of the table should also be considered because it allows the physician to move the patient to the other equipment in the room instead of requiring the physician to move around or require movement of the equipment. In addition, by rotating the patient, the physician can position the work site close to a counter or supply storage area so that twisting movements and overreaching can be minimized. A final consideration for the procedure table or chair should be its controls. The controls for moving the table or chair should ideally either be wireless or in the form of accessible, easy-to-use foot controls. And the size of the controls should not be overly large and obtrusive that they cause a trip hazard or force the doctor or staff away from the work site. The latter would result in the user leaning over the patient and put undue strain on the lower back and neck. Casework/Cabinetry Casework designed specifically for medical environments is often more durable and will not break down under medical use, unlike common wood casework. While casework does have an aesthetic effect on the image of the practice to patients and staff, it also can be tied closely to ergonomic principles.

For example, a pull-out writing surface at an approximate height of 30 inches would allow any paperwork needed during an examination to be readily and conveniently accessed. And locating the sink in the corner maintains a countertop surface closer to the working environment and isolates any splashing to eliminate potential slippery spots on the floor. Another important area on the cabinetry is the kick area of the base cabinet. This should be high enough to allow the legs of the stool to slide under the edge of the base cabinet while the user’s foot is positioned on the base in a very common use scenario. This allows the user to get in closer to the cabinets and countertop and eliminates frequent and unnecessary bending or stretching. And consideration should be given to how items are placed in the cabinetry. For example, keeping the most frequently accessed supplies on the lowest shelves keeps physicians and staff from constantly overreaching. Monitors Monitors have become a critical part of the exam/procedure room. Physicians need to be able to easily view the monitor during any procedure. For this reason, it is important to have a fully adjustable monitor on a monitor arm that allows it to be easily positioned for both sitting and standing postures and for a variety of procedures. Making sure that the monitor is of high resolution and free of smudges will eliminate any eye strain, blurred vision, dry eyes, or headaches that may result from prolonged concentration to view images that are unclear or washed out. An emerging trend is to use mobile carts that can be brought to the side of the procedure table so the physician can maintain the provider/ patient eye connection while still entering data into a practice management system or electronic health records (EHR) system. This arrangement eliminates staff twisting to access any electronic systems or eliminates any awkward balancing that happens with portable tablet computers. Ideally these mobile carts should be height adjustable so a physician can work either sitting or standing. Staff Awareness and Training OSHA recommends that practices establish a training program designed and implemented by qualified persons to provide continual ergonomics education and training. It should also be a part of any new employee orientation. The training should cover not only ergonomic hazards and principles, but appropriate procedures, such as patient lifting guidelines, as well as the proper use of the equipment. The training should also provide an overview of the potential risks, causes and symptoms of back injuries, and work-related musculoskeletal disorders. CONCLUSIONS

The well-designed esthetic office needs to not only look good but also function well. It does the physician little good if he or she is able to build a practice only to become disabled due to a herniated disk in the neck or back. By following guidelines and using well-designed equipment, the physician can enjoy a long and comfortable career. In addition, his or her patients will have the knowledge that the office has invested the time and money to make each visit comfortable and safe as possible.

6

Interviewing the cosmetic patient Susan H. Weinkle and Harriet Lin Hall

INTRODUCTION

The initial visit of a dermatology cosmetic patient has specific nuances that the medical dermatology patient visit does not have. Many of the treatments given and issues addressed are for conditions that are not pathologic, but rather for normal physiologic phenomena (1). Some patients may come to the office not necessarily knowing what they need but are unhappy with their present appearance. Other patients may come to the office with a specific concern but may not be a good candidate for cosmetic rejuvenation because of an underlying systemic disease. In order to fully meet the cosmetic dermatology patient’s expectations, a complete pre-operative assessment including a thorough medical and psychosocial history and focused physician examination is imperative. Key information is obtained through the medical interview. Mastering the skills of interviewing the cosmetic patient will assist in building trust and contribute to the successful treatment of the dermatology patient desiring cosmetic enhancement. THE MEDICAL INTERVIEW

Engel (2) stated “the interview is the most powerful, encompassing, and versatile instrument available to the physician.” The medical interview is highly personal and confidential, so much so that access to the content and records of the physician–patient conversation is protected by law (3). The Accreditation Council for Graduate Medical Education (ACGME), the American Association of Medical Colleges (AAMC), and the American Board of Medical Specialties all have adopted requirements that specify core clinical competencies and performancebased evaluations addressing clinician–patient interaction (4). Importance is placed on domains involving medical professionalism and communication with emphasis on interviewing skills. Talking with patients is not a skill reserved for such specialists as psychiatrists, psychologists, and social workers (4). Cosmetic dermatologists need to develop strong skills in medical interviewing to separate a good cosmetic candidate from a poor cosmetic candidate that may have an underlying personality disorder, such as body image dissatisfaction. In addition to solid interviewing skills, dermatologist/psychologist Richard Fried has written extensively on when patients may not be a good candidate for cosmetic rejuvenation. Dr. Fried developed a screening profile called the CPS-D (Cosmetic Procedure Screen-Derm) (5), which will be discussed in more detail later in this chapter. Sarwer has also written extensively on the psychological assessment of patients who present for cosmetic surgery plastic (6). Other organizations that help clinicians enhance their communication skills include the American Academy of Physician and Patient (AAPP) and the Bayer Institute for Health Care Communication (BIHCC) (7). CONSULTATION SUCCESS STARTS WITH EDUCATION

Historically, patient education occurs throughout the entire encounter with the medical dermatology patient with emphasis that functions toward the end of an interaction or subsequent visits. The cosmetic patient should be educated throughout the complete cosmetic consult. Educating patients means giving them information and, if necessary, motivating them to act on it (8). According to Werschler, education starts from the time before the cosmetic patient even comes to the office (9). Education can start via your website or from the receptionist who answers the phone (Fig. 6.1). Your website should in fact be an

educational tool, describing your services, credentialing you for your expertise and your experience, in addition to everything else, such as directions to the office (9). Many dermatologists who have incorporated cosmetics into their practice have spent time educating their staff and have specially trained practice coordinators. Because of the sensitive nature of the initial interaction, it is critical to have practice coordinators who are receptive, understanding, and aware that patients may display a limited understanding of cosmetic dermatology (10). The majority of cosmetic patients’ knowledge base comes from the media and fashion magazines. They may lack the knowledge and understanding of the procedures themselves, however, are often quite clear on how they want to look after the procedure (10). If the cosmetic patient elects to utilize your practice, the patient will like to have questions concerning costs and payment plans. Consultation charges are frequently questioned by cosmetic patients. The practice coordinator can address this with the patient prior to arriving at the office. Whether there is a charge or not needs to be clearly communicated. Many cosmetic dermatologists elect to waive the consultation fee if the patient decides to have a procedure performed the same day or soon after the consult. INTERVIEWING AS PART OF THE COSMETIC CONSULT

The initial cosmetic consult between the dermatologist, the staff, and patient should include some major themes of medical interviewing. During the interviewing process, the dermatologist should be objective, precise, sensitive, specific, and reliable when making observations about the patients’ cosmetic desires (8). Active listening skills connect the dermatologist with the patient. Below is a partial list of listening skills that help build a therapeutic relationship with the cosmetic patient (8). 1. Choose a mutually comfortable setting. 2. Remain attentive. 3. Observe the patient respectfully as a whole person, not just as a person needing facial rejuvenation. 4. Allow the patient to tell a story with as few interruptions as possible. 5. Note discrepancies in meaning between what the patients say and how they say it. Additionally, the need to demonstrate respect for the cosmetic patient is important in order to connect with the patient and provide optimal treatment. MEDICAL HISTORY AS PART OF THE COSMETIC CONSULT

Once a sound medical history is completed, the cosmetic component of the consult can commence. The consult should take place in a comfortable setting where the patient and physician can exchange valuable information. During this time, the patient may be assessing the environment, asking about credentials, and voicing concerns about their expectations. It is also a good practice standard to inform the patient who will be performing the procedures whether it is the dermatologist, the advanced practice nurse, the physician’s assistant, or aesthetician. Patients are increasingly knowledgeable and sophisticated about cosmetic procedures and expect the most up-to-date treatments. According to Schlessinger (10), it is advantageous to give a tour of your practice to help put your patients at ease. Someone who is knowledgeable about your practice and a firm advocate

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Figure 6.2 Having patient identify their specific concerns. Figure 6.1 Education starts with the receptionist during the first phone call.

Table 6.1 Patient Framework should give this tour. If your practice has several facets such as general dermatology, surgical dermatology, i.e., Mohs micrographic surgery, or clinical cosmetic research, these options should be highlighted. All staff encountered should be introduced, and the staff should be urged to respond pleasantly to the patient and tour guide (10). If the appropriate measures discussed have been taken, the consultation process in the exam room should progress smoothly. The patient should be much more likely to follow your lead as a physician, allowing you to take the time to explain the procedure chosen, review pictures of previous patients, interact openly and honestly with the patient and establish priorities that would offer optimal treatment (10). THE FIRST TIME COSMETIC PATIENTS VS. THE EXPERIENCED COSMETIC PATIENT CONSULT

Many first time cosmetic patients will not only have one specific concern but many. A good starting point with these patients is to provide a mirror and have them point out their specific concerns (Fig. 6.2). Patients often identify multiple areas of concern, but also tend to prioritize what bothers them the most (1). What may seem like a cosmetic flaw to the physician may not be a concern to the patient and if the physician suggests an area for treatment that the patient has not mentioned, the patient may feel offended. Werschler (9) developed a framework that divides the cosmetic patient into one of three distinct buying groups: (i) enhancement patients, (ii) rejuvenation patients, and (iii) restoration patients ( Table 6.1). According to Werschler (9), the restoration patient has traditionally been the bread and butter of dermatologists because they frequently deal with skin cancer, agerelated concerns of the skin such as rosacea, lentigos, and pre skin cancers. These patients typically have had interaction and good experience with dermatology. The enhancement patients have been patients of plastic surgery because the majority of dermatologists usually do not offer extensive facial reconstructive services for that group of patients. The rejuvenation group may opt to visit both dermatologists and plastic surgeons, depending on demographics and availability of cosmetic dermatologists. When consulting with the cosmetic patient, keep in mind their psychodynamic drivers. Give careful consideration to why they are in your office. For example, if you offer to make enhancement patients’ lips look like a famous celebrity’s lips they will probably indicate “That’s exactly what I want.” If you were to offer the same service to a rejuvenation patient, they might respond “ No, that’s a little too much,

Enhancement patient

Rejuvenation patient

Restoration patient

Very young; range 18–29 years of age; may have acne; desires better skin care, bigger lips, correct “bump” in nose; wants to look better than genetically made

Usually 30–50 years of age; complaints of looking older than they feel; want to look younger not change entire appearance; usually take good care of themselves

Generally 55+; desires to be the best looking for age group; interested in repairing sun damage, prevention of skin cancer; slowing aging process

I just want a little bit of filling and just have a bit more of a pouty look.” The notion of interacting with patients to identify their concerns and decide upon the best course of therapy should always define how cosmetic dermatologists structure their practices and evaluate the various cosmetic procedures available (10). Once the patient’s concerns are identified, the physician can proceed with a pretreatment assessment. Physician concerns should include and address the type and extent of wrinkles, folds, furrows, and other signs of aging including any disease state such as skin cancer or actinic keratosis. It is at this point that photographic documentation is crucial. The physician should set goals with the patient about cost, timeline of treatments, follow-up visits, and agreeing to the extent of correction possible. PATIENTS WHO SHOULD NOT HAVE COSMETIC FACIAL REJUVENATION

Patients that do not make good candidates for cosmetic procedures include patients displaying, underlying personality disorders including depression. Also, any patient with active systemic disease should not have cosmetic treatment. For example, a female patient in her late 60s with unstable angina is probably not a good candidate for laser surgery. According to Fried and Werschler (5), the late Eugene Farber wrote in the 1990s about the other dimension in the management of psoriasis; that intrapsychic factors and stress can affect treatment outcomes. Dermatologists frequently have patients present to their office with complaints of feeling stressed and unhappiness with their appearance. Many patients have been misinformed about cosmetic procedures and products via the internet and media. This sensory overload makes it difficult for patients to make well-chosen cosmetic interventions that maximize the likelihood of achieving their desired result (5). Fried and Werschler developed a screening tool for dermatologists to identify patients that will be most likely dissatisfied with a cosmetic

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INTERVIEWING THE COSMETIC PATIENT

CPS-D (COSMETIC PROCEDURE SCREEN-DERM) Please specify the cosmetic/skin problem(s) that bother you.

Please specify the cosmetic/skin problem(s) you would like improved or corrected.

How do you envision your life will change after your cosmetic procedure?

Will having a cosmetic procedure “fix” any of your problems?

Yes

No

Have you seen any other physicians for cosmetic concerns?

Yes :

No

If yes, how many?

What were your concerns? Were you satisfied with the results? Have you had any previous cosmetic procedures? If yes, which ones? Were you happy/satisfied with the results? Do you drink alcohol? : Yes

No

How often? How much?

Are you taking prescription medications for pain? Do you feel overwhelmed or confused?

Yes

Yes

No

If yes, which ones?/How often?

No

Are you being strongly encouraged or discouraged from having a cosmetic procedure? Yes : Are you generally satisfied with your life?

Yes

No

Are you worried about the way you look and wish you could think about it less? How many minutes or hours in an average day do you think about how you look? Do you cut or otherwise purposely harm your skin?

No

Yes

Yes

No Minutes

Hours

No

Are so distressed by your cosmetic concern to the point where it interferes with you ability to be happy or carry out your necessary daily chores? Yes No Have your cosmetic concerns gotten in the way of doing things with your friends and family?

Yes

No

Figure 6.3 Fried & Werchler Screening Tool.

intervention (Fig. 6.3). Dissatisfied cosmetic patients can drain the physician and staff and potentially damage the reputation of your practice (11). Choosing the appropriate patients is the key to selecting cosmetic treatments that will satisfy and exceed patient expectations (Fig. 6.3). Besides the self-administered CPS-D questionnaire, Fried developed the STEP (Society of Trust and Estate Practitioners) program for helping the dermatologists identify patients you should avoid treating. The STEP program encompasses medical, surgical, and psychodermatology. A PLETHORA OF OPTIONS

The availability and novel applications of dermal fillers has made the reversal of the aging face accessible to a wide range of patients. The trend is likely to continue as the public becomes more familiar with existing nonsurgical treatment options and the Food and Drug Administration (FDA) continues to approve newer treatments. The challenge for physicians is to screen cosmetic candidates to identify high risk patients that would not be appropriate for cosmetic procedures. In the moments prior to and at the initial cosmetic consultation, there are many facets of the consultation that bear scrutiny and reinforcement with staff (10). Cosmetic consultations can be a rewarding experience for both physicians and patients when appropriate key interaction is

displayed for selecting cosmetic procedure that satisfies and exceeds patient expectations. REFERENCES

1. Beynet D, Greco J, Soriano T. Approach to the cosmetic patient. In: Murad A, Gladstone H, Tung R, eds. Cosmetic Dermatology. London: Saunders Elsevier, 2009: 3–6. 2. Frankel R. Forward. In: Smith, R, ed. Patient Centered Interviewing, 2nd edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2002: ix. 3. Frankel, R. The interview in history. In: Smith R, ed. Patient Centered Interviewing. 2nd edn. Philadelphia, PA: Lippincott, Williams & Wilkins, 2003: xi. 4. Coulehan JL, Block MR. Introduction. In: The Medical Interview. Mastering Skills for the Clinical Practice. 5th edn. Philadelphia, PA: F.A. Davis Company, 2006: xvii–xviii. 5. Fried R , Werschler W. The key to mastering cosmetic dermatology patient selection. Skin & Aging 2006; 14(10): 42–5. 6. Sarwer DB, Grossbart TA, Baker AW. Understanding the cosmetic surgery patient. In: Kaminer MS, Arndt KA, Dover JS, Rohrer TE, Zachary CB, eds. Atlas of Cosmetic Surgery, 2nd edn. Philadelphia, PA: Saunders Elsevier, 2009: 3–9. 7. Coulehan JL, Block MR. Interviewing as a clinical skill. In: The Medical Interview. Mastering Skills for the Clinical

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Practice. 5th edn. Philadelphia, PA: F.A. Davis Company, 2006: xvii–xviii. 8. Smith RC. Patient centered interviewing, 2 edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2003: 235–52. 9. Werschler WP. Integrating dermatology and cosmetic dermatology practice: an expert interview with William Phillip Werschler, MD.

Medscape Dermatology, Nov 7, 2008. [Available from http:// cmemedscape.com/viewarticle/582738] 10. Schlessinger J. First contact: improving consultation techniques and procedure selection. Practical Dermatology, August 2009: 43–6. 11. Fried R. Visions of beauty. Skin & Aging 2007; 15(10): 45.

7

Red flag patients Timothy Corcoran Flynn

One of the joys of practicing cosmetic dermatology is the relationship that exists between physician and patient. Cosmetic patients are by and large intelligent, interesting, active individuals who seek to improve their appearance as an augmentation to their robust lives. Many of these patients are dynamic people who comment that their outward appearance does not match how they feel inside. They are frequently seeking to restore their face or body to a more youthful appearance. They usually wish to appear a bit younger and fresher than many in their peer group. Cosmetic patients can be delightful to work with. They are upbeat and positive individuals who enjoy coming to the dermatologist. Most cosmetic dermatologists with busy practices enjoy the interaction. Inevitably, however, one encounters individuals that are unpleasant or difficult. These patients are termed “red flag patients.” They can trigger a mental warning signal when initially encountered. These “red flag patients” should be approached with caution and if the warning signal turns into an alarm, they should be avoided. Studies have shown that up to 47% of patients seeking consultation for a cosmetic procedure meet criteria for a mental disorder (1). Ritvo et al. (2) have noted that common conditions seen in the cosmetic population include body dysmorphic disorder, narcissistic personality disorder, and histrionic personality disorder. A thorough medical and social history can be used to gain a complete understanding of the cosmetic patient and discover these traits. Usually people with personality disorders produce strong feelings in the physician. Body dysmorphic disorder patients can demonstrate a preoccupation with an imagined problem with their body or excessive concern over one body area. This concern causes them significant distress and can occupy great amounts of time and energy on their part. Listening carefully will help identify these patients with more serious psychiatric conditions. Judgment on which patients to treat and which to reject takes time to acquire. Eugene Tardy Jr.’s excellent chapter in the book Facial Aesthetic Surgery (3) wrote “surgical residents in training quickly and accurately learn the physical characteristics favorable for aesthetic surgical correction, but the experience in judgment to assess emotional motivations are less readily acquired.” He further goes on to state “every effort must be made to develop a sixth sense about patient expectations and motivation.” While some red flag patients are easy to recognize by their brashness and atypical behavior, other difficult patients require a bit more care to recognize. Oftentimes your office staff gets the first clue that a person is a drapeau rouge. They may have an unusual interaction on the telephone or during the consultation with your cosmetic coordinator. Some red flag patients, particularly those who are arrogant or feel that they are a “VIP,” may seem extremely pleasant to you, the treating physician. However, they have treated your nursing staff with contempt and disgust. It is wise for the cosmetic dermatologist to pay attention to the opinions of your office staff from the front to the back office. Staff are often correct in their assessment. Identifying difficult patients can be helped by carefully listening to the wishes and desires of the patients, fine-tuning one’s listening skills (with the emphasis on listening) will help ferret out the red flag patients. Oftentimes they give clues within their comments or expression, which helps the experienced cosmetic dermatologist know what patients to avoid. For example, there can be a warning sign if differing inflections are used in the sentence “the other doctor used a filler.” If

you detect sarcasm when the patient states “the other physician,” it is an important clue that this may be a patient who is very difficult to be pleased. The paragraphs below describe the types of “red flag patients” which one can encounter in the office.

“WHERE CAN I GET IT DONE THE CHEAPEST?”—THE BARGAIN HUNTER

Bargain hunters are people who are continually moving from doctor to doctor or calling practices trying to find the absolute best price. They are incorrectly paying attention to the cost of the procedure and not focusing on the outcome. These patients can be like a ping pong ball, going from place to place or spending hours on the phone or internet. They are frequently unhappy because they are seeking treatment from non-experts in the field, oftentimes encountering physicians outside of the non-core specialties. These physicians, in turn, are trying to lure patients to their practice using price as a motivator. They frequently do so by, for example, using less botulinum toxin units than that may be required, thus reducing their cost. Obviously the patient is not going to get as desirable a result when they are undertreated. Bargain hunters can be avoided by establishing a reasonable price for the correct therapeutic regimen. Many times they are treated by non-physicians.

“I WANT TO LOOK EXACTLY LIKE …”—THE PATIENT WITH UNREALISTIC EXPECTATIONS

The patient with unrealistic expectations come to see the cosmetic dermatologist wishing to have a wrinkle “completely removed” or to have the doctor produce “perfection.” Sometimes patients will bring in a photograph from a magazine, stating that they wish to have their complexion exactly match the one in the picture. Alternatively, they may desire something that is physically impossible to achieve, such as a person with very thin lips wishing to have 12 mm of red show on the upper lip only. These patients with unrealistic expectations fail to understand the anatomic limitations. Several of these patients may have seen other physicians or undergone scalpel surgery to try and achieve their idealized appearance. One warning sign for these patients is the feeling that they are inflexible in their goals and the cosmetic dermatologist may have a sense that the patient is not listening to or understanding the cosmetic dermatologist.

“HOW ABOUT 10% OFF DOCTOR?”—THE CHEAP PATIENT Many patients are concerned about expense, particularly in the times of a down economy. However, there are some red flag patients who continuously attempt, at each visit, to get a discount on their services. These patients can be annoying, but more so their focus is often not on the outcome, but rather on the cost. They take extra time during the treatment session, arguing over a few bucks. A statement such as “We do not discount for our services” will usually stop this constant price haggling. Some of these types of patients may be made happy by giving them a little something extra. However, you must be careful in providing a value-added service, because they usually will want it at every visit.

“DOCTOR, CAN’T WE GET MY INSURANCE TO PAY FOR IT?”—THE MANIPULATOR

While there are certain dermatological treatments that can be billed to insurance (e.g., the use of a vascular laser to treat a port wine stain),

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there are very few procedures in cosmetic dermatology which are appropriate to charge to an insurance company. It is important to clearly state to the patient that you can only do this when appropriate and in their case it is not. You can comment to them that you practice medicine with the highest ethical standard and that the patient’s medical records must reflect that. Sometimes a simple joke such as, “I don’t think the insurance company or the government would appreciate it,” can simply sum up the situation quickly and diffuse their wish for you to be dishonest.

“IT HAS TO BE PERFECT!”—THE PERFECTIONIST Perfectionistic people are frequently be encountered by the cosmetic dermatologist. These patients are often immaculately dressed and their grooming is exquisite. They may literally have “not a hair out of place.” Perfectionistic patients may come in with long, detailed lists of their problems or may write detailed letters discussing their problems. Other warning signs that you may be working with a perfectionistic patient may be that they refuse to take off their makeup when asked to do so by your staff. While they seem to understand that a dermatologist must examine the skin unencumbered with cosmetics, they cannot bring themselves to remove their camouflage. Many perfectionists will not be satisfied until every detail is corrected and their appearance becomes “flawless.” A simple phrase which the author has used not to treat perfectionists is “I don’t think I will be able to provide you what you want.” Giving perfectionists the name of other reputable cosmetic dermatologists who may be interested in treating the patient is a courteous service to the patient, but a burden for your colleagues. Perfectionistic patients can also include people with an untreated obsessive–compulsive disorder and are obsessed with their appearance. Some of these people can fall into the category of body dysmorphic disorder. These patients can seem to be greatly disturbed by their perceived cosmetic deformity when, in fact, on examination there is no disorder to be seen. These patients with normal outward appearance who focus in detail on their perceived deficiency are among the most dangerous to treat, because they are usually not satisfied and, in fact, can turn angry about the money and time that they have spent.

“DOCTOR, I CAN’T MAKE UP MY MIND”—THE INDECISIVE Indecisive patients are people who have come in for multiple inquiries, but never can quite decide to receive a treatment. They may have seen several other doctors only for consultation, never having a treatment. These patients may have trouble with decision making. This behavior can be a sign of abnormal passivity, in which their lives are full of other people making their decisions. These patients may state “it’s up to you” or “do whatever you want.” This is not a good idea because the patient should always have a clear understanding as to what will be done and have appropriate “buy in” to the situation. Their informed consent must reflect complete knowledge of what is done and then their desire to have the procedure.

“DOCTOR, YOU ARE SO GREAT!”—THE SEDUCTIVE PATIENT Occasionally, when encountering people, one gets an uncomfortable feeling of inappropriateness. It seems that the patient does not seem to understand normal social boundaries and the doctor is getting the feeling that they are being seduced. These patients range from being overly familiar to being sexually inappropriate. These patients may have a pattern in their life of getting attention and manipulating situations. They may have learned that these skills can, at times, afford them certain advantage. However, any flirtation is not appropriate between a doctor and a patient. These people are often trying to gain the favor of the physician for preferential treatment and can be difficult.

“YOU ARE THE ABSOLUTE BEST IN YOUR FIELD”—THE EXCESSIVELY COMPLIMENTARY PATIENT

We would all like to feel that we are the best in our specialty, but a good cosmetic dermatologist can usually recognize another physician whose skills in certain areas are superior to their own. Thus, the cosmetic dermatologist will understand that the patient who comes in and states repeatedly “I know you are the best” is a patient to be worried about. These people can be over-flattering and frequently commenting on the reputation and an almost magical power that the treating physician may possess. At times you may hear demeaning comments about other dermatologists or other cosmetic practitioners. One has to be careful of these patients because if the result is not what they expect, then their excessive compliments may turn into overt criticism. They may be angry and outraged following their treatment.

“DO I HAVE TO SHOWER BEFORE THE PROCEDURE?”—THE PATIENT WITH POOR HYGIENE

All patients are entitled to an occasional bad hair day, but these difficult patients are unkempt, dirty and show a lack of care for themselves. They may be at risk for skin infections due to their slovenly existence, and may not practice simple wound care. These people can be at risk to treat because they may not always follow the cosmetic dermatologist’s advice. They do not seem to care much for themselves. If they will not follow the simple rules of hygiene, brushing ones teeth or bathing, how can you know that they will follow your instructions following the procedure?

“I CAN ONLY COME IN AT NOON FOR JUST 20 MINUTES, TOPS!”— THE VIP PATIENT

People, who are involved in the media, appear before the public, or hold positions of importance frequently seeking improvement by the cosmetic dermatologist. However, some of these people can be extraordinarily demanding. Clues for this include only a limited range of times that they can be seen by the dermatologist and inflexibility surrounding their schedule. They frequently seek “special appointments,” exceptions from standardized treatments, and other forms of special care that can be of disaster to a busy practice. We have had patients who have asked us to open the office on Sunday morning and who have requested that the doctor “cancel his vacation because I need to be treated.” These people are oftentimes not worth treating, as they are unable or unwilling to follow the usual care guidelines, as they spend their life cutting corners or doing only what they want. In their minds, they are such important persons that the usual rules do not apply to them.

“LET ME TELL YOU ABOUT ME”—THE LOQUACIOUS PATIENT Many cosmetic dermatology patients are fascinating and have many stories to tell. Many of them seem to be packing more fun or activities into their lives than many folks. It is often fun to listen to them and to learn. However, there are some patients who are excessively talkative. They often interrupt the doctor, refuse to listen, and verbally dominate every encounter with the dermatologist. When obtaining an informed consent many of these individuals will not let the doctor or the nurse finish the consenting process. Occasionally this can be seen in manicdepressive individual (perhaps in a manic phase) but more often than not it simply reflects a self-obsessed individual who fails to ever listen to others.

“I KNOW I AM GOOD LOOKING”—THE NARCISSIST Caution must be exercised in people with narcissistic personality disorders. Outwardly these people seem to be extremely conceited and vain. They have an inflated sense of self-importance and are preoccupied with one’s self. They exaggerate talents and achievements and react to criticism with rage. This requires constant attention and admiration.

RED FLAG PATIENTS Inwardly they are often unhappy, frequently dissatisfied, believe they are fundamentally unacceptable to others and will often be displeased with their cosmetic outcomes. One clue for narcissism is the negative comments that they often make about others while describing how wonderful they are. They frequently take advantage of others to achieve their own ends. Narcissists are rarely satisfied and have been known to return to the office, demanding their money back due to the “terrible results,” which they may proclaim loudly at your front desk.

“YOU’RE THE EIGHTH DOCTOR I HAVE SEEN”—THE DOCTOR SHOPPER

The clue for a dissatisfied and unappeasable patient is a patient who has seen multiple physicians, often for the same cosmetic treatments. This is a clue that, as they were not satisfied with their initial treatment, they are unlikely to be satisfied even with your good outcome. It is best to decline them get treated unless you feel that you have something specifically different to offer, and that your treatment will truly improve them.

“I THINK I NEED ANOTHER PROCEDURE”—THE SURGIHOLIC Often one glimpse of this individual is enough to identify that they are a person who has had repeated cosmetic procedures, sometimes to a degree of either inappropriateness or disfigurement. Their medical history may reveal that they have had several breast augmentations, each time seeking additional improvement. These patients will continue their unending quest, moving beyond treatment to disfigurement and excess. They no longer fit into the normal range of human appearance.

“I AM GOING TO SUE THAT QUACK”—THE LITIGIOUS PATIENT There is not a doctor who enjoys hearing that their patient is involved with or considering litigation. A pause in the interaction will often cause the patient to describe their unhappiness with their previous physician and their decision to sue. It is extremely essential that the cosmetic dermatologist not make disparaging remarks about the previous physician. If one detects excessive focus on the negative

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results, or perceived negative results, avoid treating the patient. They are already angry. It is worth noting that currently in the practice of medicine, it is common to see patients who may be on psychoactive medications. We commonly see patients on an antidepressant medication such as an SSRI (selective serotonin reuptake inhibitor) or perhaps an anxiolytic. Many of these patients are fine to treat. Many of these patients have been put on the medication for minor issues or the drugs may be used off-label for treatment of other symptom collections such as menopause. Spending a few minutes discussing those medications and trying to get a sense of the patient’s psychiatric stability usually reveals that the patient is not significantly impaired. One also encounters patients with a more serious psychiatric diagnosis, which is being treated with additional or higher doses of medications. We always openly discuss the psychiatric drugs with these patients and if under regular care of a psychiatrist, usually ask to place a phone call to their treating doctor. It is important to remember that in the current practice milieu you must ask the patient’s permission to contact their psychiatrist. When the patient gives permission you should state that you have obtained permission from the patient when you call their psychiatrist. The practice of cosmetic dermatology can be rewarding and fun. Most cosmetic dermatologists state that they really enjoy their cosmetic patients and have a great deal of joy making people look and feel better. Learning to avoid red flag patients can make your practice delightful and satisfying. REFERENCES

1. Ishigooka J., Iwas M., Suzuki M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998; 52: 283–7. 2. Ritvo EC, Melnick I., Marcus GR., Glick JD. Psychiatric condition in cosmetic surgery patients. Facial Plast Surg 2006; 22: 194–7. 3. Tardy ME, Thomas JR, Brown RJ. Initial encounter: a personal approach (Chapter 3). In: Facial Aesthetic Surgery. St. Louis, MO: Mosby, 1995: 66–83.

8

Internal marketing Amy Derick

OVERVIEW

Definition In this chapter, internal marketing is defined as the process of persuading existing patients of a dermatological practice to purchase cosmetic services or products. Advantages of Internal Marketing Internal marketing is a highly effective way to increase cosmetic revenue. Whether you are serving a medical patient considering cosmetic services or products for the first time, or an experienced cosmetic patient contemplating an additional purchase of cosmetic services or products, internal marketing has the following advantages over external marketing: 1. An ongoing medical practice already has a stream of potential cosmetic patients walking through its doors without having to spend additional advertising dollars to reach them. 2. Existing patients are a captive audience during their visits to the practice. 3. Existing patients are typically receptive to the advice of their trusted provider. Leveraging these inherent advantages in a professional manner will help a practice grow its cosmetic revenue—probably to the elevated satisfaction of both patient and provider. Methods Discussed The methods of internal marketing can be assembled into the following major categories: 1. 2. 3. 4.

Building a cosmetic brand Capturing patients who are predisposed to cosmetic treatments Stimulating new cosmetic interest in existing patients Maintaining strong overall relationships with patients

Each of these categories will be discussed in this chapter. At the conclusion, the reader should feel confident about implementing these methods in his or her practice. BUILDING A COSMETIC BRAND

Defining the Cosmetic Brand A brand, in the context of this chapter, is the collection of images or ideas a patient perceives when considering to patronize a given medical practice. A good cosmetic brand will clearly convey that the medical practice in question is a “provider of choice” for cosmetic services and products. Delivering a Cosmetic Brand to Patients There are two main processes through which a cosmetic brand can be clearly conveyed to patients: explicit internal marketing and implicit internal marketing. Explicit Brand Building In explicit brand building a practice overtly states the message it wants to deliver. One advantage of explicit brand building is that the practice has complete control of the message. For example, a practice might adopt the slogan “ABC Dermatology: A Leader in Cosmetic Skin Care.”

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This message directly presents a cosmetic brand to patients. Explicit brand building can be used through vehicles such as print advertisements, radio or television advertisements, practice materials such as brochures or business cards, and the website of the practice. The first step toward developing an explicit brand building campaign is defining the value proposition of the practice. The value proposition is the unique combination of service, quality, and price that each practice offers its patients. Each organization must focus on no more than two of these elements. For example, a practice that offers the highest quality care and service will not probably be able to offer the lowest possible price. Each practice must analyze its position within its chosen marketplace and demographics to determine the best competitive approach. Once the value proposition has been determined, it needs to be communicated clearly to targeted patients. As an example, XYZ Dermatology is a practice in a small market. In the area in which it practices, the doctors have built a reputation for providing excellent medical care, but they have little cosmetic business. The primary cosmetic competition in the area is a medispa that operates without on-site physicians. XYZ Dermatology believes its practice provides higher quality care than the competition but feels it cannot compete on price with the medispa. The practice determines that it will focus on high service and quality as its value proposition. Accordingly, the practice adopts the slogan, “XYZ Dermatology: Medical and Cosmetic Skin Care Advice from the Doctors You Trust.” This slogan highlights the chosen value proposition, and it gives patients a clear reason to consider the practice for their cosmetic needs. Implicit Brand Building The second channel for communicating a cosmetic brand to patients is implicit brand building. Implicit brand building does not directly state a brand message. Instead, it conveys a brand impression indirectly through the patient experience. Some examples of implicit internal brand building covered in this chapter include the physical office environment and customer service. The physical office environment is a critical influencer of overall patient experience. The environment can either enhance or detract from the internal marketing campaign. A practice that wants its patients to feel comfortable spending money on discretionary cosmetic procedures must pay attention to details. Cosmetic services are luxuries for most patients, and the goal of the environment is to put the patient in a state of mind that is receptive to luxury spending. The office should, above all, be clean and free of clutter. Flat surfaces should be clear of papers or debris. The décor should be updated and coordinated. Furniture should be comfortable and in good condition. Ideally, the patient should “experience” the ambiance of the practice. Patients should “feel” the brand. The interaction between staff and patients presents additional opportunities for implicit brand building. Each employee of the practice, from providers to reception staff, should be cognizant of his or her individual contribution to patient experience. The common saying is that patients might not remember what a doctor said or did, but they will always remember how the practice made them feel. In the context of internal marketing, the goal should be to make each patient feel important all the time. It is common, in a busy medical practice, for staff and providers to lose focus on the patient as the constant and highest priority. Reception

INTERNAL MARKETING staff may be distracted with phone calls or chart-work. Clinical staff may be focused on documentation or assisting. Providers may be caught up in the stress of running behind schedule. All members of a practice have many important jobs and worries, and no one person can solely be responsible for providing customer service. It takes a team focus on service to make a positive impression on patients for each and every step of the patient process, and it is entirely worth the extra effort. A patient who feels truly appreciated is much more likely to trust a practice with his or her cosmetic business—and may become a source of valuable referrals as well. CAPTURING PATIENTS WHO ARE PREDISPOSED TO COSMETIC TREATMENTS

Identify Patients Who Want Cosmetic Services The simplest and most effective way to increase cosmetic business from existing medical patients is to identify patients who are predisposed to cosmetic services. After predisposed patients have been identified, the staff and providers can address these patients’ cosmetic needs. One straightforward way to determine which medical patients have an interest in cosmetic services is simply to ask them. Use a Cosmetic Interest Form at Check-in Each time a patient arrives for a medical appointment, the practice has an opportunity to gather valuable information. A cosmetic interest form is one way that a practice can easily (and with no guessing) determine what cosmetic products or services might be of interest to a particular patient. This form typically looks like a menu of services and products offered by the practice. The form allows the patient to indicate topics for which the patient might welcome additional discussion from the clinical or aesthetic staff. The key is to use the form effectively. Discuss the Cosmetic Form with Patients At the conclusion of the patient’s medical visit, a member of the staff or a provider, depending on the preferred flow of the practice in question, can discuss the patient’s cosmetic form. Here is a typical discussion:

• • • • •

Provider: “Mrs. Johnson, we have now concluded your medical visit. Do you have any further questions about your diagnosis or treatment?” Patient: “No, I think I understand everything. Thanks for your help.” Provider: “You’re welcome Mrs. Johnson. I notice on your intake forms you mentioned that you have an interest in learning more about laser hair removal. This is a service our practice provides. Would you like to hear more about laser hair removal?” Patient: “Sure. I’ve always been bothered by the hair on my upper lip, but I didn’t know your office could help with that.” Provider: “We certainly can. If you are interested, I can go over the basics with you. Then our aesthetician can come in for a few minutes and explain your options in detail. Would you like that?”

In this example, the patient had a predisposed interest in laser hair removal. Without the use of the cosmetic interest form, the provider would not have been aware of this interest. In addition, because the patient had indicated on her form that she wanted more information about this particular procedure, the provider should not feel awkward bringing it up at the conclusion of the medical visit. The form can act as an effective ice breaker between patients who may be nervous about discussing cosmetic procedures and providers who do not want to appear pushy about cosmetics.

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Reputation Is Everything The reputation of a practice is its most valuable asset. All care must be taken to protect and build a practice’s good name. Without daily vigilance, a practice can develop a negative reputation for being pushy with cosmetics. Aggressive sales behavior in the practice will almost certainly be reported by word of mouth to the detriment of the practice, that is, as referrals evaporate. No one wants the following comments to be floating around in the community: “I went to XYZ Dermatology for a wart, and the doctor spent the whole time trying to sell me Botox.” The simplest way to avoid a pushy reputation is to use the cosmetic interest form. A provider or cosmetic coordinator should discuss only the issues for which a patient has explicitly expressed interest. This policy will ensure that no patient is offended by the suggestion that he or she consider a cosmetic procedure. If the provider feels it is important to bring up cosmetics with a patient who has not expressed interest on the cosmetic interest form, this must be handled delicately. One viable approach is to ask simply, “How are you taking care of your skin?” This question usually leads to a discussion of products, routines, and cosmetic concerns. If diplomatically handled, this conversation may result in either a cosmetic service or a scheduled consultation. Focus on the Relationship To achieve long-term success as a cosmetic practice, each provider must focus on the patient relationship. Whenever a patient is considering a cosmetic purchase, there are two factors in play: the transaction and the relationship. The transaction is the short-term consummation of a purchase. The relationship is the long-term association between provider and patient that is based on trust and mutual benefit. Whenever a provider is considering a cosmetic procedure for a given patient, he or she must ensure that the transaction does not interfere with the relationship. This can be accomplished by doing only what is best for the patient. Often this means a provider will have to discourage a patient from choosing a procedure that is not a good fit for him or her. Although giving such counsel means forgoing a profitable transaction, it will build trust and benefit the patient relationship in the long run. STIMULATING NEW COSMETIC INTEREST IN EXISTING PATIENTS

Educate Patients About the Offerings of the Practice Medical patients may come to a practice having never previously considered cosmetic procedures. This does not mean that these patients would not be interested in cosmetic procedures or products if they were educated about their options. It is a primary goal of internal marketing to ensure that no potential cosmetic patient leaves a practice without at least being aware of what services the practice offers. To educate existing medical patients effectively, a practice should do the following:

• • • •

Take polite advantage of a captive audience Show off good results Offer cosmetic consultations Host group seminars

Take Polite Advantage of a Captive Audience When patients are sitting in the waiting room, or waiting in an exam room for a provider, they are effectively a captive audience. They typically have few distractions other than what the practice provides. To leverage this opportunity, a practice can offer educational materials that inform patients about cosmetic services and products provided. Brochures describing specific procedures or products allow patients to read about areas of interest in a low-pressure environment. Educational videos, such as those sponsored by the American Society for Dermatologic Surgery, can provide ambient information for patients’

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

education. Each practice will have a different comfort level with the amount of promotional material it wants to make available in the waiting room, and it is important to find a balance. Show Off Good Results Good photography is critical for any practice offering cosmetic services. One of the most effective internal marketing tools is a wellconstructed before-and-after portfolio of patient photographs. Copies of this portfolio can be displayed in the waiting room and in exam rooms. Patients will browse through the portfolio out of curiosity, and this will often stimulate interest in the displayed procedures. For many medical patients, words such as Botox, Restylane, laser, or IPL are terms they have previously heard but do not fully understand. This is what makes a before-and-after portfolio such a terrific entry point for marketing cosmetics to medical patients. A picture requires no preexisting knowledge to interpret. A patient can identify with the appearance of the person in the before picture, and admire the cosmetic improvements in the after picture. Such enlightenment will often lead to this typical discussion:

• • • •

•

Patient: “Doctor, I was looking at the before-and-after book while I was waiting today, and I noticed a picture of a lady with red veins on her nose like mine.” Provider: “Yes, those are called telangiectasias, and they are a common cosmetic complaint in fair-skinned patients your age.” Patient: “In the after picture, the veins looked much better. In the binder, I read that she had three treatments with a laser, but I don’t remember the name of the laser.” Provider: “She had three treatments with our pulsed-dye laser. If you are interested in the procedure, I can evaluate you formally to determine if you are a good candidate for this laser. If, after the evaluation, you have additional questions, or would like to discuss the price of treatment, I can have our cosmetic coordinator go over the details with you.” Patient: “That would be great. I didn’t even know those veins could be fixed.”

In this example, the patient did not know that a laser remedy is available for her telangiectasia. She did, however, know that she did not like the look of the red veins on her nose, and when she saw the before-andafter pictures, she asked questions that were important to her. This common scenario highlights the importance of showing off your good cosmetic results. Offer Cosmetic Consultations Perhaps the best way to educate existing medical patients about cosmetic services and products is to conduct a cosmetic consultation. First, though, a patient needs to be aware that cosmetic consultations are available in the practice. For example, a sign in the waiting room can alert patients that the practice offers cosmetic consultations. Cosmetic consultations can also be mentioned on the cosmetic interest form completed at check-in. During the cosmetic consultation, the patient learns (from a provider or from a cosmetic coordinator) about all available options for treating his or her cosmetic concerns. If handled properly, cosmetic consultations can expand existing medical patients into cosmetic patients. The individual practice should determine whether or not to charge for cosmetic consultations. If such consultations are complimentary, expect many more patients to schedule appointments. However, to minimize numbers of the curious only, some practices charge a fee that can be applied toward any procedure purchased. The best price structure may ultimately depend on who within the practice is actually conducting the consultation, that is, an aesthetician may not command a premium price for a consultation, but a physician may.

Host Group Seminars Another way to reach existing medical patients who are predisposed to cosmetics is to hold educational seminars. Some patients are more comfortable in a group setting, and they may prefer to attend seminars over scheduling individual consultations. Each seminar can be as general or specific as the practice chooses. Often patients are offered an incentive to attend, such as a discount on procedures scheduled at the event. These seminars can conveniently be hosted at the practice, if physical space allows. To solicit reservations for these seminars, the practice can send flyers or emails to targeted patient groups, as well as display announcements in public areas of the office. In addition, a practice can seek out patients who are social connectors and have many friends or ties to the community. These patients can be given an incentive to help organize the events. An example of an incentive could be a discount on cosmetic procedures for each attendee the patient recruits. MAINTAINING STRONG OVERALL RELATIONSHIPS WITH PATIENTS

A practice that maintains strong overall relationships with its existing medical patients will have a much easier time converting patients into cosmetic customers. Patients like to feel that they are more than a medical record number. Above all, patients want to feel important. There are many effective ways to maintain lasting and positive relationships:

• • •

Newsletters Digital marketing Patient appreciation

Newsletters A newsletter can keep patients routinely engaged with the practice. The content of a newsletter can be a mix of educational and promotional material. For example, depending on the frequency of publication it might make sense to offer seasonal skin care tips. A summer newsletter might offer sun-safety advice—thus leading to a promotional announcement about a new line of sunscreen products available at the practice, as well as a discussion of laser options for treating sun damage. Newsletters also offer the opportunity to discuss changes and developments at the practice that will be of interest to patients. For example, if the practice purchases a new laser or adds a new provider, a newsletter is a perfect vehicle to reach patients with this important information. Digital Marketing As communication has become increasingly electronic, the options available to practices wishing to stay in touch with existing patients have expanded. A website for the practice can be a valuable way to stay connected with patients. If elements such as posted lab results or online consultations are incorporated into a website, medical patients will have a reason to log in regularly. This web traffic will provide a platform that is useful for delivering marketing information. A practice might incorporate a blog to supplement the promotional information in a newsletter. Blogs have an advantage over print media in that they can be updated quickly with current information. A blog also has a low cost of publication, and its audience is more easily traceable. It is easy for a practice to know how many newsletters it mails, but it is impossible to know how many are read by patients. Web-based marketing can give accurate and up-to-date metrics on the number of people who view a practice’s marketing materials, as well as the time spent viewing. The one caveat about blogs is that a practice must be cautious about communicating content (into the public domain) that has not been approved by appropriate authorities or for which the providers are not entirely confident. If in doubt, leave it out. In addition to website-based communications, email is an important component of a complete internal marketing campaign. Email has

INTERNAL MARKETING many of the same advantages that a blog enjoys over print media with a particular added benefit. Because each email is targeted to a specific patient, the tracking data can be more specific. Email-based marketing firms can give patient-specific information on response rates to various promotions. The more information a practice can learn about what truly works, the more effective its marketing will become. Patient Appreciation A sure way to build relationships with patients is to let them know they are appreciated. A simple gesture, such as a birthday or holiday card, can keep a practice at the top of its patients’ minds. A practice can also extend special privileges to the patients it wants to recognize as VIPs. VIPs can be designated based on cosmetic dollars spent in a given year or on any metric the practice feels will adequately describe the demographic it is aiming to recognize. VIP patients can be offered perks such as increased access to providers after hours or during special time slots. VIP patients could also qualify to participate in special promotions the practice occasionally offers. These benefits can create an additional incentive for medical patients to seek and accept cosmetic services and products at the practice.

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CONCLUSION

Key Lessons from This Chapter All practices that want to maximize cosmetic volume should first direct their attention toward internal marketing. The cost of delivering a message to existing patients is relatively low compared with the cost of creating new patients. In addition, the likelihood that a marketing message will be well received is much higher in a base of patients who already know and trust a given practice. Apply These Lessons in Practice There are many channels through which a practice can pursue internal marketing. Ultimately it will be up to the individual practice to determine which methods will work best with its specific patient population. Ideally, all four major categories discussed in this chapter can play a role in a coordinated internal marketing campaign. A practice that successfully builds a cosmetic brand, captures patients who are predisposed to cosmetic treatments, stimulates new cosmetic interest in existing patients, and maintains strong overall relationships with patients will dramatically improve patient satisfaction and the sale of cosmetic services and products.

9

Financial benchmarking for the aesthetic medical practice Page S. Piland

FINANCIAL HEALTH OF THE PRACTICE

The financial performance of a cosmetic practice is, next to patient care, the most important component of your practice. Yet, in most instances, it receives little attention until a problem arises that calls attention to it. Frequently, this problem is of a magnitude that it affects the viability of the practice and its ability to meet its financial obligations. Many physicians have become complacent with respect to the financial health of their practices. They rely heavily upon the skills of others, some of whom have little more than a high school degree and a paucity of experience. In many practices, the financials are left to the office manager and the physician defers to his staff. In my experience, this is a mistake because no one has more of a vested interest in the financial health of the practice than the physician. In order to make good decisions, it is imperative to have the right information and to act upon it in a timely manner. Over the past decade, I have had the opportunity to work with many of the leading cosmetic practices and in this chapter, I would like to share some of what I have gleaned. Knowing the necessity of measuring the financial health of your practice is the first critical step. Carving out the time to actually do this is the second. Many of the practices that I work with have a mandatory meeting with me and their financial team (which can include an accountant, bookkeeper, office manager, etc.) on a quarterly basis. The demand for this type of meeting has dramatically increased during 2009 when many such practices were impacted by the global economic downturn. One cautionary note to remember while analyzing your financial data is to avoid the pitfall of analysis paralysis. This occurs when the data cause the physician to freeze like a deer in the headlights—this is bad and should be avoided. The goal of any analysis is to gather pertinent information and use it to take action. Physicians that spend too much time diving deep into the data without confronting their problems will become victims of data overload. This chapter will help one to identify significant numbers and understand the metrics that will define the success or failure of your practice. INSPECT

There are several ways to inspect the financial health of a medical practice. I highly recommend comparing your practice’s performance to both internal and external metrics. Internal metrics include a profit and loss statement prepared by an accountant, productivity reports, payroll summary reports, and an accounts receivable aging analysis. Areas that deserve special attention include collections, new and existing patient encounters, fixed and variable overhead ratios, net collected revenue by provider, and revenue per patient encounter. Comparing this with prior year’s data will help one to identify trends that define the success or failure of your practice. INTERNAL ASSESSMENT

Evaluate Once you have completed the internal assessment, it is essential to understand how it compares with other practices. External practice data are available from many sources. Among the ones that I use are the AAD, ASAPS, and ASPS, The Health Care Group, Kline and Company, the Healthcare Group and the BSM Consulting Group/Allergan Practice Consulting.

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Most physicians have a familiarity with a profit and loss statement. Unfortunately, the amount of time spent reviewing this statement is usually minimal and is focused only upon the top and bottom line numbers. The numbers in between frequently tell the real story of the practice and physicians need to spend more time looking at them and understanding these. Spending hours evaluating and re-calculating the numbers is not productive. Your accountant and bookkeeper should already have a mastery of these and be able to distill them for you. I recommend increasing your understanding of the larger, individual line-item expenses. Typical large areas include payroll, rent, medical supplies, and marketing. These line items are all areas that represent an opportunity to increase efficiency and eliminate wastage. Once the larger items have been scrutinized, attention can be turned to the items lower on the list. Table 9.1 provides a quick reference that can be used to compare your practice’s financial performance to the key benchmarks of the Allergan/ BSM Consulting Financial Database. The table includes the mean and median values for the key benchmarks from the years 2006, 2007, and 2008. Each category will be discussed in detail throughout this chapter. COSMETIC MEDICAL PRACTICE BENCHMARKS: INCOME

One of the biggest challenges faced by practices when trying to measure the practice financial performance is obtaining reliable data. There are many sources for data but most physicians do not know where to access it or how reliable the data are. Most practices rely on the data from the Allergan/BSM Consulting Group Financial Benchmarking database. These data have been collected from the actual financial documents, tax returns, payroll summary reports, and practice summary reports. The data come from dermatology, plastic surgery, facial plastics, and oculoplastic practices. These data are verified, published every year, and shared freely with the industry. I will reference many of the Allergan/BSM Consulting 2008 benchmarks in this chapter. There are many terms and formulas used when discussing the financial performance of the medical practice that can very often be confusing to non-accountants. I will attempt to simplify the terminology and focus upon the areas that provide the most pertinent data for measuring your practice performance. Let’s start with the top line number also known as net collected revenue. The net collected revenue is classified as all monies received by the practice during the fiscal year by way of professional services, facility fees income, and spa services. Basically it is the money the practice has brought in before expenses. The usefulness of the top line number is not as pertinent when making comparisons because of the large variety and types of practices. The different practices include solo, group, and multi-specialty. Many practices also have mid-level providers and aestheticians that contribute to the practice revenue. Therefore, a direct practice comparison is not the most accurate method to measure your practice performance. For this reason, we will look at all of the key contributors on an individual basis in order to compare “apples to apples.” NET COLLECTED REVENUE PER FULL TIME EQUIVALENT PHYSICIAN

The net collected revenue per full time equivalent (FTE) physician is the first category we will examine (Fig. 9.1). An FTE physician is classified as a physician who works 1600 hours per year or 4 days per week. The total net collected revenue of the practice is divided by the

51

FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE

Table 9.1 Key Benchmarks 2006 Benchmark Net collected revenue per FTE physiciana ($) Revenue rate per hour per FTE physicianb ($) Net Collected revenue per FTE non-physician providerc ($) Collected revenue by cosmetic providersd ($) Net collected revenue per FTE aestheticiane ($) Revenue rate per hour per FTE aestheticianf ($) Net collected revenue per FTE support staffg ($) Operating expense ratioh (%) Non-provider payroll ratioi (%) Rent expense ratioj (%) Marketing and advertising ratiok (%) Number of FTE support staff per FTE providerl

2007

2008

Mean

Median

Mean

Median

Mean

Median

1,395,469

1,244,391

1,467,812

1,306,776

1,478,829

1,385,389

872

778

917

817

924

866

399,385

349,450

453,016

391,667

485,360

426,768

283,482

209,281

308,870

199,840

300,421

207,636

145,675

122,026

141,701

125,799

152,412

132,281

70

59

68

61

73

64

345,545

313,716

365,020

322,991

337,748

304,497

62.8 15.3 5.1 4.4

62.8 14.9 4.5 3.2

63.0 15.0 5.2 4.5

62.2 14.3 4.7 3.4

65.3 15.7 5.7 4.7

66.0 15.6 5.0 3.7

4.82

4.33

4.95

4.46

5.40

4.99

a

Net collected revenue per FTE physician—The total physician-collected revenue divided by total full-time equivalent physicians. A full-time physician is assumed to work 1600 hours or more per year. b Revenue rate per hour per FTE physician—The total physician collected revenue divided by the total hours worked by the physician. This measure provides an evaluation of physician productivity in relation to hours worked during the measured period. c Net collected revenue per FTE non-physician provider—The total non-physician provider collected revenue divided by total full-time equivalent non-physician providers. Non-physician providers include physician assistants and nurse practitioners and full time is calculated at 2080 hours per year. d Net collected revenue by cosmetic providers—The total revenue collected for services performed by cosmetic providers. A cosmetic provider includes registered nurses, licensed practical nurses, medical assistants, and others who are performing injections, laser procedures, and other cosmetic services. This excludes licensed aestheticians, physician assistants, nurse practitioners, and other service providers performing non-medical procedures, i.e., massage therapists. e Net collected revenue per aesthetician—Total aesthetician-collected revenue divided by total full-time equivalent aestheticians (FTEs calculated at 2080 hours per year). f Revenue rate per hour per FTE aesthetician—The total aesthetician-collected revenue divided by the total hours worked by the aestheticians employed by the practice. g Net collections per FTE support staff—The practice’s total collected revenue divided by the sum of full-time equivalent support staff employees. A support staff employee includes cosmetic providers, licensed aestheticians, and non-physician providers working in a support capacity, i.e. those not producing revenues independently. A full-time support staff employee is assumed to work 2,080 hours per annum. h Operating expense ratio—Total expenses (cost of goods sold and operating expenses) divided by the total net collected revenue as reported on the practice’s financial statements or tax return. Operating expenses exclude provider compensation, bonuses, retirement contributions, automobile expenses, as well as depreciation. i Non-provider payroll ratio—Gross non-provider payroll divided by the total net collected revenue as reported on the practice’s financial statements or tax return. j Rent expense ratio—Total rent expense or occupancy costs divided by the total net collected revenue as reported on the practice’s financial statements or tax return. k Marketing and advertising ratio—Total marketing and advertising costs divided by the total net collected revenue as reported on the practice’s financial statements or tax return. l Support staff per FTE provider—Total full-time equivalent support staff divided by the sum of full-time equivalent physicians and non-physician providers.

$1,400,000 $1,350,000 $1,300,000 $1,250,000 $1,200,000 $1,150,000

2006

2007

Figure 9.1 Net collected revenue per full time equivalent physician.

2008

52

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

actual number of FTE physicians working in the practice. The 2008 median range was $1,100,000 to $1,600,000. The median is $1,385,389.a The percentage growth rate over 2007 ($1,306,776) was 6.02%. The percentage growth rate of 2007 versus 2006 ($1,244,391) was 5.01%. Many economic factors contributed to the slower growth rate in 2008. There aren’t any data available for 2009 yet, but it should prove to be an interesting year. Some early anecdotal information suggests that the 2009 growth will be flat. It appears that practices that were primarily focused upon high dollar surgical procedures saw a decline in revenue in 2009. Practices that had a balanced portfolio of cosmetic services were able to weather the storm a little better and in some cases actually grew their revenue over 2008. REVENUE RATE PER HOUR PER FTE PHYSICIAN

The revenue rate per hour per FTE physician is another important number to monitor (Fig. 9.2). The pertinence of this metric is that helps physicians understand the value of their time. This measurement also helps achieve perspective pertaining to the physician’s daily activities. Example I have worked with many physicians who insist upon performing non-patient’s care-related projects in order to avoid the expense of paying someone else to do these projects. Some physicians undertake projects such as creating marketing materials or working on their website because it is a “hobby.” When this information was discovered, most of these physicians found a new hobby, hired additional personnel, or outsourced specific projects. By comparing the value of their time versus the much lower cost of finding the right person for the right job, most physicians opted to bring in additional personnel. The revenue rate per hour per FTE physician is calculated by dividing the actual net collected revenue of all of the physicians in the practice by the total number of physician hours worked. The hours worked assumes 1600 hours for an FTE physician and is adjusted for part-time physicians working less than 1600 hours. The median revenue rate per hour per FTE physician for 2008 was $866 per hour and the healthy benchmark range was from $625 to $1000 per hour.b The percentage

growth over previous years is similar to the growth seen in the net collected revenue per FTE provider. The percentage growth over 2007 ($817 per hour) was 6% and the percentage growth of 2007 over 2006 ($778 per hour) was 5.01%. NET COLLECTED REVENUE PER FTE NON-PHYSICIAN PROVIDER (MID-LEVEL PROVIDER)

Physician assistants and nurse practitioners continue to make a significant contribution to the profitability and quality of patient care in the aesthetic medical practice. The median net collected revenue value for 2008 was $426,468, which was an 8.89% growth over 2007. The 2008 growth percentage was lower than the 2007 versus 2006 growth percentage of 12.08%. The median value for 2007 was $391,667 and for 2006 it was $349,450.c The number of Physician Assistants and Nurse Practitioners continues to increase as more physicians understand the positive impact achieved by incorporating them into the practice. This is reflected by the positive growth seen in the number of practices that have a nonphysician provider (Fig. 9.3). In 2006, 22.5% of the practices in the Allergan database had an MLP/NPP. In 2007, the number was 24.5% and that grew to 28% in 2008.d The increase in the popularity of mid-level providers has been caused by several factors. The fact that the demand for specialized care has outpaced the supply of physicians for several years is one primary reason. Physician assistants and nurse practitioners have done a more than adequate job in helping practices meet this demand. Another reason contributing to their success is that they have been accepted by the patients. This acceptance continues to grow as the patients are educated and gain understanding of the qualifications and capabilities of physician assistants and nurse practitioners. This is supported by the consistently high scores they have earned on patient quality of care surveys conducted over the last few years (Fig. 9.4). NET COLLECTED REVENUE PER FTE AESTHETICIAN

The median value for aesthetician’s net collected revenue for 2008 was $132,281e (Fig. 9.5). This number reflects aesthetician services only. The median net collected revenue value for 2008 was $132,281, which was a 5.15% growth over 2007. The 2008 growth percentage

$880 $860 $840 $820 $800 $780 $760 $740 $720

2006

2007

2008

Figure 9.2 Revenue rate per hour per full time equivalent physician.

c a b

Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.

d e

Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.

FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

2006

2007

2008

Figure 9.3 Practices with non-physician providers.

$500,000

$400,000

$300,000

$200,000

$100,000

$0

2006

2007

2008

Figure 9.4 Net collected revenue per FTE non-physician provider.

$64 $63 $62 $61 $60 $59 $58 $57 $56

2006

2007 Figure 9.5 Revenue rate per hour per FTE aesthetician.

2008

53

54

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

outperformed the 2007 versus 2006 growth percentage of 3.09%. The median value for 2007 was $125,799 and for 2006 it was $122,026. Product sales are not included in this number and will be reviewed separately. The aesthetician median revenue rate per hour for 2008 was $64 per hour, which was an increase of 4.92% over 2007 at $61 per hour. The aesthetician net collected revenue rate per hour for 2006 was $59 per hour. I have often debated with physicians regarding the value of offering aesthetician services in the cosmetic medical practice. The argument I hear from physicians and managers is that the aestheticians are barely breaking even when they look at the profit and loss statement. The first point I like to emphasize is that it is important to include the aesthetician’s revenue generated from product sales (Fig. 9.6). This is often approximately equal to the revenue generated from aesthetician services. The second point I like to make is that there is a value that is difficult to measure because of intangible factors. Aestheticians often offer gateway procedures that bring in new patients. If the practice has a conversion strategy in place, these new patients often convert to the higher valued services provided by the practice. Depending upon the job description and office infrastructure, many aestheticians contribute to the front and back office serving as back-up or patient educators.

RETAIL PRODUCT SALES

Retail product sales continue to be one of the biggest areas of opportunity for the cosmetic medical practice in regard to revenue earning opportunities. According to the 2009 market overview published by Kline & Company, the total cosmeceutical market volume for 2008 was $1,055,700,000. The market grew by 7.54% in 2008 over 2007. Medical care providers generated 26.4% or $279,200,000 of this volume, which represents an 11.5% growth change from 2007. Spas and salons continue to hold the lead position in the market share at 50.7% or $535,700,000 but experienced the slowest growth over 2007 at 5.4%. Retail stores have the lowest volume at $240,800,000 and were in second place with a growth of 8% over 2007f (Fig. 9.7). The fact that medical care providers hold only ¼ of the market share should be enough information to motivate most practices to take action. This is the low hanging fruit in my opinion because nobody knows more about skin health and maintenance than a qualified medical practice. To further emphasize this point, consider the following facts. The median retail sales volume per office in 2008 was $118,300 according to the 2008 Allergan Practice Consulting Financial Benchmarking database. This was one of the largest growth areas in the database at 28.3% over 2007, which was $92,204. The 2007 growth over 2006

$134,000 $132,000 $130,000 $128,000 $126,000 $124,000 $122,000 $120,000 $118,000 $116,000

2006

2007

2008

Figure 9.6 Net collected revenue per FTE aesthetician.

$120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0

2006

2007 Figure 9.7 Retail sales.

f

Source: 2009 Kline & Company.

2008

FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE of $86,597 was 11.47%.g This growth trend leads me to the conclusion that medical practices are beginning to recognize the opportunity this represents and are formulating strategies to better provide their patients with the highest quality of skincare products available. COSMETIC MEDICAL PRACTICE BENCHMARKS: EXPENSES

This section pertains to the less glamorous, but equally important area of cosmetic medical practice expenses. We will examine several areas which are traditionally the largest line item expense categories but are easily controlled with proper attention and focus. Similar to income categories, it is easier to measure your internal performance because you already have the data on hand and can compare it to data from previous years. Measuring against external data is more difficult because it is often harder to find. Inspecting the financial health of the medical practice requires vigilance on the part of the physician and management team. The physician needs to have a working knowledge of the components of a profit and loss statement, but as stated before, the physician should avoid being consumed with data analysis. There are several ratios and line items that can be evaluated to provide a snapshot of the financial health of the practice. When the financial numbers are running in the appropriate ranges, then scrutiny is sometimes relaxed because of a false sense of security. When they began to go outside of the desired ranges, then some practices increase their attention level to investigate more deeply into what is causing the fluctuations. Sometimes this can be too late to make quick course corrections. The goal should be to create a habit of reviewing the data on a monthly basis, which will enable the practice to make small course corrections as needed rather than trying to turn the ship away from the iceberg one minute before impact. OPERATING EXPENSE RATIO

The operating expense or overhead is the ongoing cost for running a business or all of the money you spend to run your practice. Fixed and variable expenses are the two main components of a practice’s total overhead expense. Fixed costs are those that do not fluctuate with changes in productivity or sales volume. Examples of fixed costs include rent, insurance, society dues, journal subscriptions, equipment leases, payments on loans, management salaries, and advertising. Variable costs are those that respond directly and proportionately to

changes in activity level or volume, such as surgical supplies, hourly wages and commissions, utilities, cosmeceutical inventory, office supplies, mailing, and shipping costs. The operating expense ratio is calculated by dividing the operating expenses by total practice net collected revenue. Operating expenses used in this ratio exclude physician and non-physician provider compensation, bonuses, retirement contributions, depreciation, and automobile expense. The cost of goods sold is included in the operating expenses. The benchmark healthy range of the operating expense ratio for the cosmetic medical practice in 2008 was 55% to 70%. The median was 66%, which is an increase of 3.8 percentage points. The median in 2007 was 62.2%, which was down from 62.8% in 2006h (Fig. 9.8). NON-PROVIDER PAYROLL RATIO

The non-provider payroll or the support staff payroll is traditionally the largest line item expense that a cosmetic medical practice has. This ratio is calculated by dividing the total non-provider gross payroll by the total net collected revenue. Payroll includes the gross wages but does not include employee benefits or payroll taxes. The median non-provider payroll ratio for 2008 was 15.6% with a benchmark healthy range of 12% to 18%. This was 1.3 percentage points higher than the 2007 median of 14.3%. The median for 2007 was slightly lower than 2006, which was 14.9%i (Fig. 9.9). Example If your net collected revenue is equal to the mean of the database at $1,385,389 and your non-provider payroll ratio is also at the mean value of 15.6%, then your yearly payroll should be around $216,121 to be considered within the healthy range. There are a couple of ways to verify whether your payroll ratio is right for your practice. The first is to calculate your number of FTE support staff per provider. FTE support staff includes all non-provider personnel working 2080 hours. The FTE number can be calculated by adding all support staff hours from your payroll summary report and dividing by 2080. In 2008, the FTE support staff ratio was 4.99 support staff to one provider. This is up from 2007, which was 4.46 and 2006, which was 4.33j (Fig. 9.10). The second method of verifying your payroll expenses is to compare your individual support staff positions to published data. The Health

66.00% 65.00% 64.00% 63.00% 62.00% 61.00% 60.00%

2006

2007

2008

Figure 9.8 Operating expense ratio.

g h

Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.

55

i j

Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.

56

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Care Group conducts an annual Staff Salary Survey which provides nationwide salary statistics for 38 key office positions. It is organized by position, years of service, and locale and also provides data on benefits and turnover rates. One example of these data is for the position of medical assistant (MA). The data collected for this position came from 1248 surveys collected from multiple types of practices across the United States. An MA with less than 2 years of experience earned $12.41 per hour. An MA with 2 to 5 years of experience earned $13.52 per hour and one with more than 5 years of experience earned $15.32 per hour.k While these data are not specific to cosmetic medical practices, it is still very useful in gauging the range of salaries you will be competing with when recruiting. It is also a valuable measurement tool you can use to ensure that you are offering your current employees a competitive wage. It is also a useful management tool that can be used to improve employee performance by holding them to a higher standard if you are currently paying them at the top of the range. RENT EXPENSE RATIO

Many physicians I work with throw up their hands in surrender when the discussion turns to the rent. They basically say “it is what it is and it is something that I have no control over.” Whether you are paying a landlord or if you own the property and pay yourself, this ratio will at the least give you an idea of where you stand. You may not be in a

position to negotiate your rent now, but when the time comes you will know that there is a benchmark available regarding healthy ranges. The rent expense ratio is calculated by dividing the total practice rent by the total practice net collected revenue. Rent expense does not include additional occupancy expenses such as utilities and maintenance. The 2008 median rent expense ratio for cosmetic medical practices was 5% (Fig. 9.11). The rent expense ratio has increased slightly over the two previous years in which it was 4.7% in 2007 and 4.5% in 2006.l Example If your net collected revenue is equal to the mean of the database at $1,385,389 and your rent expense ratio is also at the mean value of 5% then your yearly rent should be around $69,269 to be considered within the healthy range. MARKETING EXPENSE

The discussion pertaining to marketing expense is usually very interesting. Some practices are lackadaisical in regard to advertising/ marketing their practice and consider the printing of business cards sufficient in meeting their needs. Other practices feel compelled to be on every billboard in town, on the back of the phone book, and on broadcast media once every hour. I will defer judgment on what is beneficial and what is not because each practice is different and what works for one may not work for another.

16.00%

15.50%

15.00%

14.50%

14.00%

13.50%

2006

2007

2008

Figure 9.9 Non-provider payroll ratio.

5.00 4.80 4.60 4.40 4.20 4.00

2006

2007

2008

Figure 9.10 Number of FTE support staff per FTE provider.

k

Source: The Healthcare Group – Year 2008.

l

Source: Allergan/BSM Consulting Financial Database.

FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE Two activities regarding marketing that have proven to be effective are as follows. The first is to maximize your internal marketing efforts before considering external marketing. It is more cost effective, easier to manage, and typically has a much higher return on investment. The other tip is to track your advertising. Whether it is internal or external marketing, it is very difficult to know what is working and what is most cost effective if you do not track and measure it. This can be easily accomplished by assigning each marketing program a unique identification code and adding a “How did you hear about us?” type of question to your intake form or on patient surveys. The mean value ratio of marketing expense for 2008 was 3.7% of the total net collected revenue. This ratio has continued to increase as demonstrated in 2007 when it was 3.4% and 2006 at 3.2%m (Fig . 9.12). Example If your net collected revenue is equal to the mean of the database at $1,385,389 and your marketing expense ratio is also at the mean value of 3.7% then your yearly marketing should be around $51,594 to be considered within the healthy range. TACTICAL OPPORTUNITIES

The financial benchmarks provide the healthy parameters for practice operations. If you are outside of the healthy range or if you want to

ensure that you stay there then the next question is usually “now what do I do?” If you have gone through the inspection and evaluation of your practice and you have identified areas of opportunity, the next step is to modify or take action. The financial health of your practice can be impacted by reviewing your internal controls and processes. A good place to begin is to review your cash-handling procedures. Ensure that you appropriately segregate duties. Investigate all areas in which cash and checks are handled. One good idea is to have different personnel receive the monies and another to post the payments. The goal is to minimize the risk of embezzlement by removing the temptation. A good offense is to create an oversight process that is known by all. It is important to educate the staff and to demonstrate that all cash handled is accounted for and scrutinized during all phases from landing in the mailbox to being deposited at the bank. This will effectively reduce the opportunity and temptation to embezzle by the fact that if the books do not add up at the end of the day then a full audit will be conducted and the loss will be identified. Example I worked with a practice many years ago that had just begun offering cosmetic services. Before then the practice was all medical and did not receive cash from the patients. The majority of the transactions were through third party payers. The checks came in the mail and went

5.00% 4.90% 4.80% 4.70% 4.60% 4.50% 4.40% 4.30% 4.20%

2006

2007

2008

Figure 9.11 Rent expense ratio.

3.70% 3.60% 3.50% 3.40% 3.30% 3.20% 3.10% 3.00% 2.90%

2006

2007 Figure 9.12 Marketing and advertising expense ratio.

m

Source: Allergan/BSM Consulting Financial Database.

57

2008

58

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

straight to the bookkeeper. They did not have a process in place to receive cash payments directly from the patient. This all became evident during a financial benchmarking analysis. The chief concern from the physician was that they were performing more and more cosmetic procedures but the growth percentage was not in line with revenue. This was verified by comparing the productivity analysis report with income statement. The revenue growth was a flat and slightly smaller percentage than the aesthetic versus medical procedure growth. This was the first red flag. It was fairly simple to identify the problem and create a solution in this scenario. We simply discussed the cash flow process, identified the problem, and created a solution. The problem was that all cash received from patients was put into an unlocked drawer at the front desk. There was no cash tray, no lock box, no cash register, and no organization. Sometimes a handwritten receipt was given to the patient, but usually only if the patient asked for it. The cash was not regularly deposited, and sometimes weeks would pass between deposits. No one ever really knew how much cash was on hand or much less how much cash was supposed to be on hand. The cash was completely accessible to staff and patients. It was often treated as petty cash for staff lunches, office supplies, etc. It was also unattended which provided disgruntled employees and/or employees who thought they were underpaid or overworked the opportunity to supplement their income. The solution was to take away the opportunity by creating new cash-handling procedures with multiple waypoints for inspecting and auditing. A cash register was purchased and incorporated into the daily operations. The cash register provided organization and security. Each person performing check-out duties had an individual batch. These batches provided the link to the superbill and were reconciled at the end of each day. These minor changes effectively removed temptation and created the necessary oversight to ensure accurate accounting. EXTERNAL PROFESSIONALS

This is the right time to re-assess the relationships you have with external professionals. It amazes me that some businesses have not figured out that a down economy is one that you can’t take their business for granted in. The competition for the customer has increased dramatically, and these businesses don’t provide exemplary customer service and a high quality product, then the chances of being replaced increase exponentially.

finally established communications it took another week to receive the management report. To add insult to injury, the payroll company charged her a ridiculous fee for a document that they should have provided many months before. The result of this experience was that the medical practice now has a new payroll company that understands customer service and provides timely management reports as part of the service. The demand for better service applies to all professionals who support your practice. These are some questions that you need to ask yourself. Are you getting what you need from your current attorney, accountant, and consultants? Are they serving your practice to the best of their abilities, or have they taken your business for granted? Are they delivering timely, accurate, and useful information at a fair market price? Make sure you are getting your money’s worth and that you utilize them to the fullest. This is also a good time to review all of your insurance policies and evaluate the necessity. Are any of them redundant? You may want to consider having several brokers bid for your policies. EXPENSE CONTROL: NEW OPPORTUNITY

A new opportunity for aesthetic medical practices in the area of decreasing medical and surgical supply costs has recently emerged in the form of a group purchasing organization (GPO) offered by the Aesyntix Physician Network. This GPO can help practices achieve cost savings from 5% to 20% on their medical, surgical, and business supply purchases. It is endorsed by ADA/M and is a free service to ADA/M members. Additional information is available by following this link: http://www.corehc.com/articles.html. TACTIC: CREATE A BUDGET

The single biggest area of opportunity I have observed regarding fiscal responsibility in the medical practice lies in the area of budgeting. The days of falling backwards into the flowery fields of success have come to an end for most medical practices. Having a plan and a budget with operational and expenditure parameters is essential to successful daily operations. A budget is simply a financial planning tool that lists all planned expenses and revenues. It is a forecasting tool which enables the management team to apply appropriate intervention in a timely manner. A simple six-step process for creating a budget is outlined below. 1. Gather all historical income and expense financial data. 2. Separate into fixed and variable expenses. 3. Perform assessment of future trends and changes based upon past performance. 4. Establish expenditure limits. 5. Monitor and compare the actual results on a monthly basis (at a minimum) and compare it to the plan. 6. Make necessary changes and modifications.

Example I was recently conducting a financial analysis for one of my clients. They were having difficulty obtaining one document that we needed in order to complete the analysis. The document was a year-end payroll summary report. The practice administrator couldn’t get her payroll company representative to call her back for several weeks. When she

Table 9.2 Specialty Breakdown of Cosmetic Practices 2006 Specialty type Plastic surgery Facial plastics Oculoplastics Cosmetic dermatologya Total a

2007

2008

No. of practices

Percentage (%)

No. of practices

Percentage (%)

No. of practices

Percentage (%)

162 38 7 82 289

56.1 13.1 2.4 28.4 100.0

160 36 7 73 276

58.1 13.0 2.5 26.4 100.0

113 23 5 53 194

58.2 11.9 2.6 27.3 100.0

Dermatology practices where 50% or more of collections are attributable to cosmetic procedures.

FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE Make sure that you diligently work within the parameters of your budget. Celebrate success with your management team when this is accomplished. When you exceed the budget, strive to understand what happened. Have your management team provide the cause and then offer coaching and counseling to avoid going over budget in the future. Holding yourself and the management team accountable is essential to the success of budgetary compliance. The budget planning process will provide you with the information needed to implement changes. Appropriate oversight, accountability, and flexibility will help you achieve the goal of improved financial growth and stability for the practice. The first step to improve the financial strength of your practice is to take action. Find the time to work with your management team and

59

communicate what you are looking for and why it is important. Schedule monthly meetings to review the top line data and hold yourself and your team responsible for sustaining your financial diligence. SUPPLEMENTAL INFORMATION

Allergan/BSM Consulting Financial Database Parameters As of December 2009, the database includes information from 289 practices for 2006, 276 practices for 2007, and 194 practices for 2008. A breakdown of participating practices by specialty is illustrated on Table 9.2. Since participating offices typically provide data for the most recent complete year plus two previous years, the number of practices in the database for each year will continue to grow as additional practices submit their information.

10

Forms, forms, forms Kenneth Beer

Our lives as cosmetic specialists depend not only on our skills and education but on the various forms that define our daily practice. Whether these forms are on paper or in an electronic format, they are the means by which we document what we have done, define the risks and benefits to the patients and instruct them on what we expect them to do before and after each treatment. In broad terms, forms may be divided into pre-operative instructions, financial agreements, examination/ progress notes, procedure/ operative notes, consent forms, and postoperative care sheets. PRE-OPERATIVE

Pre-operative checklists for the operating room staff need to have all of the required lab and examination data checked off to ensure patient safety (Fig. 10.1). Equipment and instrumentation required for the procedure is also spelled out and this avoids the risk of delay that occurs when a procedure occurs without the correct equipment (Fig. 10.1). Good patient pre-operative forms articulate the dos and don’ts that will have an impact on the outcome of the procedure. The length and depth of this form depend on the level of invasion and impact of the procedure as well as the style of the physician and prevailing norms for the medical community in the area. For instance, some highly litigious areas will have several pages of pre-procedure instructions for a routine soft tissue augmentation procedure and this is the norm. In these locations, the form will be delivered to the patient and a signed, carbonless copy will be retained to document the transaction. For geographic areas that have more reasonable attitudes, the norm will be to either verbally discuss what is required or to provide a written form advising the patient on what they should and should not do. The length of the form should be long enough that it encompasses the various factors that will optimize outcomes but short enough that patients can read the form and integrate the information. For injectables such as soft tissue augmentation and botulinum toxins, many physicians do not routinely provide pre-operative forms but rather will advise the patient on ways to minimize bruising such as avoiding aspirin and other platelet inhibitors. Fractional lasers, intense pulsed lights, laser hair reduction, and vascular lasers require more pre-procedure instructions (such as sun avoidance and herpes prophylaxis) and thus the forms need to encompass the entire scope of pre-procedure requirements. Lack of proper information in the form for these procedures will result in postponement of procedures or increased rates of complications. As the level of invasiveness increases, the pre-operative form must also be more comprehensive. Thus, for breast augmentation, liposuction, blepharoplasty, and other procedures in this category the pre-operative forms need to be more encompassing and patients need to articulate and agree with the regimen prior to the procedure. Elements of a good pre-operative form include all elements of pre-operative preparedness. This may include preoperative antibiotics and antivirals (which need to be spelled out), avoidance of certain foods, supplements, and medications. In addition, if general anesthesia is involved, when the patient should refrain from eating needs to be carefully communicated. Laser and light procedures need to have sun avoidance discussed and treatments involving dark skin types should mention pre-treatment bleaching creams when appropriate.

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FINANCIAL AGREEMENTS

When and what type of financial agreements to use depend on the relationship with the patient (is it a first time consultation leading to a procedure or a patient you have known for decades?) and the amount of money involved. Bringing financial agreements into a consultation for botulinum toxins used in one area probably is not appropriate but not having one in place for a face lift is similarly inappropriate (Fig. 10.2). A good financial agreement needs to be clear about what is provided and how much it will cost. If a surgical procedure will involve a facility fee, anesthesia, and pathology charges, these need to be spelled out so that the patient has a complete understanding of the costs involved. In addition to these costs, what is not covered is also important to discuss. Some physicians routinely use antibiotics and pain medications and it makes sense to tell patients that the fee for this is or is not included (depending on whether the physician dispenses these drugs). When multiple procedures are contemplated (whether these are spaced out over time as in a fractional laser procedure or they are performed at the same time) each of these should be defined with a clear cost attached to it. If discounts are applied to these combinations, they should also be spelled out so that patients know that such discounts are only applicable when the entire program is performed. Despite the degree of preparation associated with each of these agreements, some patients will fail to honor them. Whether they believe that the results obtained were not “worth” the fee charged or they intentionally defraud the practice, there will be costs associated with recovering the fee if the physician chooses to pursue this route. If the physician intends to attempt to recover fees when this occurs, the costs associated with this need to be part of the financial forms. Financial forms are a necessary part of esthetic medicine and surgery but the degree of detail depends on the philosophy of the individual practitioner. EXAMINATION/PROGRESS NOTES

In order to capture the information about what was done to a patient, the data must be documented in a form devoted to this activity. In broad categories, injectables, lasers, intense pulsed lights, chemical peels, and sclerotherapy each require a separate progress note. Surgical procedures also require an operative note specific to each. No matter what the procedure, each form needs to have documentation of patient allergies, materials, devices and settings used, and areas treated. The fact that post-operative care is discussed and that a post-operative care sheet is given (if one does this routinely) is also documented. It is highly recommended that each form documents the fact that photographs were taken and by whom they were obtained. Notation of any adverse events should also be recorded. There are many different forms to choose from and in this section, I will detail some of the components that I find helpful but by no means find definitive (Figs. 10.3–10.8). Injectable forms typically have several sections (Fig. 10.3). The first ascertains whether or not the patient has any allergies. In addition, a section documenting the type of anesthetic and quantity used is included. A diagram of the face with the underlying muscle groups and folds typically targeted forms the middle of the form. This is used to sketch out what products have been used in each area so that a botulinum toxin dose can be documented in each of the muscles injected, fillers are diagrammed where injected and other notes are also made to

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FORMS, FORMS, FORMS

PREOPERATIVE CHECK LIST OPERATING SURGEON ________________________________ Patient Name_____________________________ Chart# _________________________________________ Date of Surgery: ______________________________________ Date of Pre-op: ____________________________

8:00 arrival

On-call for arrival time

Pre-op Nurse:_______________________________

PROCEDURE(S):_________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ TO BE COMPLETED PRIOR TO SURGERY: ()

Date pre-surgical packet sent___________________

()

Pre-op consent forms completed

()

Mentor gel consent *dated 7 days prior to sx

()

Labs:

( ) CBC, ( ) CMP, ( ) PT, PTT, ( ) EKG ( ) CXR ( ) STRESS TEST

Received

( ) CBC, ( ) CMP, ( ) PT,PTT, ( ) EKG ( ) CXR ( ) STRESS TEST

mail

email

Required

in person

N/A

Additional Orders:______________________________________________________________ Labs at S.P.S. ________________________________ ()

Medical Physician:______________________________

Medical Clearance Required Phone:______________________

Medical clearance received:__________

Faxed Request: _______________________ ()

Mammogram_________________________________

()

Prescriptions:___________________________________

()

Pre-op Pictures: Day of surgery

()

Implant (s): ___________________________________________________________________ Breast Implants:

Saline

Gel

Profile:

Required Called in

moderate

mod +

N/A

Under age 40

written script given

high

()

Implant (s) ordered: _____________________________________________________________

()

Operative garmet:

()

Weight:______________ Measurements:______________ Waist _________________Hips

Surgibra

Girdle _____________________________________________

copy of checklist to O.R.___/_____/____ _

Completed chart to O.R.____/_____/____

Account Balance Paid in Full________________________________ Reviewed by: ________________________________ Chart ready for Sx ( ) Yes ( ) No R.N. _________________________________ Chart ready for Sx ( ) Yes ( ) No Anesthesiologist _________________________________ Chart ready for Sx ( ) Yes ( ) No Surgeon Revised 05/22/08

Figure 10.1 A sample pre-operative checklist.

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

MEDICAL HISTORY and PHYSICAL Patient Name: Patient No:

4241

Today’s Date:

11/6/2009

Surgery Date:

11/10/2009

Surgeon Name: Jason N.Pozner, M.D., F.A.C.S. AUGMENATION MAMMAPLASTY (Silicone): BILATERAL

Procedures: Chief Complaint:

Past History:

Family History:

Allergies: Medications: Operations – Minor: – Major:

Physical Findings:

BP: WNL

Temp:

Pulse:

Resp.

Abnormal Findings

Head Neck Chest Cardio–Vascular Abdominal Genito–Urinary Skin Bones and Joints Glandular Neuromuscular Working Diagnosis Physician’s Signature: Date: Figure 10.2 Pre-operative form for breast augmentation. (Continued)

Wt.

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FORMS, FORMS, FORMS

FINA NCIA L

P OLICIES As patients approach surgery, they frequently need information about the various payment options and have questions about their potential insurance benefits. We hope the following information will be helpful. Our financial coordinators are readily available to meet with you personally to provide the specific information you desire. They specialize in this area and will use their expertise to help you obtain the maximum benefits from your policy.

PAYMENT OPTIONS

Payment for cosmetic plastic surgery is due in full at the time of your preoperative visit. We provide a number of payment options which may be used individually or combined according to your wishes. CASH OR CHECK:–Personal check, cashier’s check, or cash. CREDIT CARDS:–Visa, Master Card, Discover or American Express.

OPTIONAL FINANCING PLANS: We will be happy to assist you with applying for financing should you so desire. INSURANCE COVERAGE

INSURANCE: Our practice does not accept insurance. If you are having a procedure that may be covered by insurance, we will be happy to provide you with insurance forms however payment is expected in full for all procedures. PATHOLOGY: On certain occations it will be necessary to send tissue samples to the pathologist for examination. The fee for this service will be billed directly to you the patient by the pathologist. We will inform you if this service is necessary and you can contact them regarding insurance coverage. Please discuss all arrangements regarding payment of your account with us.

CANCELLATION POLICY

We understand that a situation may arise that could force you to postpone your surgery. Please understand that such changes affect not only your surgeon but other patients as well. Dr. Pozner’s time, as well as that of the operating room staff, is a precious commodity, and we request your courtesy and concern. A non-retbndable deposit of 10% of your surgical fees are due at the time you book your surgery. The balance of your surgical fees are due 2 weeks before surgery. If you cancel your surgery within 48 hours, your fees will not be refunded. Surgery can only be rescheduled due to medical reasons. If you have any questions or need assistance with financial matters, please ask Valerie Pasqualini, R.N. to help you.

SIGNATURE

SIGNATURE: I understand and agree to the afore stated financial policies.

Signature of Patient Jason N. Pozne, MD., F.A.C.S. (561) 367-9101

Figure 10.2 (Continued).

Date

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

BOTULINUM TOXIN TYPE A AND SOFT TISSUE AUGMENTATION/VOLUME REPLACEMENT OPERATIVE NOTE Patient Name Date of Birth

ALLERGIES

Date of Service

_________________ HX COLD SORES _________________ ANESTHESIA 1% lidocaine/septocaine/ citanest with 1:100k epi ml injected locally infraorbital mental <30 ml topical _____________ FILLER Evolence Juvederm Perlane Prevelle Silk Restylane Radiesse Sculptra ___ml/bottle

Reason for Cosmetic Evaluation:

AREAS TREATED with Soft Tissue Augmentation nasal labial cease upper lip lower lip glabella marionette zygoma

Prior Cosmetic Treatment Include: Date of last Cosmetic Procedure: Adverse Effects to Prior Cosmetic Procedure Y / N ? If Yes,

Examination/Assessment/Plan: AREAS TREATED with Botox/Dysport glabella mentalis periorbital frontalis neck other _____________

Procedure:

TOTAL UNITS OF BOTOX/DYSPORT INJECTED ________ PHOTOS TAKEN

Risks, benefits, alternatives including no treatment, duration spectrum of treatment proposed havealso been discussed: (initial/date)

/

/

Figure 10.3 Operative note for botulinum toxin type A and soft tissue augmentation/volume replacement.

Revised: 09.22.09

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FORMS, FORMS, FORMS

Kenneth Beer MD PA Esthetic, Surgical & General Dermatology Center Kenneth Beer, M.D.

Hillary Oakley, PA-C

LASER CENTER: IPL/PDT OPERATIVE REPORT Patient Name_____________________ Consult

Date_______________________ Follow-up treatment

Initial Treatment

Consent reviewed

Treatment #________________

# of Levulan Stick: _____________________

Protective eyewear

Allergies___________________

Time Levulan Applied: __________________

Photos

Pre

Post

Laser Time: ________________________

Current Meds:_________________ Date of last sun exposure:_______________________________ Diagnosis: ____________________________Location _____________________________ Examination/Assessment/Plan_____________________________________________________________ ______________________________________________________________________________________ LASER TYPE StarLux IPL Palomar

Ellipse IPL

Blue Light : Yes

No

Minutes: _____

Other____________

The patient was fully informed of the planned procedure, the alternative methods of treatment, the limitations, the expected results, the risks and complications, both short and long term. Written consent was obtained. < 30ml topical/local/no anesthesia was obtained with____________no occlusion. Laser procedure was performed using all standard safety precautions. Starlux IPL Parameters Treatment Site

Energy Density J/cm2

Pulse Width (ms) 1st pass

Hand Piece

Energy Denisity J/cm2

Pulse Width (ms) 2nd pass

Energy Density J/cm2

Pulse Width (ms) 3rd pass

Ellipse IPL Parameters Treatment site

Laser

Laser setting

Skin Type

Pigment

Energy

# Pulses

IPL

Comments____________________________________________________________________________________ ____________________________________________________________________________________________ ___________________________________________________________________________________________ __ Post-op instruction given & reviewed _________initial/date Ice applied

Answered all questions

SPF 30 Applied SBR Lipocream/Aquaphor/Clinique Recovery/Revale Intensive Repair/Other______________________________ Follow-up was recommended in _________weeks/months. Complications:_________________________________________________________________________________ ___________________________ Provider Signature/Date

____________________________________ Staff Signature/Date

Figure 10.4 A sample operative report for an intense pulsed light/photodynamic therapy (IPL/PDT) procedure.

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Kenneth Beer MD PA Esthetic, Surgical & General Dermatology Center Kenneth Beer, M.D.

Hillary Oakley, PA-C

PIGMENTED LESION LASER TREATMENT CONSENT FORM I, ___________________________ have a benign pigmented lesion called a café-au-lait/ solar lentigo / nevus of Ota / benign nevus/ hair removal /Other__________ for which I have requested treatment. Dr. Beer or Hillary Oakley, PA-C has explained to me that although laser surgery is effective in most cases, no guarantees can be made that I will benefit from the treatment. I understand that several treatment sessions may be needed to obtain the desired level of improvement and that there is a separate charge for each subsequent treatment. Sometimes a lesion will not completely clear, but should appear paler in color. Rarely, a pigmented lesion may not respond to laser treatment at all. The most common side effects and complications of the pigmented 755 Alexandrite specific laser area: PAIN. The snapping and heating sensation of each laser pulse may produce minimal to moderate

discomfort. An

anesthetic cream or injection may be used to reduce pain.

Initial ___________

BRUISING. Immediately after the laser treatment, the skin may appear red or bruised. The discoloration over the next several hours, but bruising can last as long as two weeks.

will fade Initial ___________

SWELLING. Areas most likely to swell are under the eyes, lips or neck. The swelling subsides within 3-5 days with ice or cool compress application.

Initial ___________

BLISTERS or SCABS. These rarely develop and can take 1 to 2 weeks to resolve.

Initial ___________

INFECTION. Swelling, crusting, pain and fever could indicate an infection, requiring the use of topical or oral antibiotics. This is rarely seen. Rarely may also have reaction to anesthetic.

Initial ___________

SKIN DARKENING. (Hyperpigmentation) “Tanning” of the skin can occur in treated areas and usually fades within 2 to 6 months. This reaction is more common in patients with olive or dark skin tones or after laser treatment on legs and can worsen if laser treated area is exposed to the sun.

Initial ___________

SKIN LIGHTENING. (Hypopigmentation). Light spots can occur, particularly in skin areas that have received prior treatments. The pale areas usually darken or re-pigment in 3-6 months, but could be permanent in rare cases. Initial ___________ ULCERATIONS/SCARRING. This is extremely rare after pigment-specific laser therapy, but scarring can occur upon any disruption of the skin’s surface. Following all advised post-operative instructions will reduce the possibility of this occurrence.

Initial ___________

LESION PERSISTENCE. Some lesions may not disappear completely despite the best efforts made by the doctor. Initial ___________ OCULAR (EYE) DAMAGE. Risks to the retina, uvea, choroids and iris exist when using near infrared and IPL devices. Metal eyeshields will be used if treatment is inside the bony orbit. Contact lenses MUST be removed prior to the use of metal eyeshields. Cryogen, Zimmer cooler and topical anesthesia may damage the cornea

Initial ___________

I further understand that, if left untreated, my Pigmented lesion would not be expected to go away on its own. It also may become darker, larger or more raised with time. By providing my signature below, I acknowledge that I have read and understood all the information above and have had all my questions answered to my satisfaction. I feel that I have been adequately informed of my alternative treatment options, the risks of the proposed laser surgery and the risks of not treating my condition as well as the treatment benefits. Any questions or concerns I have, have been discussed and fully answered to my satisfaction. I have no history of cold sores, fever blisters or shingles.

Initial ___________

I do or donot have a history of cold sores, fever blisters or shingles. (Circle as appropriate) Most recent outbreak (area/date): _______________

Initial ___________

Treated with Zovirax/Acyclovir, Famvir, Valtrex, Other ______________________________ (Circle as appropriate) I understand that multiple laser treatments may be needed.

Initial ___________

Initial ___________ I understand that there is a separate charge for each treatment. I hereby freely consent to the laser surgery to be performed by Dr. Beer or Hillary Oakley, PA-C and give authorization for clinical photographs, which will be used for education, clinical and/or publicity use. __________________________________ Patient or Guardian Signature Date

_____________________________ Witness Signature Date Updated 09.14.09

Figure 10.5 Consent form for pigmented lesion laser treatment.

FORMS, FORMS, FORMS

67

Operative Note:TCA Chemical Peel Kenneth Beer,MD, PA Patient name: Date of Chemical Peel: Type of Chemical Peel: 20%TCA Jessners& %TCA Informed consent signed and in chart: Y / N Preoperative photographs taken Y / N Post Care Instructions Given To Patient and explained to patient: Y/ N Patient with history of cold sores: Y / N (if yes, preoperative antiviral and rx for antiviral has been given to the patient: Y / N Areas treated: Face and Ears/ Neck / Hands / Arms / Legs / Neck / Chest After informed consent is obtained and post peel care is discussed, the patient’s skin is cleansed with alcohol/ acetone. Using eye protection the peeling agent is applied in an even manner to the entire area being treated. The patient tolerated the procedure well. Following frosting of the TCA, ice chilled compresses are applied to the patient’s skin. The skin is then cleansed with a mild cleanser such as Cetaphil. An intramuscular injection of 40 mg Kenalog was / was not given to the patient after discussion of the relative risks and benefits as well as ascertaining that the patient is not diabetic nor had a history of tuberculosis The patient is instructed in postoperative care(including sun avoidance) and is to call with any questions and to return for follow up care. Figure 10.6 Operative note for trichloroacetic acid (TCA) chemical peel.

ensure that whatever was done in that particular procedure is captured. Intense pulsed lights and laser forms need to have areas to document the type of issue being addressed, anesthetic used (if any), the devices used, areas treated and energy settings, and spot sizes utilized (Figs. 10.4 and 10.5). Whether or not the patient has a history of herpes and what treatment for this is prescribed is also noted. Documentation of the anticipated number of treatments may also be noted in this form. Chemical peel forms are among the easiest to formulate (Fig. 10.6). These need to capture the area treated and indication for treatment. The type of peel used as well as the concentration and duration of peel (when applicable) need to be noted. Post-treatment care should be charted. Sclerotherapy forms require notation of the area treated and the type of veins found in these areas (Figs. 10.7 and 10.8). Use of ultrasound to identify the vessels is noted when appropriate. The type of sclerosant and amount injected must be recorded. Extravasation, when it occurs, should also be documented. Operative procedures are the most complicated forms as they require multiple data points. The type, time, and amount of anesthetic and the person administering it are requirements for any procedure using anesthesia. Start time and end time of the procedure are also integral to the form. The narrative of what actually transpired is the heart of the form and this must be captured in enough detail to enable another physician to re-create what happened when read. Any unusual events or complications should be noted. For procedures requiring sponges, the counts should be noted. It is beyond the scope of this chapter to detail the entirety of a good operative note but examples are available at most university hospitals during training.

Liposuction operative notes should include the areas treated, amount of tumescent fluid infused, time of infusion, use of any additional medications, vital signs at regular intervals, and the instrumentation used during the procedure. In addition, the amount of material removed should be noted by area. Infratant and supranatant should be documented so that the amount of fat removed can be calculated. For breast augmentation, facelifts, rhinoplasty, blepharoplasty, and other similar procedures, the induction of anesthesia and mode of anesthetic should be noted. The time of incision, type of incision, implant used, blood loss, and other relevant information need to be captured. Most of these procedures have standardized operative forms and it is beyond the scope of this chapter to provide them in great detail. CONSENT FORMS

Consent forms are the legal documentation that detail the patient’s permission to perform the procedure as well as some disclosure of the risks. A good consent form should detail the likely adverse events as well as the rare events that can be catastrophic such as anaphylaxis. For botulinum toxins, it is important to have mention of the newer medical guidance required by the Food and Drug Administration (FDA) (Figs. 10.9–10.11). Filler consent forms should have the most common adverse events listed as well as some of the most severe ones so that the patients have a broad perspective on the treatments they are undergoing (Fig. 10.12). The best consent forms may not always be practical as they would be intrusive and time consuming beyond the scope of what would be practical. For instance, some surgical procedures are so fraught with liability that surgeons have taken to videotaping the patient during the consent form and they have the patient verbalize

68

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

Kenneth Beer, M.D., P.A. 1500 N. Dixie Hwy., Suite 303 West Palm Beach, Florida OPERATIVE REPORT Patient Name: Date: PreOperative Diagnosis: Post Operative Diagnosis: Procedure:

Surgeon: Anesthesia:

Localized Lipodystrophy Same Suction Assisted Lipectomy of: Face/Neck/Upper abdomen/Lower Abdomen/Breasts/Hips/Flanks(lovehandles)/ Arms/Inner Thighs/Outer Thighs/Buttocks/ Knees/Ankles/Other Areas:_______________________________________________ ________________ Kenneth Beer, M.D. Local Tumescent Anesthesia With Oral Sedation(standard Klein solution of 50cc 2% lidocaine/ 1cc Epinephrine 1:1000/12.5cc NaBicarb 10mEq/0.25 cc 40mg/cc kenalog)

Oral Sedation: _________________ Total Amount Of Tumescent Fluid Infused: _____Liters Total Amount Of Lidocaine: ______mg Amount of Lidocaine in mg/kg: ______mg/kg Complications: NONE Blood Loss: _____cc Preparation: Surgical antimicrobial scrub Indications:

Procedure:

This patient has lipodystrophy and desires improvement in his or her appearance. The risks of surgery including adverse reaction to anesthesia, bleeding, scarring, rippling, irregularity, asymmetry etc were discussed. The patient accepts the risks and agrees to proceed. After preoperative evaluation and oral sedation, the patient was marked in the upright position and then placed in the supine position on the operating table. The patient was prepped and attached to monitoring equipment. Using several 3-5 mm incisions made with an 11 blade, the areas to be treated were infiltrated with tumescent solution. Using a combination of cannulas including Mercedes and Cobras ranging from 3-4mm, suction assisted lipectomy was performed on the following areas : Face/Neck/Upper abdomen/Lower abdomen/Breasts/Hips/Flanks (lovehandles)/Arms/Inner Thighs/Outer Thighs/Buttocks/Knees/Ankles OtherAreas:_________________________________________ until satisfactory change in pinch and contour was obtained. A total of _________cc of fatwas resected. Sutures were placed in several incisions while others are left to drain. Dressings are placed over the incisions and a garment is placed on the patient. The patient tolerated the procedure well and is monitored during the recovery phase Kenneth Beer, M.D. Figure 10.7 Operative report for a suction assisted lipectomy procedure.

FORMS, FORMS, FORMS

Kenneth Beer, M.D., P.A. LIPOSUCTION PRE-OPERATIVE/POST-OPERATIVE STANDING ORDERS LIPOSUCTION STANDING (PRE/POST-OP) ORDERS 1.

Patient Name:

2.

Date of Surgery:

3.

Diagnosis (Lipodystrophy/Localized Adiposity - 278.1)

4.

Signed surgical, anesthesia and photo consents for liposuction surgery.

5.

Pre-op laboratory tests to include; SMA 21, CBC with Diff., PT, PTT, HIV 1 and 2, UA, Hepatitis C Antibody, Hepatitis B Antigen, Pregnancy Test (qualitative βHCG). Patient understands the cost of testing is separate from the procedure.

6.

Diet: No solid food after midnight for morning cases; no solid food 5 hour prior to surgery for later cases. Patient may take clear liquids in small amounts before surgery.

7.

Insert heplock for IV access(optional)

8.

Anesthesia: Local anesthesia standard Tumescent Technique.

9.

Concentration of local anesthetic as per verbal order of Dr. Beer (no to exceed 45mg/kg Lidocaine). See Anesthetic Record Flow Sheet for specific concentrations.

10.

Patient may have small frequent sips of apple juice during surgery.

11.

Keflex 500 mg. PO TID, begin day before surgery.

LIPOSUCTION POST-OP ORDERS: 1.

After orthostatic blood pressure and pulse is taken, may disc. Heplock.

2.

Post op dressings: Apply standard sterile absorbent dressings and compression garment.

3.

Written after care instructions given to patient and companion.

4.

May discharge 30 minutes post op.

5.

Tylenol 500mg. 2 tabs PO PRN. pain.

6.

Return appointment to be made for 1 weeks post op.

Signature:_____________________________________Date:____________________ Kenneth Beer, M.D. Figure 10.8 Standing pre-operative/post-operative orders for a liposuction procedure.

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT

KENNETH BEER MD PA Surgical, Esthetic & General Dermatology Center Kenneth Beer, M.D.

Hillary Oakley, PA-C

Dear Patient, Attached to this letter is a medication guide for botulinim toxins such as Botox and Dysport. This medication guide is given out per FDA guidelines to all patients receiving Dysport and/or Botox treatments. This guide outlines all ofthe risks associated with the medical use of Dysport, not necessarily for cosmetic use. The FDA has acknowledged that none of these serious life-threatening side effects for Dysport and Botox have been seen in patients receiving cosmetic treatments and have only been seen in patients receiving large amounts of Botoxfor conditions such as cerebral palsy. We strongly believe that the use of Dysport or Botox is both safe and effective. There are risks to any medication however, and those risks will be discussed and are outlined in the consent. If you have any questions, please ask your physician or our physician assistants.

Sincerely,

Kenneth Beer MD Figure 10.9 Letter accompanying the medical guide for botulinum toxins.

each of the salient risks as well as any questions about the procedure. Other forms that are used have spaces for the patient to write the risks in a blank area so that all of the relevant adverse events are documented by the patient in his or her own hand. Following either of these, it is difficult for a patient to argue that he or she was not properly informed. Patients frequently complain that they are presented with so much information as to render it useless. One potential to this is to break the consent form into smaller pieces and have each component piece initialed and dated. Perhaps the most important aspect of the consent process is the one most overlooked—the rapport with the patient. Each of us will have adverse events provided we do enough procedures. Patients, in general, will be forgiving of a great deal if the physician has explained the risks and benefits in a thorough and compassionate manner. When a physician does not have a good fit with the patient, it is best to let him or her find someone else to perform the cosmetic procedure. For instance, during the consent process for skin cancer reconstruction I will sometimes have patients ask whether they will have a scar. These are usually the patients that do not understand the nature of the proposed procedure and I will try to get them to understand it by explaining it again. If the same question persists, it means that they need to find someone that can do a better job of explaining or guarantee that they will not

have a scar, but at that point I recognize that I can do neither. For those patients, the consent process serves as a triage for patients that have unrealistic expectations. POST-OPERATIVE CARE SHEETS

These forms are among the least recognized in practice but they can be the most important. Patients have the ability to undermine their own progress by actions that they take following a procedure. In the absence of a documented post-operative care sheet that has been reviewed and explained, the physician will be blamed for any adverse events resulting from these actions. After a surgical procedure, it may be mandatory to ambulate in order to avoid the risk of developing deep vein thrombosis but just as important to avoid lifting so that sutures don’t dehisce. Patients undergoing procedures are frequently anxious about the procedure and are presented with a great deal of information during the perioperative period. These factors mean that they may not integrate any of the information essential for optimal healing. For botulinum toxins and fillers, one needs to determine what guidance to provide following each procedure (Figs. 10.13 and 10.14). Some physicians recommend avoiding lying down, exercise, and sun exposure while others think that none of these have any relevance. Whatever one’s

FORMS, FORMS, FORMS

MEDICATION GUIDE BOTOX™ (Bo-tox) DYSPORT™ (DIS-port) (abobotulinumtoxinA) Injection Read the Medication Guide that comes with BOTOX™/DYSPORT™ before you start using it and each time BOTOX™/DYSPORT™ is given to you. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment. You should share this information with your family members and caregivers. What is the most important information I should know about BOTOX™/DYSPORT™? BOTOX™/DYSPORT™ may cause serious side effects that can be life threatening. Call you doctor or get medical help right away if you have any of these problems after treatment with BOTOX™/DYSPORT™:

•

Problems swallowing, speaking, or breathing. These problems can happen hours to weeks after an injection of BOTOX™/DYSPORT™ usually because the muscles that you use to breathe and swallow can become weak after the injection. Death can happen as a complication if you have severe problems with swallowing or breathing after treatment with BOTOX™/DYSPORT™.

•

People with certain breathing problems may need to use muscles in their neck to help them breathe. These patients may be at greater risk for serious breathing problems with BOTOX™/DYSPORT™.

•

Swallowing problems may last for several weeks. People who can not swallow well may need a feeding tube to receive food and water. If swallowing problems are severe, food or liquids may go into your lungs. People who already have swallowing or breathing problems before receiving BOTOX™/DYSPORT™ have the highest risk of getting these problems.

•

Spread of toxin effects. In some cases, the effect of botulinum toxin may affect areas of the body away from the injection site and cause symptoms of a serious condition called botulism. The symptoms of botulism include:

• • • • • • •

loss of strength and muscle weakness all over the body double vision hoarseness or change or loss of voice (dysphonia) trouble saying words clearly (dysarthria) loss of bladder control trouble breathing trouble swallowing

These symptoms can happen hours to weeks after you receive an injection of BOTOX™/ DYSPORT™. These problems could make it unsafe for you to drive a car or do other dangerous activities. See “What should I avoid while receiving BOTOX™/DYSPORT™. What is BOTOX™/DYSPORT™? BOTOX™/DYSPORT™ is a prescription medicine that is injected into muscles and used: • to treat the abnormal head position and neck pain that happens with cervical dystonia (CD) in adults • to improve to the look of moderate to severe frown lines between the eyebrows (glabellar lines) in adults younger than 65 yearsof age for a short period of time (temporary) Figure 10.10 Medication guide for botulinim toxins. (Continued )

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CD is caused by muscle spasms in the neck. These spasms cause abnormal position of the head and often neck pain. After BOTOX™/DYSPORT™ is injected into muscles, those muscles are weakened for up to 12 to 16 weeks or longer. This may help lessen your symptoms. Frown lines (wrinkles) happen because the muscles that control the facial expression are used often (muscle tightening over and over). After BOTOX™/DYSPORT™ is injected into the muscle that control facial expression, the medicine stops the tightening of these muscles for up to 4 months. It is not known whether BOTOX™/DYSPORT™ is safe or effective in children under 18 years of age. It is not know whether BOTOX™/DYSPORT™ is safe or effective for the treatment of other types of muscle spasms. It is not known whether BOTOX™/DYSPORT™ is safe or effective for the treatment of other wrinkles. Who should not take BOTOX™/DYSPORT™? Do not take BOTOX™/DYSPORT™ if you:

• are allergic to BOTOX™/DYSPORT™ or any of the ingredients in BOTOX™/DYSPORT™. See the end of this Medication Guide for a list of ingredients in BOTOX™/DYSPORT™

• are allergic to cow’s milk protein • had an allergic reaction to any other botulinum toxin product such as Myobloc®* or Botox®* • have a skin infection at the planned injection site What should I tell my doctor before taking BOTOX™/DYSPORT™? Tell your doctor about all your medical conditions, including if you have: • a disease that affects your muscles and nerves (such as amyotrophic lateral sclerosis [ALS or Lou Gehrig’s disease], myasthenia gravis or Lambert-Eaton syndrome). See “What is the most important information I should know about DYSPORT™? • allergies to any botulinum toxin product • had any side effect from any botulinum toxin product in the past • a breathing problem, such as asthma or emphysema • swallowing problems • bleeding problems • diabetes • a slow heart beat or other problem with your heart rate or rhythm • plans to have surgery • had surgery on your face • weakness of your forehead muscles (such as trouble raising your eyebrows) • drooping eyelids • any other change in the way your face normally looks Tell your doctor if you:

• are pregnant or plan to become pregnant. It is not known if BOTOX™/DYSPORT™ can harm your unborn baby

• are breast-feeding or planning to breast-feed. It is not known if BOTOX™/DYSPORT™ passes into breast milk. Tell your doctor about all the medicines you take, including prescription and nonprescription medicines, vitamins and herbal and other natural products. Using BOTOX™/DYSPORT™ with certain other medicines may cause serious side effects. Do not start any new medicines while taking BOTOX™/DYSPORT™ without talking to your doctor first. Figure 10.10 (Continued ).

FORMS, FORMS, FORMS

Especially tell your doctor if you: • have received any other botulinum toxin product in the last four months • have received injections of botulinum toxin, such as Myobloc® (Botulinum Toxin Type B) or Botox® (Botulinum Toxin Type A)* in the past; be sure your doctor knows exactly which product you received • have recently received an antibiotic by injection • take muscle relaxants • take an allergy or cold medicine • take a sleep medicine Ask you doctor if you are not sure if your medicine is one that is listed above. Know the medicines you take. Keep a list of your medicines with you to show your doctor and pharmacist each time you get a new medicine. How should I take BOTOX™/DYSPORT™? • BOTOX™/DYSPORT™ is an injection that your doctor will give you • BOTOX™/DYSPORT™ is injected into the affected muscles • Your doctor may give you another does of BOTOX™/DYSPORT™ after 12 weeks or longer, if it is needed • If you are being treated for CD, your doctor may change your dose of BOTOX™/DYSPORT™ until you and your doctor find the best dose for you • The dose of BOTOX™/DYSPORT™ is not the same as the dose of any other botulinum toxin product What should I avoid while taking BOTOX™/DYSPORT™? DYSPORT™ may cause loss of strength or general muscle weakness, blurred vision, or drooping eyelids within hours to weeks of taking BOTOX™/DYSPORT™. If this happens, do not drive a car, operate machinery, or do other dangerous activities. See “What is the most important information I should know about BOTOX™/DYSPORT™? What are the possible side effects of BOTOX™/DYSPORT™? BOTOX™/DYSPORT™ can cause serious side effects. See “What is the most important information I should know about BOTOX™/DYSPORT™? Other side effects of BOTOX™/DYSPORT™ include: • dry mouth • injection site discomfort or pain • tiredness • headache • neck pain • muscle pain • eye problems: double vision, blurred vision, decreased eyesight, problems with focusing the eyes (accommodation), drooping eyelids, swelling of the eyelids • allergic reactions. Symptoms of an allergic reaction to BOTOX™/DYSPORT™ may include: itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness of feeling faint. Tell your doctor or get medical help right away if you get wheezing or asthma symptoms, or if you get dizzy or faint Tell your doctor if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of BOTOX™/DYSPORT™. For more information, ask your doctor or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. Figure 10.10 (Continued ).

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General information about BOTOX™/DYSPORT™: Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. This Medication Guide summarizes the most important information about BOTOX™/DYSPORT™. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about BOTOX™/DYSPORT that is written for healthcare professionals. For more information about BOTOX call 800-433-8871 or go to www.botoxcosmetic.com for DYSPORT™ call 877-397-7671 or go to www.dysport.com or www.DysportUSA.com. What are the ingredients in BOTOX™/DYSPORT™? Active ingredient: (botulinum toxin Type A) Inactive ingredients: human albumin, and lactose. DYSPORT™ may contain cow’s milk protein. *All trademarks are the property of their respective owners Figure 10.10 (Continued ).

CONSENT FOR BOTULINUM TOXIN (BOTOX/DYSPORT) TREATMENT Purified Botulinum Toxin (Botox/Dysport) is FDA approved for cosmetic use to minimize frown lines in the glabella area. Botulinum Toxin (Botox/Dysport) works by causing temporary weakness or paralysis of the muscles in this area. Often purified Botulinum Toxin (Botox/Dysport) is used “off-label” for non-FDA approved indications, specifically for areas of the face and neck other than the glabella. Dr. Beer will discuss with you the suggested areas of treatment, some of which will be non-FDA approved or off-label uses. What you can expect: The effects of purified Botulinum Toxin (Botox/Dysport) begin to appear in as early as 24 hours, but often may take up to 7 days or more to be fully effective. You can expect some slight swelling and occasionally bruising in areas where the injections are given. Botulinum Toxin (Botox/Dysport) generally lasts between 3 and 4 months, but may have a shorter or longer effective life depending upon your individual physiology. Your doctor will discuss the choice of the two different FDA approved toxins, Botox or Dysport. While these toxins work in a similar way, they are not interchangeable. There are differences in the effects of the toxins and individuals who have received Botox in the past may not have exactly the same effects with Dysport. The treatment may not be effective in individuals. You may have temporary asymmetry of your face. Contraindications to receiving Botulinum Toxin (Botox/Dysport): You should not take Dysport or Botox if you are: 1. Allergic to Dysport or Botox or any of the ingredients in Dysport or Botox. 2. If you are allergic to cow’s milk protein. 3. If you had an allergic reaction in the past to any Botulinum Toxin (Botox/Dysport) including Myobloc or Botox. 4. If you have a skin infection in the injection site. 5. You should also not take Botulinum Toxin (Botox/Dysport) if you are pregnant, or if you possibly think you could be pregnant. Figure 10.11 Consent form for botulinum toxin treatment. (Continued )

FORMS, FORMS, FORMS

6. You should not take Dysport or Botox if you are breast-feeding. 7. Additionally, you should tell your doctor about all your medical conditions, specifically if you have a disease that affects your muscles or nerves such as ALS or Lou Gehrig’s disease, myasthenia gravis or Lambert-Eaton syndrome. INITIAL: DATE :

Risks and complications: Significant complications from cosmetic use of Botulinum Toxin (Botox/Dysport) are very rare, but risks and complications from the procedure can include the following: 1. 2. 3. 4.

5. 6.

7.

8.

Patients can have swelling or bruising at injection sites. Patients may occasionally have numbness lasting 2 to 3 weeks or longer. Transient headaches can occur. Toxin has a rare potential to spread from the specific site of injection and in clinical trials approximately 2 percent of individuals can have a temporary droop of an eyebrow or an eyelid. You may also experience temporary asymmetry. Rarely patient’s may experience temporary blurring or double vision. Additionally, many side effects including death have been reported with the use of Botulinum Toxin (Botox/Dysport) for conditions other than cosmetic use. Primarily these have occurred in patients including children with cerebral palsy who were injected with much larger doses of Botulinum Toxin (Botox/Dysport) in areas such as the neck, arms, legs and back. You will be given a patient guide, which outlines all of the known risks for Botulinum Toxin (Botox/Dysport). The FDA has clearly indicated that none of the severe complications that have been seen in the clinical use of Botox and Dysport such as in patients with cerebral palsy and other medical conditions. None of the severe complicationshas been seen in patient’s receiving cosmetic Botulinum Toxin (Botox/Dysport). I understand that several sessions may be needed to complete the injection series and the multiple sessions are planned understand that there is a separate charge for any subsequent treatments. I understand that I need to remain upright for four hours after my procedure and not exercise for 24 hours following my treatment. Also, that I am to exercise the muscles treated by frowning and smiling for one day.

Photographs: I authorize to taking new clinical photographs in the use for scientific purposes, both in publication/presentations and publicity. Payment: I understand this procedure is cosmetic and the payment is my responsibility.

I have read the above and understand it. My questions have been answered satisfactorily by the doctor and the doctor’s associates. I accept the risks and complications of the procedure. In signing this, I also acknowledge that I have reviewed the patient bulletin regarding Botulinum Toxin (Botox/Dysport).

Signature of Patient____________________________________________________________ When patient is under age 18 or unable to affix signature; signature of person authorized to consent for Patient:________________________________Date:_______________________ Witness:_______________________________Date:_______________________ Figure 10.11 (Continued ).

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Kenneth Beer MD PA Esthetic, Surgical, & General Dermatology Center Kenneth Beer, M.D.

Hillary Oakley, PA-C

Consent to Treatment: Injectable Tissue Augmentation with Juvederm, Radiesse, (Radiance), Restylane, Perlane, Evolence andPrevelle Silk This is to certify that I consent to a tissue augmentation treatment given by XXXX; at this time. I am not known to be allergic to hyaluronic acid products or lactic acid. I understand that complications may occur with any injectable substance.

Initial_______ I also understand waviness of the skin, bumps, depressions, movement of product and cysts can result from Juvederm, Radiesse, (Radiance), Restylane, Perlane, Evolence, Prevelle Silk and Elevesse injections. I understand that each of these injections may NOT be FDA approved for cosmetic indications and its use constitutes an “off label” indication. Results will NOT Initial_______ be a perfect resolution of wrinkles but will be a best effort by the physician to improve my appearance. In addition, rare but possible complications may include: infection, damage to nerve resulting in numbness or paralysis, anaphylaxis (allergic reactions) which could result in death and injection of material into a blood vessel resulting in blindness. other rare complications include necrosis (death) of the skin resulting in large scars requiring skin grafting. Initial_______ I understand that any of these problems may occur at any time, even after having uneventful treatments in the past. I UNDERSTAND THAT THERE IS NO GUARANTEE REGARDING LONGEVITY OR DEGREE OF CORRECTION WITH THE USE OF JUVEDERM, RADIESSE (Radiance), RESTYLANE, PERLANE, EVOLENCE, PREVELLE SILK, AND ELEVESSE INJECTIONS.

I understand there is a subsequent charge for each syringe used on this or subsequent visits (including “touch-ups”).

Initial_______ Initial_______

I understand that if XXXX; judges at any time that my surgery should be postponed or canceled for any reason he/she may do so. I understand that if in the event of an emergency, I will be transferred to the nearest hospital. Subcutaneous nodules and papules may occur with any soft tissue filling agent and the most frequent adverse events noted with Radiesse (Radiance). No assurance regarding the extent or duration of the correction is given or implied.

Initial_______

I hereby state that the information furnished to XXXX; during my evaluation is correct and that I have disclosed all known medical conditions, allergies or adverse reactions to medical preparations.

Initial_______ I agree to follow the instructions given to me by XXXXXX; to the best of my ability before, during and after the procedure, and that I will, as soon as possible, notify them of any questionable conditions that may arise.

Initial_______ I understand this is an elective cosmetic procedure and I assume full financial responsibility for my procedure today as well as

Initial_______

any revisions or corrective treatments that may be needed.

I hereby waive and hold harmless XXXXX; from any and all financial costs, including but not limited to facility fees and anesthesia charges, laboratory and other costs associated with such revisionary procedures.

Initial______ I give permission to XXXXXXX; to use photographs of me for education and/or publicity. I understand that a caresheet is available and if I do not receive one I can ask for one.

Initial______ Initial______

_________________________________________________________________________________________________ Patient

Date

_________________________________________________________________________________________________ Witness

Date

Updated 09/14/09

Figure 10.12 Consent form for treatment by injectable tissue augmentation procedure.

FORMS, FORMS, FORMS

Botulinum Toxin Post-Operative Instructions 1. Do not lie down for 4 hours. 2. Work the treated areas by wrinkling the forehead or frowning for 1 – 2 hours. 3. Do not exercise (running, aerobics, weight lifting, etc…) for 24 hours. 4. Try to avoid aspirin or ibuprofen for 24 hours. 5. It will take 3 – 7 days for the full effect to be achieved. If you have any questions or concerns, we are here for you, please call 561-655-9055. The Medical Assistant who cared for you was _____________________ Figure 10.13 Post-operative instructions for botulinum toxin.

Care Sheet for Fillers Some bruising is normal and may last for 5-7 days. Aspirin, Vitamin E and non-steroidal anti-inflammatory drugs may make the bruising worse. We normally do not recommend discontinuing these drugs and we expect some bruising following these procedures. There will be minimal discomfort for a day or two. You may apply antibiotic cream to the site following treatment for 1 – 2 days (twice a day). You may apply makeup immediately following the treatment. Some lumpiness and swelling is normal and lasts up to 7 days. Swelling typically is the worst two days after treatment. Some patients need more treatment for optimal results. If you have any questions or concerns, we are here for you, please call 561-655-9055. The Medical Assistant who cared for you was _____________________ Figure 10.14 Care sheet for fillers.

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philosophy, it is important to document it and make certain that the patient understands so that any adverse events are not blamed on a lack of instruction. Fractional laser patients need to be instructed what products to apply to the skin and at what intervals. Intense pulsed light and chemical peel patients need to be told what sun protection to use and what products to apply. Each procedure performed by a cosmetic physician will have its own post-procedure requirements that can help to optimize the outcome attained. Laser hair reduction care sheets need to mention the fact that hairs may look more prominent as they emerge and that multiple treatments will help to minimize the residual hairs present. CONCLUSION

Forms are a necessary evil and it will save time and effort to find and use the best forms possible. My own goal is to convert all of my

forms into electronic versions that are on wireless clipboards in each room. The forms provided here are just starting points for discussion. Perhaps future versions of this text will have online forms for collaborative form postings. I have added several of my forms to this chapter and those of you who wish to use them are welcome to do so. For those of you with better forms, please consider this chapter an invitation to send them to me so that they might be included in future versions or perhaps posted in an online accompaniment for this book. These forms are provided for educational purposes only and are in no way to be construed as legal documents for use without review by an attorney or appropriate advisor in compliance with State and Federal regulations to determine the appropriateness of them (in sum or in part) to the practice of medicine such as it is.

11

Skin type classification systems: Cosmetic consideration and planning for procedures Wendy E. Roberts

Evaluation of skin type is part of the standard physical examination of the skin prior to procedure. This chapter will elucidate why skin type determination is essential before any cosmetic procedure is planned or performed The three objectives of this chapter are firstly, to provide you with the tools to identify your patient’s skin type; secondly, understand how to plan for the two most common untoward effects in procedure’s dyspigmentation and scarring; and lastly provide tips on intervention to prevent these adverse outcomes, There are skin components which clinically react more than others to surgery, light, laser, and many modalities discussed in this book. As the cosmetic surgeon, we must be able to predict the responses of the skin to these procedures prepare the skin for optimal outcomes and protect the skin from adverse side effects. This chapter focuses on considerations and recommendations for intervention and prevention. Chemical peels, ablative and non-ablative laser resurfacing, intense pulsed light (IPL), and hair removal laser are some of the more commonly performed cosmetic procedures that have a higher risk of complications. The most common overriding assumption based on past experience is that skin types I–II rarely develop postinflammatory hyperpigmentation and scarring whereas skin types IV–VI have a greater chance of developing these complications. In fact the skin of greatest risk for complication is the skin that has not been skin typed or classified. Beware of the blue-eyed blonde from Oklahoma. … she is half Cherokee Indian (native American) and you do not want to find that out after you administer a deep resurfacing procedure and face severe hyperpigmentation. It is well known that post-procedural hyperpigmentation and hypopigmentation is increased in skin types IV–VI. But does this account for the phenotypical type II patient who has skin that behaves like type IV. This is an area of unknowns, trial, and conjecture. CHANGING GLOBAL DEMOGRAPHICS

In a world population of 6.7 billion, 80% of the world’s population consists of individuals with pigmented skin (1). Mixed racial marriage and progeny has resulted in an increase of interracial genotypes and an emerging phenotype that may be hard to classify unless you specifically ask the question. Where are your birth grandparents from? It is not enough to simply elicit the race of an individual because skin type is much more complex. The 2000 U.S. Census Department records the U.S. population at 281.4 million people (2). There are six races which are catagorized as (i) White, (ii) Black or African American, (iii) American Indian and Alaska native, (iv) Asian, (v) native Hawaiian and other Pacific Islander, and (iv) some other race. The term “White” refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes Irish, German, Italian, Lebanese, near Easterner, and Arab. In addition 35.3 million Hispanic people (12.5%) of the population, which includes Mexico, Cuba, Central America, South America, Spain, and Caribbean, are considered White. Clearly these diverse groups under the umbrella of “White” have a rainbow of skin color and skin types. The term “Black” refers to 36.4 million people (12.9%) who indicate Black, African American, Nigerian or Haitian decent. It also includes Blacks who indicate Hispanic origin American Indian. The term “American Indian” is often used in this chapter to refer to the American Indian and Alaska native population totaling 4.1 million (1.5%). “Asian” refer to the 11.9 million people (4.2%) having origins in any of

the original peoples of the far East, Southeast Asia, or the Indian subcontinent (e.g., Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam). “Native Hawaiian and other Pacific Islander” total 874,000 (.3%) and are people with origins from Hawaii, Samoa, Guam, Fiji and of Polynesian, Micronesian, Melanesian ancestry (1). With the introduction of the “mixedrace” category, the 2000 census showed interracial marriage to be somewhat further widespread, accounting for 2,669,558 such marriages, or 4.9% of the total statistics; however, they do not take into account the mixing of ancestries within the same “race;” e.g., a marriage involving Indian and Japanese ancestries would not be classified as interracial due to the census regarding both as Asian. Likewise, since Hispanic is considered White, Hispanic marriages with non-Hispanic Whites are not registered as interracial because both are considered White (3). Interracial marriage results in new potential skin types (Table 11.1). This mixing of ethnicities leads to a significant evolution in the world demographics as we continue to diversify at unprecedented levels. We are developing new skin types at a rapid rate. The U.S. Census Bureau statistics in 2000 lists six race categories with 57 possible combinations (2). To classify a person by skin color is obsolete. Skin color is a complex subject. There are many factors which determine the appearance of skin color. Nordlund et al. state that a number of chemicals contribute to skin color. A major determinant of skin color is melanin, its quantity, type, distribution, and location of melanin within the epidermis and dermis. Other significant determinants are capillary blood flow, chromophores such as carotene or lycopene, and collagen within the dermis (4). To that end, we understand that we are dealing with biologically separate structures i.e., keratinocyte, melanocytes, collagen, ground substance, blood vessels and these all may have an individual or cumulative effect on skin color and also “the aesthetic” of the post-procedure skin appearance. Historically we have identified patient at risk for untoward procedures by their Fitzpatrick skin phototype. The Fitzpatrick skin type classification system has been the gold standard in communicating skin type (5). It is by definition, however, a “phototype” limited to describing the predilection for burning and tanning only. It does not address the predilection for hyperpigmentation and scarring. Hyperpigmentation and scarring are the two most common complications from skin injury and insult in cosmetic procedures in diverse skin types. They are followed by prolonged erythema, hypopigmentation, and keloid formation. While many skin type classifications have been proposed, the Roberts skin type classification system is unique in its focus on four elements, which include hyperpigmentation and scarring. Though not as user friendly as the Fitzpatrick scale because it encompasses more parameters, it is a tool to communicate important data needed for safe outcomes (6). ROBERTS SKIN TYPE CLASSIFICATION SYSTEM

To determine a patient’s profile using the Roberts skin type classification system the clinician should first refer to Tables 11.2 and 11.3. There are four elements and each element is assigned a numeric value called a feature. Clinical Patient Example 1 A 25-year-old blonde hazel eyed woman of Caucasion and Cuban decent would like to know if she is a good candidate for a skin resurfacing procedure. She, per history, burns minimally and tans well (FZ3).

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Table 11.1 Married Couples in the United States in 2006 (3) White wife

Black wife

Asian wife

White husband

50,224,000

117,000

530,000

Other wife 489,000

Black husband

286,000

3,965,000

34,000

45,000

Asian husband

174,000

6,000

2,493,000

13,000

Other husband

535,000

23,000

41,000

558,000

Table 11.2 Roberts Skin Type Classification System Four elements with the corresponding feature aka number 1. *Fitzpatrick (FZ) scale (measures skin phototypes) Fitzpatrick features (numbers) Type FZ I white skin, always burns, never tans Type FZ II white skin, always burns, minimal tan Type FZ III white skin, burns minimally, tans moderately and gradually Type FZ IV light brown skin, burns minimally, tans well Type FZ V brown skin, rarely burns, tans deeply Type FZ VI dark brown/black skin, never burns, tans deeply 2. Roberts hyperpigmentation (H) scale (measures propensity for pigmentation) Roberts features (numbers) Type H0 hypopigmentation Type H I minimal and transient (<1 year) Type H II minimal and permanent (>1 year) hyperpigmentation Type H III moderate and transient (<1 year) hyperpigmentation Type H IV moderate and permanent (>1 year) hyperpigmentation Type H V severe and transient (<1 year) Type H VI severe and permanent (>1 year) hyperpigmentation 3. Glogau (G) scale (describes photoaging) Glogau features (numbers) Type G I no wrinkles, early photoaging Type G II wrinkles in motion, early to moderate photoaging Type G III wrinkles at rest, advanced photoaging Type G IV only wrinkles, severe photoaging 4. Roberts scarring (S) scale (pre-existing scar morphology) Roberts scarring features (numbers) Type S 0 atrophy Type S I none Type S II macule Type S III plaque within scar boundaries Type S IV keloid Type S V keloidal nodule

She has, per medical history, moderate and transient hyperpigmentation. Post-inflammatory hyperpigmentation (PIH) is noted on skin examination of old acne sites (H3). She has no wrinkling, or early photo-aging (G1). She has two hypertrophic knee scars (S3) also seen on skin examination. Her Roberts skin type profile is FZ3, H3, G1, and S3. The clinical response included the following: Given her Roberts skin type profile, this individual is not a candidate for a deep resurfacing procedure. There is a risk for hyperpigmentation with her H3 score and also a risk for scarring with her scarring score of S3. Alternatively, you could proceed with IPL but at a very low fluence. She would also benefit from some superficial peeling with low percentage glycolic acid or even salicylic acid for her acne. She would need more treatments than a patient with a lower score so it would also be necessary to inform the patient about the pros and cons of staged treatments (Fig. 11.1).

Table 11.3 Using the Robert’s Skin Type Classification System To define patients’ individualized skin type profile using the Roberts skin type classification system, the clinician does the following three steps 1. Conducts a physical examination, performing a complete visual review of the skin 2. Gathers historical information, such as ancestry, history of pigmentation, and scarring. May need to perform and evaluate test site reactions 3. Assign a feature (number) to the four elements according to the guidelines for each following the serial format FZ number/H number/G number/S number Once a clinician establishes the skin type profile using the four-part Roberts system, the data can be used to outline a safe, efficacious treatment plan based on the patient’s likely response to the procedure. Patients may carry this designation from clinician to clinician, similar to a blood type, and use it as a means of communication, when necessary, to identify procedural or environmental risks.

Figure 11.1 Patient 1. Roberts type profile: FZ3, H3, G1, S3.

Clinical Patient Example 2 A 50-year-old Caucasian woman is referred for excision of a presternal nevus and on physical examination has an abdominal hypertrophic scar. She is given her Roberts skin type profile of FZ2, H1, G3, and S3. Given the patient’s Roberts skintype profile and the location of the nevus, she is at possible risk for a scar in a highly visible location. Despite her white complexion she has a propensity to scar, which is determined by history and skin examination. When this is discussed with the patient, she decides to keep the benign nevus versus risk an unsightly scar on her décolleté (Fig. 11.2). Clinical Patient Example 3 A 60-year-old Hispanic male has solar lentigines and is scheduled for chemical peeling. His Roberts profile is FIV, H2, G4, and SO. His Roberts skin type profile indicates a risk for hyperpigmentation but not scarring. He can be pre- and post-treated with topical hydroquinone and retinoids to prevent this possible occurrence (Fig. 11.3). PREVENTION OF DYSPIGMENTATION AND SCARRING IN AT RISK PATIENTS

The field of color blind devices, chemical peeling agents, and lasers continue to grow but it is still important to be completely knowledgeable

SKIN TYPE CLASSIFICATION SYSTEMS: COSMETIC CONSIDERATION AND PLANNING FOR PROCEDURES

Figure 11.2 Patient 2. Roberts type FZ2, H1, G3, S3.

Figure 11.3 Patient 3. Roberts type FIV, H2, G4, SO.

about the best device and technique to use for your at risk patient. A simple removal of a DPN may result in scarring and hyperpigmentation if not performed well (7). The entry into cosmetic surgery is wrought with possible complications if you are not knowledgeable about your patient’s skin type, your tool’s characteristics, and the best practices of the specific procedure. This is most important with laser and light-based modalities (8–11). DYSPIGMENTATION

We know that the melanocyte is more reactive to injury, UV, and heat in certain skin types (12). Interestingly, there is also evidence that melanin as well as being a photoprotectant may also act as a photosensitizer in certain skin types (13). Pigmentary changes in the skin are among the most common side effects of chemical, laser and light therapies. In laser therapies they are caused by the absorption of light

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by epidermal melanin. The darkening of the skin in or around the treatment site is the result of increased melanin production by epidermal and follicular melanocytes in response to thermal changes. The higher the epidermal melanin content, the more at risk the patient may be. Patients with darker skin types tend to be particularly at risk of unwanted pigmentary changes especially if the treatment area is on a part of the body that is likely to be exposed to sunlight, such as the face (14). Inflammatory dermatosis may result in dyspigmentation. In vitro studies have shown that cytokines and inflammatory mediators have effects on melanocytes (13). The following inflammatory mediators have been reported to increase melanogenesis: leukotriene B4, prostaglandins D2 and E2, endothelins, interleukins 1 and 6, and tumor necrosis factor-α. A decrease in melanogenesis has been reported to be caused by leukotriene C4. Particular cytokines and leukotrienes, such as leukotriene C4 and transforming growth factor-α, cause movement of melanocytes (15). In each individual, certain inflammatory mediators are released. Those specific mediators that are released will be responsible for either increasing melanogenic function of the melanocyte or decreasing melanogenic function of the melanocyte, thus leading to the postinflammatory hyperpigmentation or hypopigmentation. Primary cytokines may be acutely induced after wounding of the skin (16). Is the production of cytokines a common pathway for both inflammatory and injury-induced dyspigmentation? Does this cytokine cascade impact on the intensity of erythema? The role of erythema during a cosmetic procedure in darker skin types cannot be overemphasized. Transient erythema, a precursor to PIH is an adverse effect with most of the ablative and non-ablative laser procedures and can affect up to 100% of patients (17). It is caused by heat resulting from absorption of laser light by epidermal melanin (18). It is this author’s opinion based on the body of evidence that darker skin with high melanin content will have increased laser absorption more than lighter skin. This may result in intense and prolonged erythema, possibly coupled with increased cytokine production, which may increase the risk of dyspigmentation. The development of PIH may be inextricably linked with erythema. Unfortunately erythema in darker skin types may be hard to diagnose for the novice. Ratner et al. report that PIH occurs in 5% to 83% of patients who have undergone cutaneous laser resurfacing. Although seen in all skin types, the majority are skin types III-VI (19). The unwanted darkening or lightening of the skin in or around treated areas is normally a transient effect. PIH occurs between 2 weeks and 2 months after the procedure, it is preceded by erythema and resolution times may vary widely between 6 and 12 months without intervention. Often pigmentary changes may not become evident until months after treatment and can endure for several months and, in the case of hypopigmentation, may sometimes be permanent (20). Goh et al. in 2002 looked at PIH in a small series of Asian patients with skin types IV–VI post-laser resurfacing, moderate pigmentation developed in 15% at 6 weeks. At 3 months 33% had varying degree of pigmentation. At 6 months one (12%) patient had residual pigmentation. One patient developed mild minimal hypopigmentation at 6 months, which cleared at 12 months (21). PERIPROCEDURAL INTERVENTION TO AVOID ERYTHEMA AND DYSPIGMENTATION

Because of the difficulty to diagnose erythema in darker skin a deliberate strategy is warranted. A strategy to enhance laser safety in ethnic skin is listed in Table 11.4. The five S’s of laser safety in ethnic skin are as follows. 1. Skin type is identified by physical examination and medical/ family history. 2. Safe laser choices are made for the skin type, the procedure, and desired outcome.

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Table 11.4 Five S’s of Laser Safety in Ethnic Skin 1. Skin type identification by examination and history 2. Safe laser choices for the outcome based on selective photothermolysis 3. Skin cooling throughout the procedure with cool gel, chilled air, or ice (trim hairs that may further conduct heat) 4. Stage/spread out the visits for safe outcomes 5. Set low fluences and long pulse durations on first laser session which can be increased slowly on subsequent visits as tolerated. Avoid stacking of pulses which can lead to hypopigmentation

3. Skin cooling throughout the entire procedure beginning before the laser makes contact with the skin. Apply cool gliding gels when possible, with chilled air on the skin and periprocedural ice packs throughout the entire procedure. For high risk patients a 5 to 10 minute ice break halfway through the procedure is advisable. Note that cryogen sprays may create dyspigmentation specifically where the spray contacts the skin similar to liquid nitrogen. Check with your manufacturer and you can always perform a test site. 4. Staged procedures or spreading out the laser procedure over two or more sessions. 5. Set low fluences and long pulse durations on your first session and increase slowly as tolerated. Pre-treatment application of depigmenting agents and retinoids to prevent primarily hyperpigmentation has been well demonstrated in the chemical peeling literature (22). The skin is pre-conditioned with hydroquinone, kojic acid, Azelaic acid or depigmenting agent of choice for 2 to 4 weeks prior to the procedure. Often retinoids are mixed together with the depigmenting agent. Care must be taken to have the patient discontinue the pre-conditioning mixture 3 days prior to the procedure. The reason for pretreatment with hydroquinone is for suppressing melanocyte activity and the tretinoin adds for enhanced penetration of the peeling agent and a more predictable outcome. There have been some who disagree feeling that preconditioning the skin with tretinoin added time for erythema (23). The literature is even less supportive for preconditioning or treating the skin of darker skin types with hydroquinone and tretinoin before laser resurfacing. Alster et al. concluded that there was no significant difference in the incidence of post-CO2 laser resurfacing hyperpigmentation between subjects who received pretreatment with either topical glycolic acid cream or combination of tretinoin/hydroquinone creams and those who received no pretreatment regimen (24). Though there was a great study design the 100 patients, were all Fitzpatrick skin types I–III and may not be indicative of the same outcome as skin types IV– VI. Regarding the use of retinoids in the preconditioning treatment to speed wound healing Orringer et al. concluded there was no evidence of enhanced collagen formation, accelerated re-epithelialization, or quicker resolution of postoperative erythema with tretinoin pretreatment before laser resurfacing (17). A depigmenting agent should be used for 2 to 6 weeks postoperatively or as soon as re-epithelialization is complete (19). There is a high incidence of periprocedural dyspigmentation with cutaneous laser resurfacing in darker skin types and phenotypically light skinned individuals with darker skinned family members. These high risk patients need to be identified prior to the procedure. Outcomes and periprocedural management should be discussed. Broad spectrum sunscreen should be used generously but knowledgeably to avoid possible photocontact dermatitis especially with products containing octyl methoxycinnamate and para-amino benzoic acid (PABA) (25). Sun avoidance and sun protection by limiting sun exposure and using sun protective clothing especially wide brimmed hats is most effective for decreasing the UV stimulus of melanin synthesis.

Figure 11.4 White skin with a keloid.

SCARRING

The evaluation of scars has been very subjective with sparse clinical organization. Roberts introduced an easily communicated scarring scale which encompassed the spectrum of atrophic scarring to the furthest end of the scarring spectrum, keloid formation (6). As we center on the prevention and management of periprocedural scar formation, we must be alert to those who are predisposed to scarring. Both keloids and hypertrophic scars have an incidence 5 to 18 times higher in African Americans and 3 to 5 times higher in Asians compared with Caucasians. It is estimated that they affect both the African American and Hispanic populations between 4.5% and 16% (26). While we all are comfortable with the increased incidence of scarring in the Black population, there is an unfamiliarity with scarring in other global populations. In a large subject study that looked at keloidal scarring in Malaysian, Indian, and Chinese patients the incidence of keloidal scars was highest in the Chinese at 56%, followed by Indian at 22.9% and 17.15% in the Malaysian (27). Lim et al. reported keloids as the sixth most common self-reported diagnosis in the Arab American community (28). In my own practice, I have seen severe hypertrophic scars and keloids on patients with eastern European/Baltic ancestry (Fig. 11.4). It is clear with increasing globalization of skin types the safest way to determine the propensity of a patient to scar is through visual examination of the skin. When encountering scars on complete body skin examination inquire about the type of injury, the duration of the scar and any treatments that were used. These all provide insights on how to create a treatment plan. Remember, keloidal scar formation may run in families so take a quick family history of scarring. Scarring results from dermal trauma from surgery, tattoos, burns, piercings, or aggressive lasering, and some times they may arise spontaneously. PERIPROCEDURAL INTERVENTION OF SCARRING

Once you have determined that your patient is at high risk for scar development by virtue of the patient’s skin type, early recognition of the emerging scar is critical in its management. One of the simplest choices for initial medical therapy for impending scars is the use of corticosteroids. These are substances that are based on four fused carbon rings that derive from the cholesterol molecule. The glucocorticoids (e.g., triamcinolone, hydrocortisone, methylprednisone, and dexamethasone), in the corticosteroid family, have immunomodulatory, and anti-inflammatory properties. Inflammatory mediators such as cytokines, cellular adhesion molecules, and other enzymes are

SKIN TYPE CLASSIFICATION SYSTEMS: COSMETIC CONSIDERATION AND PLANNING FOR PROCEDURES decreased (29). The exact mechanism is unknown but it is thought to be related directly to the anti-inflammatory properties, reduction of collagen, glycosaminoglycans, and fibroblasts, along with overall lesion growth retardation. Used as a topical, both with and without occlusion, there is a wide range of clinical response. Be warned that prolonged topical corticosteroid use (greater than 3–5 days) has also been shown to retard wound healing (30,31). It is this diminished fibroblast effect that I find particularly useful in the initial woundcare for a patient who is at risk for scarring. For patients at risk of scarring I will often apply a low potency corticosteroid preparation to the wound immediately after the procedure for a one time application that will be removed during subsequent wound care on the following day. For emerging scars, I may select a higher potency corticosteroid with occlusion for 1 week. After 1 week we will evaluate for ongoing treatment with retinoids, imiquimod, or silicone gel. The body of the literature is vast for the treatment of hypertrohic scars and keloids with occluded topical and intralesional corticosteroids and devices. The reader is referred to other sources for the treatment of existing lesions (32,33). RETINOIDS

Pretreatment with retinoids before epidermal injury is thought to speed wound healing (34). One study found that 0.1% tretinoin pretreatment for 2 weeks before a 35% trichloroacetic acid peel significantly accelerated wound healing with 75% of the tretinoin-pretreated hemifaces completely healed as opposed to only 31% of the placebotreated hemiface (35). One study however showed that continued and daily tretinoin therapy was associated with delayed re-epithelialization and persistent dermal inflammation (36). To date the overall body of information would suggest that that anti-inflammatory immunoregulation properties of topical retinoids would be favorable to prevent post-procedure scarring, Topical retinoids should be applied in the evening only; avoid using if the patient cannot wear daily sun protection factor (SPF) due to lack of epithelium or contact sensitivity. SILICONE GEL/SHEETING

Two studies examined the prevention of hypertrophic scars after surgery. The first study by Ahn et al. (37) prospectively followed 19 scars resulting from elective surgery. They treated half of the scars with silicone gel. Nine scars became hypertrophic; the untreated parts of the scar were 25% to 75% larger than the treated parts, suggesting that silicone gel may be useful in preventing scars from developing. No statistical analysis of the treatment results was provided. In the second study Nissen et al. (38) evaluated 129 patients who had undergone breast-reduction surgery. Silicone products were used postoperatively to prevent hypertrophy of scars. No keloidal scars formed with use of the silicone. Neither of these studies had controls of the studies on silicone treatment had controls. At present, this treatment appears to be most useful for treating hypertrophic scars. Its role in prophylaxis is uncertain. There were no adverse effects from the silicone products. Silicone sheeting also helps minimize new hypertrophic scarring when applied about 2 weeks after wounding Gold et al. (39) showed that in patients at high risk—those who had a significant history of hypertrophic scar or keloid formation after a surgical procedure—29% developed hypertrophic scars after silicone gel sheeting whereas 44% developed hypertrophic scars after routine postoperative care. Most notably, in those patients identified as high risk who underwent scar revision there was a significant statistical difference (P = 0.035), suggesting that topical silicone sheets are effective in reducing the development of abnormal scars after surgical excision. Katz (40) supported these findings in an examination of 14 patients with 14 hypertrophic scars less than 3 months old. Nine patients had long-standing hypertrophic scars that were completely excised and treated with silicone sheeting

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soon after re-epithelialization. Five patients had a history of hypertrophic scar formation and were given silicone sheeting within 2 months of operation to prevent recurrence. In 11 of these cases (79%), hypertrophic scars did not recur after at least 6 months of follow-up. IMIQUIMOD

A randomized, double-blinded study of 15 patients investigated the use of 5% Imiquimod cream in the prevention of hypertrophic scarring after breast operation (41). Imiquimod or Petrolatum was gently rubbed over the scar for 5 minutes once every 3 to 4 days for a period of 8 weeks. At 24 weeks postsurgery, imiquimod treatment improved scar quality, especially color and elevation, when compared with the control groups. This treatment may be beneficial for surgical scars in at risk patients. VITAMIN E

Despite anecdotal reports there is little scientific evidence exists to support the beneficial claims of vitamin on any aspect of wound healing. Jenkins et al. in an attempt to reduce scarring after reconstructive surgery in patients with burn, used topical vitamin E in the postoperative period. No significant differences were found in range of motion, scar thickness, change in graft size, and overall cosmetic appearance between the vitamin E treatment group and base cream control group 1 year after surgery. In addition, 20% of patients reported local reactions to the vitamin E cream (42). ONION EXTRACT

There is no evidence that it is beneficial in improving or preventing hypertrophic scars. In the few studies conducted to date, more patients in the petrolatum control group reported greater improvements in wound healing when compared with those who used onion extract (43,44). SUMMARY

The body of knowledge regarding skin type awareness and classification systems continues to grow. Since a patient may not have the expected phenotype and actually look nothing like their skin type, It is most important to be alert to the changing demographic in your cosmetic practice, and be able to recognize the patient with the “at risk” skin type. The Roberts classification system is a tool for classifying your cosmetic and medical patients. This classification system is designed to stay relevant as new skin types continue to emerge with world diversity and population expansion. The five S’s of laser safety in Ethnic skin are a simple way to insure safe outcomes for your laser patient with global or ethnic skin. Most importantly the objectives of this chapter are to provide you with the tools to identify your patient’s skin type, understand how to plan for the patient at risk for dyspigmentation and scarring, and lastly provide tips on intervention to prevent these adverse outcomes, A cosmetic treatment plan based on skin type classification that includes pretreatment evaluation, preoperative preparation, fastidious procedural technique, and targeted post-procedural care will lead to optimal outcomes. REFERENCES

1. Halder RM, Noothi PK. Ethnic skin disorders overview J Am Acad of Dermatol 2003; 48(Suppl 6): S143–S148. 2. US Census Bureau. [Available from: http://www.census.gov/ population/www/cen2000/briefs/]. 3. Jones NA, Smith AS. [Available from: http://www.census.gov/ prod/2001pubs/c2kbr01-6.pdf]. 4. Nordlund JJ, Ortonne JP, Cestari T, Grimes P, Chan H. Confusions about color: Formulating a more precise lexicon for pigmentation, pigmentary disorders, and abnormalities of “chromatics”. J Am Acad of Dermatol 2006; 54(5 Suppl 2): S291–7.

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5. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I-VI. Arch Dermatol 1988; 124: 869–71. 6. Roberts WE. The Roberts skin type classification system. J Drugs Dermatol 2008; 7(5): 452–6. 7. Lupo MP. Dermatosis pupulosa nigra; treatment options. J Drugs Dermatol 2007; 6: 29–39. 8. Jacskson BA. Lasers in ethnic skin: a review. J Am Acad Dermatol 2003; 48(Suppl 6): S134–8. 9. Battle EF, Hobbs LM. Laser therapy on darker ethnic skin. Dermatol Clin 2003; 21(4): 713–23. 10. Drosnor M, Adatto M. Photo-epilation guidelines for care of the European Society for laser dermatology. J Cosmet Laser Ther 2005; 7: 33–8. 11. Lanigan SW. Incidence of side effects after laser hair removal. J Am Acad Dermatol 2003; 49: 882–6. 12. Taylor SC. Skin of color: biology, structure, function, and implications for dermatologic disease. J Amer Acad Dermatol 2002; 46(2) C: S41–62. 13. Hill HZ, Li W, Xin P, Mitchell DL. Melanin: a two-edged sword? Pigment Cell Res. 1997; 10: 158–61. 14. Alster TS, BryanH, Williams CM. Long pulsed Nd:YAG laserassisted hair removal in pigmented skin: a clinical and histological evaluation. Arch Dermatol 2001; 137: 885–9. 15. Morelli JG, Norris DA. Influence of inflammatory mediators and cytokines in human melanocyte function. J Invest Dermatol 1993; 100: 191S–195S. 16. Morelli JG, Kincannon J, Yohn JJ, Zekman T, Weston WL, Norris DA. Leukotriene C4 and TGF-alpha are stimulators of human melanocyte migration in vitro. J Invest Dermatol 1992; 98: 290–5. 17. Orringer JS, Voorhees JJ, Hamilton T, Hammerberg C, Kang S, Johnson TM, Karimipour DJ, Fisher G. Dermal matrix remodeling after nonablative laser therapy. J Am Acad Dermatol 2005; 53(5): 775–82. 18. Handley JM. Adverse events associated with nonablative cutaneous visible and infrared laser treatment. J Am Acad Dermatol 2006; 55(3): 482–9. 19. Ratner D, Tse Y, Marchell N, Goldman M, Fitzpatrick RE, Fader DJ. Cutaneous laser resurfacing. J Amer Acad Dermatol 1999; 41(3): 365–92. 20. Chan HH, Lleung RS, Ying SY, Lai CF, et al. A retrospective analysis of complications in the treatment of nevus of ota with other Q switched alexandrite and Q switched Nd;YAG lasers. Dermatol Surg 2000; 26; 100–6. 21. Goh Cl, Khoo L. Laser skin resurfacing treatment outcome of facial scars and wrinkles in Asians with skin types III/IV with the Unipulse CO2 laser system. Singapore Med J 2002; 43: 28–32. 22. Rubin MG. Basic Concepts in Skin peeling: Manual of Chemical Peels. Philadelphia, PA: Lippincott, 1995: 44–59. 23. Alt TH. The value of effective therapeutic and cosmetic dermabrasion. In: Epstein E, Epstein EJ, eds. Controversies in Dermatology. Philadelphia, PA: WB Saunders, 1984: 439–46. 24. West TB, Alster TS. Effect of pretreatment on the incidence of hyperpigmentation following cutaneous CO2 laser resurfacing. Dermatol Surg 1999; 25: 17–7. 25. Victor FC, Cohen DE, Soter NA. A 20 year analysis of previous and emerging allergens that elicit photoallergic contact dermatitis. J Am Acad Dermatol 2010; 62(4): 603–10.

26. Shaffer JJ, Taylor SC, Cook-Bolden F. Keloidal scars: a review with a critical look at therapeutic options. J Am Acad Dermatol 2002; 46(2(Suppl 2): S63–S97. 27. Alhady SM, Sivanantharajah K. Keloids in various races: a review of 175 cases. Plast Reconstr Surg 1969; 44: 564. 28. El-Essawi D, Musial JL, Hammad A, Lim HW 2. A survey of skin disease and skin related issues in Arab Americans. J Am Acad Dermatol 2007; 56(6); 933–8. 29. Norris DA. Mechanisms of action of topical therapies and the rationale for combination therapy. J Am Acad Dermatol 2005; 53(Suppl 1): S17–25. 30. Hengge UR, Ruzicka T, Scwartz RA, Cork MJ. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol 2006; 54(1): 1–15. 31. Jalali M, Bayat A. Current use of steroids in management of abnormal raised skin scars. Surgeon 2007; 5: 175–80. 32. Urioste SS, Arndt KA, Dover JS. Keloidal scars and hypertrophic scars: review and treatment strategies. Semin Cutan Med Surg 1999; 18: 159–71. 33. Zurada JM, Kriegal D, Davis IC. Topical treatments for hypertrophic scars. J Am Acad Dermatol 2006; 55(6): 1024–31. 34. Mandy S. Tretinoin in the preoperative and postoperative management of dermabrasion. J Am Acad Dermatol 1986; 15: 848. 35. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates healing after trichloracetic acid chemical peel. Arch Dermatol 1991; 127: 678. 36. Ruiz-Esparza J, Gomez JMB, DeLaTorre OLG, David L. Erythema after laser skin resurfacing. Dermatol Surg 1998; 24: 31–4. 37. Ahn S, Monafo WW, Mustoe TA. Topical silicone gel for the prevention and treatment of hypertrophic scar. Arch Surg 1991; 126: 499–504. 38. Nissen FB, Spauwen PHM, Robinson PH, Fidler V, Kon M. The use of silicone occlusive sheeting (Sil-k) and silicone occlusive gel (epiderm) in the prevention of hypertrophic scar formation. Plast Reconstr Surg 1998; 102: 1962–1972. 39. Gold M, Foster TD, Adair MA, Burlison K, Lewis T. Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting. Dermatol Surg 2001; 27: 641–4. 40. Katz B. Silicone gel sheeting in scar therapy. Cutis 1995; 56: 65–7. 41. Prado A, Andrades P, Benitez S, Umana M. Scar management after breast surgery: preliminary results of a prospective, randomized, and double-blind clinical study with aldara cream 5% (imiquimod). Plast Reconstr Surg 2005; 115: 966–72. 42. Jenkins M, Alexander JW, MacMillan BG, Waymack JP, Kopcha R. Failure of topical steroids and vitamin E to reduce postoperative scar formation following reconstructive surgery. J Burn Care Rehabil 1986; 7: 309–12. 43. Clarke L, Baker B, Trahan C, Myers L, Metzinger SE. A prospective double-blinded study of Mederma skin care vs placebo for post-traumatic scar reduction. Cosm Dermatol 1999; 12: 19–26. 44. Chung V, Kelley L, Marra D, Jiang SB. Onion extract gel versus petrolatum emollient on new surgical scars: prospective doubleblinded study. Dermatol Surg 2006; 32: 193–8.

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When non-invasive is not enough: Limits to individual treatments Roxanne J. Guy

INTRODUCTION

We have all heard the old adage “if all you have is a hammer, everything looks like a nail.” So is it also in medicine, and particularly, in surgery. For that reason, plastic surgeons tend to evaluate patients with an eye toward a surgical correction, while nonsurgeons will likely look for a nonsurgical approach. Presently, the new age of non-invasive and minimally invasive aesthetic medicine has allowed a paradigm shift in the thinking of the plastic surgeons and an empowerment of nonsurgeons in the realm of aesthetic medicine. In plastic surgery residency, we were taught to “climb the reconstructive ladder” on each case needing reconstructive surgery. That is, perform the most effective surgery, using the least invasive and complicated approach, which would provide a stable and long-lasting solution for the defect, as well as one which the patient could tolerate and would ultimately accept. Once one eliminates the lower rungs of the so-called “ladder” as not adequate, then one can climb up the steps, one-by-one, to the more sophisticated and complicated approaches and procedures. The sea change for plastic surgeons is to do the same thing for aesthetic deformities. Non-invasive and minimally invasive modalities have allowed us to fill-in the lower rungs of the “aesthetic ladder.” It is, however, also important to address the filling of the upper rungs of the ladder for the nonsurgeons. When does one refer to a plastic surgeon? When does one embark on a surgical approach, albeit minimally invasive? When and how does one know his or her own limits and, more importantly, ascertain the kind of correction expected by the patients for full satisfaction? What are the limits of the fillers, toxins, and non-ablative lasers? I have (gratefully) learned from my dermatology colleagues that some patients will never desire a surgical remedy for an aesthetic problem. Others may never be satisfied with anything but the full surgical endeavor along with every adjunctive treatment available. The devil is, as always, in the details. The details of the deformity, the patient’s history and health status, and that often nebulous entity we refer to as “patient expectations” (which can, of course, be moving targets). In addition, it is the physician’s duty to explain the relative risks, benefits, alternatives and limitations of the different treatments, as well as cost comparisons. If some patients spend several thousand dollars on fillers, neurotoxins and collagen tightening treatments over several months and still have significant skin laxity that continues to vex them a year later, we may not have made any friends nor done any favors for our practice. Likewise, patients who have not been adequately apprised of the process of surgical post-operative healing and wound maturation may be upset about “down” time, swelling, bruising, and scarring. So, the all-important selection of the right procedure for the right patient at the right time is the true “art” of being a physician, regardless on which side of the surgical fence one may reside. MECHANISMS AND CLASSIFICATIONS OF AGING

Skin clarity and beauty generally decrease with the natural aging process. This change is exacerbated by sun damage, smoking, and disease. Dyschromias, telangiectasias, actinic keratoses, dryness, dullness, sallowness, enlarged and clogged pores and comedones are signs of aging skin. Thanks to the advances in skin research, we have various topical agents to counter and postpone many of these issues, keeping skin looking fresh, healthy, and reflective longer. Tretinoin, topical acid products, and bleaching agents, along with

effective sunscreens can truly maintain skin beauty for much longer than previously. Along with the textural and surface changes of the skin with age, come wrinkles. A natural loss of collagen and hyaluronic acid occurs, as well as a decrease in elastin resilience. The dermis thins, collagen decreases, and the skin folds upon itself, resulting in wrinkles. There are many different wrinkle scales used in medicine to categorize the severity of wrinkles. One example is the Glogau classification (1) wherein type I describes no wrinkles, type II describes wrinkles in motion, type III describes wrinkles at rest, and type IV describes only wrinkles (Fig. 12.1). In addition to the skin changes, loss of soft tissue volume in the face contributes greatly to the aging process, as described by Lambros (2). Volume loss, along with the skin changes, causes the skin to appear lax and ptotic. In fact, not just skin aging, but changes in the integrity of all tissues affect the enveloping connective tissue, as well. Recent studies by Rohrich and Pessa of individual, distinct fat pads of the face reveal descent of these fat pads with age. Certain of the fat pads descend earlier than others (3). The loss of overall collagen and elastin resilience, along with a decrease in soft tissue volume and the descent of the individual fat pads of the face, cause drooping of the facial tissues and a conversion of the normally aesthetic oval shape of the face to one which is square and less aesthetic (Fig. 12.2). Many skin laxity scales also exist, such as the Dedo classification of neck aging (4), for example. In his classification, a class I neck is youthful and normal, class II and III show early abnormalities of skin and fat, class IV shows platysmal abnormalities, such as platysmal banding, and class V shows loss of the cervicomental angle with an obtuse neckline (Fig. 12.3). Aesthetic endeavors should attempt to rejuvenate the surface color and texture of the skin, and fill-in and/or relax lines. Various skin care regimens, fillers, and neurotoxins do these jobs quite well. Skin laxity and fat pad descent can be filled or camouflaged by volumizing fillers, such as poly-l-lactic acid, placed strategically. However, these modalities do have their limits. It is not difficult to agree, for example, that a Glogau class IV or a Dedo class V will not do very well with noninvasive modalities unless the patients’ expectations are relatively low. Using examples of these scales to advise patients of probable results or to query them of the results they expect, can be quite helpful in ascertaining which type of aesthetic modality should be used. LASER SKIN RESURFACING OR DEEP PEELING

Brighter, clearer skin will improve anyone’s appearance and enhance any aesthetic or cosmetic intervention. In fact, a soon-to-be-published series of over 100 poly-l-lactic acid facial injections showed a more dramatic and long-lasting effect of the volumizing filler if the patient used tretinoin routinely (5). Sometimes skin care alone may be enough improvement for the time being, and sets up the patient for a lifetime of good skin health habits. Thus, skin care is often the first intervention for a patient seeking rejuvenation and a relatively non-intimidating foray into the realm of aesthetic medicine. Once the surface texture, color, and clarity of the skin have been optimized and superficial rhytids improved, one may move to neurotoxins and fillers to relax and fill lines. The success of these modalities depends upon the patient expectations and the severity and location of

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1

2

3

4

Essentially no wrinkles Mild skin changes

Wrinkles on animation Moderate skin changes

Wrinkles at rest (static) Very visible skin changes

Only wrinkles Severe skin damage

Figure 12.1 Examples of the Glogau wrinkle scale.

Figure 12.2 Facial shape changes from square to oval after facelift surgery.

the deformities. Deeper lines and dyschromias not reversed with topical skin care can require a referral for more aggressive treatments. I find the skin rhytids that require more aggressive techniques than skin care products, toxins or fillers are the Glogau IV classification type of patients who have lines virtually all over the face. Facelifting alone is also not adequate (Fig. 12.4). In these instances, the referral for a deep ablative resurfacing laser procedure, such as a CO2 or erbium skin

resurfacing, or some variation of a deep facial peel, such as the Hetter modification of the phenol peel (6), would be more efficacious. It is quite common for patients to present with significantly deep vertical perioral rhytids that are not adequately improved with fillers, toxins, or light peels. These lines are also not amenable to “lifting” as are some forehead or cheek wrinkles and do not improve with facelifting alone. I find that early, aggressive ablative laser treatment of these

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WHEN NON-INVASIVE IS NOT ENOUGH: LIMITS TO INDIVIDUAL TREATMENTS

1

2

3

4

5

Normal, youthful neck

Mild laxity

Moderate laxity and submental fat

Laxity, fat and platysmal bands

Obtuse neck: loss of angle

Figure 12.3 Examples of the Dedo neck aging classification scale.

Figure 12.4 Patient with Glogau IV skin rhytids pre- and post-facelifting procedure. Treating the surface rhytids with deep resurfacing would have greatly augmented the surgical result.

lines is the best approach, before the lines become quite deep. Once the lines become very deep, adequate ablation with lasers or peels are more likely to cause irreversible complications, such as hypopigmentation or scarring of the perioral skin. It is advisable to treat before the patient gets to the severely deep stage (Fig. 12.5). BLEPHAROPLASTY

A blepharoplasty for excess, hanging upper eyelid skin, with or without medial upper eyelid fat pad protrusion is often one of the first

surgical procedures patients seek from a plastic surgeon for a younger looking appearance. Most complain that they are asked by friends or co-workers if they are tired when, in fact, they are not. They may be bothered that they can no longer apply eye shadow without it collecting in the lines of the redundant skin, or mascara without it smearing on the redundant skin sitting on the base of the lashes. A referral for an upper lid blepharoplasty can take years off of a persons’ appearance and, if needed later, can allow neurotoxins and fillers

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Figure 12.5 Patient pre- and post-treatment with deep (600 µm depth) erbium laser ablative perioral and chin resurfacing.

Figure 12.6 Patient pre- and post -treatment with upper eyelid blepharoplasty.

for brow and crow’s feet amelioration to become much more effective (Fig. 12.6). Lower eyelid complaints include excess hanging skin, which may be associated with lower eyelid fat pad descent (lower eyelid “bags”). Because of the fat protrusion, the light reflection on the face from overhead lighting throws the tear trough areas into shadows, adding to the “dark circled” look under the lower eyelids. Excess lower eyelid skin, combined with animation can produce rows of lower eyelid lines which curve down over the lateral cheek. Removal of some of the redundant skin and removal or repositioning of the fat pads can rejuvenate the lower eyelids immensely. For very lax and patulous lower eyelids, a lateral canthopexy and/or an orbicularis muscle sling may be needed. A few animation lines are likely to persist, which are then much more effectively treated with fillers or neurotoxin. The patient in this example opted for fillers to her tear troughs. She clearly has herniated orbital fat in all three lower lid fat compartments. While the filler did help to some extent, she was not satisfied with the result and her expectations were not met. A lower eyelid blepharoplasty would have been a better choice for her (Fig. 12.7).

The next patient example had long-lasting (1 year indication) filler material used throughout her cheeks, nasolabial folds, and jowl/chin area. She has very visible herniated lower eyelid fat bags on the pretreatment view, which are much improved on the middle view at 17 days post filler treatment. The third view is 1 year post filler treatment and the patient is about back to midline. A lower eyelid blephroplasty would have been a more permanent solution and would have cost about the same amount as the multiple vials of filler which she received 1 year previously (Fig. 12.8). BROW LIFTING

Neurotoxins have revolutionized the treatment of glabellar frown lines, transverse forehead lines, and mild lateral brow ptosis (the so-called “chemical brow lift”). Fillers in the lateral supra-brow area and as an adjunct with neurotoxins for filling toxin relaxed glabellar and transverse forehead lines can be amazingly effective. Many patients who use the products early and often enough can virtually prevent the static, deeply etched lines of the glabella. But aging of the brow often takes on many other forms than mild rhytids or brow ptosis.

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Figure 12.7 Patient treated with tear trough fillers. Lower lid blepharoplasty may have been a better choice.

Figure 12.8 Patient treated with calcium hydroxyapatite fillers, five vials, at pre-treatment, 17 days post treatment and at 1 year.

Referral for a brow lift is appropriate when one or more of the following exist. 1. Severe glabellar static rhytids even after neurotoxin and filler. 2. Heavy, hypertrophied corrugator muscles with medial brow ptosis, which ptosis is made worse with neurotoxin. 3. Transverse forehead rhytids which are essential and compensatory for raising very ptotic brows or heavy or hooded eyelids. 4. Severe lateral eyelid hooding with laxity and numerous “crow’s feet” lines. 5. Severe brow ptosis with brow position at or below the supraorbital rim in a woman (the aesthetic of male brows can tolerate this). Fillers above the brow and/or neurotoxin in the subbrow cannot correct the deformities adequately. Several methods of brow lifting can be performed. Endoscopic brow lifting is minimally invasive and effective. For severe ptosis with heavy

corrugators and etched transverse forehead lines, I prefer one of the open approaches with excision of the redundant skin and excision of the corrugator and procerus muscles from between the nerve branches under direct vision. The patient in the example (Fig. 12.9) presented with the complaint that people told her she always looked angry, though she did not often feel that way. The photos show severe brow ptosis, eyelid hooding, transverse forehead wrinkles, and static glabellar lines at rest. She was treated with a four-lid blepharoplasty and an open, coronal brow lift with resection of the corrugator and procerus muscles, and skin excision. FACE AND NECK LIFTING

Early signs of facial aging usually consist of deepening of the nasolabial folds, loss of facial volume, diminution of the ogee curve (7) of the cheek on oblique view, lateral oral commissure lines, marionette lines, fat pad descent with mild jowling, and the beginning of submental neck skin laxity.

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Further aging intensifies these deformities and adds concentric cheek rhytids, vertical perioral rhytids, lip thinning, more volume loss in the cheeks and areas around the chin, and platysmal banding of the neck. As stated previously, the face, on frontal view, takes on a square appearance, with loss of the ideal oval shape (Fig. 12.2). Early changes can be improved with volumizing fillers to the malar and submalar areas, the pre-jowls, nasolabial folds, tear troughs, and other areas. Neurotoxins can help efface the lips and soften the platysmal bands. Facelifting should be considered when the fillers no longer convert the face to an adequate oval or when the neck skin is simply too lax to be camouflaged. In addition, if the amount of filler needed to produce the desired result and the required re-injection schedule is

more expensive relative to the amount of correction and longevity of the facelifting procedure, one should certainly consider the latter (Fig. 12.8). Modern face and neck lifting generally includes lifting and repositioning of the ptotic deeper structures, plication of the neck platysmal bands with lower neck platysmal band interruption, attention to the vectors of pull which will enhance the shape of the face (and may be different on each side of the face), and often soft tissue volume augmentation at the time of surgery. The patient in Figures 12.10 and 12.11 is the same as in Figure 12.2, showing the oblique view and the lateral view, to illustrate the improvement in the jowls and neck, as well as the nasolabial folds, marionette lines, crow’s feet, eyelids, and lateral brows (Figs. 12.10 and 12.11).

Figure 12.9 Patient pre- and post-op from coronal brow lift and four-lid blepharoplasty.

Figure 12.10 Oblique views. Patient pre- and post-op from facelift, browlift, and four-lid blepharoplasty.

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COMBINATION PROCEDURES

The most gratifying results I have experienced have been from patients who do their best to address all the areas which are in need of intervention: skin care, dyschromias, rhytids, skin ptosis, and volume loss. The following is a patient who first had 6 weeks of intensive skin care. She later had a full face ablative laser resurfacing and a brow lift (Fig. 12.12).

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The next patient had a full facelift, a four-eyelid blepharoplasty and chemical peeling to her facial dyschromias, as well as a new hair color and style (Fig. 12.13). The patient in the next figure (Fig. 12.14) had a facelift, a browlift, and fat injections to her cheeks. The next examples are of a patient who underwent facelifting, rhinoplasty, chin implantation, and browlifting. She also began a regimen of

Figure 12.11 Lateral views. Patient pre- and post-op from facelift, browlift, and four-lid blepharoplasty.

Figure 12.12 Patient pre-treatment on left. Middle view—patient treated first with intensive skin care for 6 weeks. Right photo is of a patient treated with a brow lift and full face ablative laser resurfacing, using the Erbium laser.

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facial care, make-up, and a new wardrobe, for a full make-over. All the elements combine together to make the whole. My assessment is that she went from a rather matronly, middle-aged woman to a rather glamorous, mature woman (Figs. 12.15–12.17). INJECTABLES, TOXINS, LASER, AND SKIN CARE POST SURGERY

Relinquishing a patient to the plastic surgeon does not mean, however, that their toxin, filler and skin care days are over. Surgery does

not get rid of every line, nor should it. The best surgery is that which provides for a natural and non-operated look. I often use fillers post surgery to fill the cheeks, as the aging process continues to deplete the face of volume, sometimes more so after the surgery (Fig. 12.18). In addition, the glabellar musculature is quite resilient even to surgical intervention, and toxins are often still needed in the glabella, forehead or crow’s feet. This is particularly true after an endoscopic forehead lift or transconjunctival lower blepharoplasty.

Figure 12.13 Patient pre- and post-op from facelift, browlift, chemical peeling of facial dyschromias, and new hair coloring and styling.

Figure 12.14 Patient pre- and post-op from facelift, browlift, and fat injections to cheeks.

WHEN NON-INVASIVE IS NOT ENOUGH: LIMITS TO INDIVIDUAL TREATMENTS Good skin care should be an ongoing process, regardless of intervention. LONG-TERM RESULTS

Modern aesthetic medicine has been a boon to patients and physicians because it satisfies the desire for correction which is fast,

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without time off of life activities and with subtle, natural results. Never-the-less, the return on investment over time must be taken into account. As stated previously, some patients will never wish to entertain a surgical solution because of fear, risks, the possibility of not looking “natural”, and worry over what others may think and because of finances. The collective modern consciousness, however,

Figure 12.15 Frontal views. Patient pre- and post-facelift, browlift, rhinoplasty, chin implant, skin care regimen, make-up, hair, and wardrobe change.

Figure 12.16 Oblique views. Patient pre- and post-facelift, browlift, rhinoplasty, chin implant, skin care regimen, make-up, hair and wardrobe change.

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Figure 12.17 Lateral views. Patient pre- and post-facelift, browlift, rhinoplasty, chin implant, skin care regimen, make-up, hair and wardrobe change.

Figure 12.18 Previous facelift patient pre- and post-treatment with malar and submalar poly-l-lactic acid volumizing fillers; without and with make-up.

has adopted an attitude that early intervention with non-invasives will prevent the need for later surgical intervention. To some extent, that may be true, but aging never rests. Time is, indeed, the “subtle thief of youth.” To continue to espouse that the non-invasives will

prevent such eventualities is disingenuous. There will be patients who want a more dramatic and longer-lasting solution. Those are the patients who should be counseled and, perhaps, referred. The last few examples are of surgical patients who enjoyed correction

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Figure 12.19 Frontal views. Left photo shows a patient at age 51 years prior to surgery of facelift and perioral dermabrasion. Middle photo shows the same patient 12 years after the surgery. Right photo shows the same patient at age 63 years, 6 months after a secondary facelift, browlift, and lower lid blepharoplasty.

Figure 12.20 Oblique views. Left photo shows a patient at age 51 years prior to surgery of facelift and perioral dermabrasion. Middle photo shows the same patient 12 years after the surgery. Right photo shows the same patient at age 63 years, 6 months after a secondary facelift, browlift, and lower lid blepharoplasty.

for many years and returned for a repeat surgical correction many years later. I submit that both of these examples look in many ways better after each of their two procedures than they did before their first.

In both cases, however, skin care and adjunctive procedures were also continued. All this denotes the motivation of the individuals to do the best they can to look good throughout their different life stages (Figs. 12.19–24).

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Figure 12.21 Lateral views. Left photo shows a patient at age 51 years prior to surgery of facelift and perioral dermabrasion. Middle photo shows the same patient 12 years after the surgery. Right photo shows the same patient at age 63 years, 6 months after a secondary facelift, browlift, and lower lid blepharoplasty.

Figure 12.22 Frontal views. Left photo shows a patient at age 53 years prior to surgery of facelift, four-lid blepharoplasty, and perioral dermabrasion with removal of skin lesion above right brow. Middle photo shows the same patient 6 months post-op from the surgery. The right photo shows the same patient at age 63 years, 6 months following secondary facelift with full face laser resurfacing.

CONCLUSION

Cosmetic or aesthetic medicine has been a boon for modern, busy people wishing to look their best. Skin care, toxins, fillers, and nonablative laser treatments are excellent as first-line therapies, as well as

adjunctive therapies. The use of plastic surgery with non- or minimally invasive aesthetic medicine is certainly not mutually exclusive, but can work in synergy to produce beautiful results.

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Figure 12.23 Oblique views. Left photo shows a patient at age 53 years prior to surgery of facelift, four-lid blepharoplasty, and perioral dermabrasion with removal of skin lesion above right brow. Middle photo shows the same patient 6 months post-op from the surgery. The right photo shows the same patient at age 63 years, 6 months following secondary facelift with full face laser resurfacing.

Figure 12.24 Lateral views. Left photo shows a patient at age 53 years prior to surgery of facelift, four-lid blepharoplasty, and perioral dermabrasion with removal of skin lesion above right brow. Middle photo shows the same patient 6 months post-op from the surgery. The right photo shows the same patient at age 63 years, 6 months following secondary facelift with full face laser resurfacing. REFERENCES

1. Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg 1996; 15: 134–8. 2. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 2007; 120:1367–76. 3. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007; 119: 2219–27. 4. Dedo DD. “How I do it” – plastic surgery. Practical suggestions on facial plastic surgery. A preoperative classification of the

neck for cervicofacial rhytidectomy. Laryngoscope 1980; 90: 1894–6. 5. Casas LA, MD, FACS, personal communication. 6. Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg 2000; 105: 1061–83. 7. Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast Reconstr Surg 2000; 105: 252–66.

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Complications A to Z Vince Bertucci

INTRODUCTION

The promise of aesthetic enhancement with minimal down time and highly favorable safety profile has fuelled tremendous public interest in minimally invasive procedures over the last decade. Whereas surgery was the treatment of choice in the very recent past, today we have a rapidly growing number of options available to us in our quest for facial rejuvenation. Nothing less than a paradigm shift is occurring in the way we assess and treat the aging face. The aging face is the result of more than the effect of simple gravitational forces—it is a combination of cellular senescence, photodamage, environmental factors, loss and redistribution of soft tissue volume, and remodeling of the craniofacial skeleton, amongst other things. With new and evolving procedures and techniques, one inevitably sees adverse effects and complications, some predictable and others not. Many definitions for the term complication have been put forth over the years. For the purposes of this chapter, the term complication shall refer to any undesirable outcome. In this chapter, I will discuss complications associated with some common cosmetic procedures including botulinum toxin, injectable fillers, and lasers. By understanding mechanisms for these complications and by incorporating preventive measures into his or her practice, it is hoped that the practising physician will minimize or altogether avoid adverse outcomes. Finally, where available, management options for complications will be presented so as to help the physician minimize or avoid long-lasting adverse effects. BOTULINUM TOXIN COMPLICATIONS

Many physicians, industry observers, and the public credit botulinum toxin with starting the tremendous boom in minimally invasive aesthetic enhancement procedures. For many, Botox® (OnabotulinumtoxinA, Allergan Inc., Irvine, California, USA) is synonymous with minimally invasive cosmetic enhancement procedures. So pervasive is the awareness of botulinum toxin, sold under various brand names around the world, that many members of the public erroneously use the term to denote all cosmetic procedures and believe it to be the solution for all facial aging issues. The ability to precisely tailor muscular activity so as to create desirable facial expressions, shapes, and features has provided aesthetically minded physicians with an irreplaceable tool in their armamentarium as they seek to enhance and precisely sculpt facial features. However, botulinum toxin must be used precisely with a deep understanding of fluid facial anatomy and careful patient assessment so as to provide outstanding results and minimize adverse outcomes. Non-Specific Complications Complications associated with use of botulinum toxin are quite predictable. Some adverse effects are strictly related to injection with a needle. These include local discomfort, bleeding, ecchymosis, and edema. Use of ultra-fine, 31-gauge short needles helps to reduce discomfort and shearing that sometimes occurs with dull needles or needles that have burrs (1). Some individuals report development of headache after botulinum toxin treatment, although many actually report improvement of headaches, probably related to resultant muscular relaxation in headaches of muscular origin. Most headaches are mild and self-limited but, rarely, severe headache may occur requiring stronger analgesics or corticosteroids (2).

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Forehead Over-treatment with botulinum toxin results in reduced ability to contract the affected muscle, leading to varying effects, depending on the site of treatment. When the forehead is treated excessively, frontalis muscle activity is diminished, leading to reduced elevator activity, possibly leading to brow ptosis. Thus, although transverse forehead rhytides will be diminished, the overall effect may be to give an appearance of fatigue as the brows rest lower on the face, possibly giving rise to upper eyelid “hooding.” This complication may be avoided by reducing forehead dosing and/or injecting higher up on the forehead with advancing age and in those individuals who have evidence of preexisting brow ptosis. In some cases of prominent pre-existing brow ptosis, it may be best to avoid frontalis treatment altogether. Concomitant treatment of the brow depressors (i.e., the procerus, corrugators, depressor supercilii, and orbicularis oculi lateral to the temporal fusion line) helps to minimize this complication by diminishing the downward pull of the depressors, thus permitting further upward mobility of the brow (3). Another consideration when assessing and treating the forehead is the vertical distance between the brows and the frontal hairline. With shorter distances or “small” foreheads, one may wish to consider treating higher up on the forehead to reduce the risk of brow ptosis. Additionally, if the glabella is to be treated as well, one may wish to either reduce the dose or altogether avoid frontalis treatment in these individuals. Botulinum toxin diffusion from glabellar injections in individuals with a small forehead may be adequate to soften transverse forehead rhytides. It is certainly easier to add more botulinum toxin at a follow-up visit than to have to deal with brow ptosis because of over-treatment. Most individuals would agree that a few residual forehead wrinkles are preferable to brow ptosis, the impression of fatigue, and lack of expressivity that results from the lowered brow position. Glabella In treating the glabella, as with other areas, careful physical examination prior to botulinum toxin treatment is mandatory. Brow position, muscle bulk, redundant upper eyelid skin, facial symmetry, and the presence of static rhytides are some of the features that should be carefully assessed and documented. Gaining an understanding of the patient’s needs and wishes is particularly important for the glabella, perhaps especially so in individuals whose occupation may require glabellar movement to convey certain feelings or emotions. While some individuals wish to retain some ability to furrow the glabellar region, others do not wish to have any movement in this area. Eyelid ptosis, a complication that can be seen with botulinum toxin treatment of the glabellar region, is thought to be related to local toxin spread to the levator palpebrae muscle (4). By injecting 1 cm above the superior orbital rim, one may reduce the risk of ptosis while still adequately treating glabellar furrows. Eyelid ptosis is typically transient and mild but may occasionally last over one month. In addition to reassuring the patient that it spontaneously resolves, ptosis may be ameliorated with an alpha adrenergic agent such as apraclonidine hydrochloride ophthalmic solution 0.5% (Iopidine®, Alcon Laboratories Inc., Fort Worth, Texas, USA). Application of one to two drops three times per day as needed may achieve 1 to 2 mm elevation of the eyelid, secondary to contraction of Müller’s muscle. Rapid access to such an

COMPLICATIONS A TO Z alpha adrenergic agent is important for physicians using botulinum toxin in the glabellar region. Upward migration of botulinum toxin will diminish brow elevator activity, possibly leading to brow ptosis or mid-brow droop. Avoidance of inadvertent injection into the frontalis helps to avert this undesirable outcome. Another potential complication of botulinum toxin treatment of the glabella is the so-called quizzical brow or diabolical brow. This appearance consists of prominent lateral brow elevation without medial brow elevation, leading to the unusual appearance. This effect is easily prevented by using a small amount of botulinum toxin over the lateral forehead in those individuals that show prominent lateral brow elevation prior to treatment. Correction of the quizzical brow may be achieved by injecting a very small amount of botulinum toxin into the frontalis muscle that shows exaggerated elevation. Treatment of the glabellar complex may lead to splaying of the eyebrows. I advise my patients of this ahead of time as it may alter the way they care for their eyebrows. Lower dosing minimizes but may not completely prevent this effect. Crow’s Feet Treatment of the crow’s feet rhytides presents its own unique challenges. Once again, careful pre-treatment assessment and knowledge of anatomy will help to prevent unwanted outcomes. The zygomaticus major and minor muscles, which elevate the corners of the mouth, may be inadvertently weakened if one injects too low in the area of the zygomatic arch. This leads to an asymmetric smile because of the inability to raise the ipsilateral side of the mouth when smiling. The risk of this complication may be minimized by injecting superior to the zygomatic arch. When injecting the crow’s feet it is important to stay at least 1 cm lateral to the orbital rim so as to avoid diplopia (5). The latter may occur when botulinum toxin is injected too close to the orbital rim, allowing it to diffuse to the extraocular muscles, leading to reduced contractility of one or more of these muscles. The clinical outcome is reduced movement of the globe in certain directions and resultant diplopia. Static and dynamic assessment of the cheeks is critical when treating the crow’s feet. In those individuals who have large cheeks that prominently move upward with a smile, it is advisable to use lower dosing toward the inferior portion of the crow’s feet so as to avoid the appearance of a cheek “shelf ” when smiling. This undesirable appearance occurs when the cheek moves upward with a smile but movement is stopped at the lower end of the crow’s feet, giving the appearance of a bulge inferiorly with flattening superiorly. Infraorbital Region Treatment of the infraorbital region has many benefits in the appropriate patient, including reduced infraorbital rhytides and a more alert appearance with widened palpebral aperture, and more rounded lower eyelid shape. Complications related to botulinum toxin injection that may arise in this region include excessive scleral show, festooning, and excessive tearing. Excessive scleral show typically occurs in individuals who have a significant pre-existing portion of the ocular globe visible, or, what some may describe as “large eyes.” It may be best to avoid treating the infraorbital area in these individuals. Individuals with skin laxity in the infraorbital area, or who have poor elastic recoil as demonstrated by the snap test, tend to develop festoons after botulinum toxin treatment. Festoons refer to soft tissue bulging that develops in the infraorbital region after injection. It is thought to be secondary to inhibition of the lymphatic muscle pump after botulinum toxin treatment. It tends to be most prominent in the morning and often improves with gravitational effects as the day progresses. Gentle massage may ameliorate this complication which may last for days to weeks.

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Excessive lacrimation is a rare complication seen when too much botulinum toxin is injected in the infraorbital area, leading to poor apposition of the lower eyelid against the ocular globe, thus leading to impaired ability of the lacrimal duct to collect tears. The end result is that tears drain onto the cheek. The best treatment for this is prevention. Lower Face Lower face treatment with botulinum toxin is considered by many to be an advanced technique that is best reserved for experienced injectors. Some of the areas that may be treated include the perioral region, depressor anguli oris (DAO), mentalis, and masseter. Treatment of each of these areas can lead to predictable benefits, and, in some cases, predictable complications. When treating the perioral area, the orbicularis oris muscle is weakened, leading to reduced perioral rhytides. Excessive treatment may reduce one’s ability to purse the lips firmly, resulting in an inability to properly enunciate the letters “B” and “P”. The resultant weakness may also impair one’s ability to whistle, drink out of a straw, or play a musical instrument, amongst other things. When the DAO is injected too medially and superiorly or when the mentalis muscle is injected too high, the depressor labii muscle may be inadvertently weakened, leading to an inability to depress the lower lip and an asymmetric elevation of the ipsilateral lower lip. The latter may be especially evident with smiling (Fig. 13.1). The risk of this complication may be minimized by injecting the DAO at the intersection of the jawline and a line formed by the caudal continuation of the nasolabial fold. Low injection into the mentalis, staying away from the mental crease, will similarly reduce risks associated with treatment of this muscle. If the masseter muscles are unevenly injected in individuals with hypertrophy, one may see fascicles of muscle contraction, giving the appearance of a focal bulge. Careful distribution of botulinum toxin at the time of treatment will minimize this risk. If this occurs, a small amount of botulinum toxin injected into the area of fasciculation will correct the problem. When the masseters are injected too far medially, inadvertent weakening of the risorius muscle may occur, with resultant reduced smile

Figure 13.1 Following injection of 5 units of Botox® (OnabotulinumtoxinA) into each depressor anguli oris (DAO) muscle, lower lip asymmetry develops. This complication occurs when product migrates superiorly to the right depressor labii muscle, leading to inability to move the ipsilateral lower lip inferiorly.

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excursion on the ipsilateral side. Avoiding medial injections reduces this risk. Neck Treatment of the neck with botulinum toxin is helpful in reducing platysmal bands and horizontal neck lines. Additionally, the jawline contour may be improved with the ‘Nefertiti lift’ technique (6). The dose-related risks associated with treatment of the neck region include dysphagia and neck weakness. The former is secondary to over-treatment and diffusion of botulinum toxin into the muscles of deglutition. Dysphagia may rarely be so severe as to require nasogastric tube feeding. Neck weakness is also dose dependent and is best demonstrated by asking the patient to lift the head while in the supine position. For platysmal bands, precise injection into the bands themselves so as to avoid inadvertent injection of deeper muscles, and avoidance of aggressive dosing will help to prevent these complications. Transverse neck lines are best injected superficially, avoiding the subcutaneous plane so as to prevent weakening of the muscles of deglutition (7). Although there is no definitive agreement on maximal dosing for the neck, precise injection of up to approximately 60 units OnabotulinumtoxinA may be safe. Other Safety Considerations Distant spread of botulinum toxin beyond the site of injection has been raised as a concern and prompted the U.S. Food and Drug Administration to modify the labeling of botulinum toxins. It is important to note that “… no definitive serious adverse event reports of distant spread of toxin effect associated with dermatologic use of Botox at the labeled dose of 20 Units (for glabellar lines) or 100 Units (for severe primary axillary hyperhidrosis) have been identified” (8). The majority of reported problems occurred in children with cerebral palsy being treated for muscular spasticity. The majority of adult cases occurred when treating spasticity or cervical dystonia. In light of the above, cosmetic use of botulinum toxin in adults does not appear to be a concern. However, patients and caregivers should be aware of potential adverse events that may occur due to distant spread of botulinum toxin. These effects include unexpected loss of strength or muscle weakness, dysphonia, dysarthria, bladder incontinence, difficulty breathing, dysphagia, diplopia, and eyelid ptosis. These adverse events have been reported as early as several hours and as late as several weeks after treatment. Patients should be advised to seek immediate medical attention if they develop any of these symptoms. In order to avoid accidentally over-treating with botulinum toxin, it is important for physicians to recognize that botulinum toxin doses are not interchangeable from one botulinum toxin formulation to another. Thus, for example, the dosing and injection technique for OnabotulinumtoxinA is unique and distinct from that for AbobotulinumtoxinA. INJECTABLE FILLER COMPLICATIONS

The injectable filler market has exploded in recent years in concert with the dramatic expansion in the number of good treatment options. An evolving appreciation of the importance that facial shape and volume play in facial aging has allowed the experienced injector to use fillers to restore aesthetically pleasing facial contours. An exhaustive discussion of all fillers is beyond the scope of this chapter. I will limit my discussion to complications associated with hyaluronic acid (HA) fillers (e.g., Restylane®, Medicis Pharmaceutical Corp., Scottsdale, Arizona, USA; Juvéderm®, Allergan Inc., Irvine, California, USA), collagen-based fillers (e.g., Zyderm®/Zyplast®, Allergan Inc., Irvine, California, USA; CosmoDerm®/CosmoPlast®, Allergan Inc., Irvine, California, USA; Evolence®/Evolence Breeze®, Johnson & Johnson, Morris Plains, New Jesrsey, USA), silicone, calcium

hydroxylapatite (CaHA) (Radiesse®, Merz Aesthetics Inc., San Mateo, California, USA), poly-L-lactic acid (PLLA) (Sculptra®, Sanofi–Aventis, Bridgewater, New Jersey, USA), and polymethylmethacrylate (ArteFill®, Suneva Medical Inc., San Diego, California, USA). A pre-requisite for physicians using fillers is what might be termed an “aesthetic eye.” While this intangible is difficult to quantify, an appreciation of the features that together make for an aesthetically pleasing face is key to successful outcomes. Although there is no universally accepted definition of beauty, it seems that certain features of beauty cross racial lines include, amongst other things, prominent zygomatic arches with high, full, convex cheeks as well as convexities of the temples, lips and jawline. Over the years, a number of attempts have been made to analyze and quantify facial attractiveness (9). By recognizing these and other features of facial attractiveness, physicians will be better able to achieve aesthetically desirable results while minimizing the likelihood of creating an unsightly appearance. Physicians, especially novices, may wish to consider using reversible, short-lasting HA-based fillers prior to proceeding with long-lasting fillers in challenging areas such as the lips and infraorbital region and in first-time patients who are unsure of their desired outcome. This will allow the patient to become comfortable with the appearance prior to committing to a longer term solution. HA fillers are perhaps the most widely used fillers in the world and offer numerous advantages: Wide availability, ease of use, low risk of inflammatory reaction, and reversibility. Although some believe HA fillers to be the gold standard and safest of all fillers, adverse events may occur even with this group of products. Non-Specific Complications As with botulinum toxin, some of the complications seen with injectable fillers are related to the act of injection itself, rather than to the specific filler being used. These non-specific complications include pain, tenderness, redness, bleeding, and ecchymosis. Knowledge of anatomy and careful attention to detail will help to minimize the risk of bleeding and ecchymosis. Sometimes, gentle stretching of the skin allows better visualization of vessels, reducing the risk of vessel perforation and ecchymosis. A history of recent use of acetylsalicylic acid, non-steroidal anti-inflammatory drugs and some vitamin supplements may increase the risk of bleeding (10). Of course, it is not possible to completely predict bleeding and ecchymosis no matter how careful the technique is. Injection scheduling should thus take these risks into consideration. Pain may be minimized with local anaesthetic, either topically, as a nerve block or injected locally. Recently, some injectable fillers premixed with lidocaine have become available. In the absence of premixed formulations containing lidocaine, some physicians manually add a small amount of local anaesthetic such as lidocaine into their filler of choice. Edema and swelling may occur with all injectable fillers but may vary in timing and severity with the particular agent used. For example, collagen-based fillers tend to cause less edema than HA fillers. With the latter, edema may be delayed as the hygroscopic nature of HA results in binding of more water with time. Patient factors such as dermographism may also influence the amount of swelling. Asking about a tendency to swell may be help to identify some individuals who are prone to more pronounced swelling. Glogau and Kane found that local adverse events in patients treated with non-animal stabilized hyaluronic acid were associated with rapid flow rates, higher volumes, rapid injection, and fanlike injection technique, while injection depth, single injection correction, and intrinsic properties of the non-animal stabilized hyaluronic acid did not have a significant effect on adverse events (11).

COMPLICATIONS A TO Z

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Appropriate choice of the injection technique for a given filler can improve outcomes and reduce the risk of complications. Examples of accepted techniques include the microdroplet technique for silicone, linear threading for polymethylmethacrylate, and depot for Perlane® (Medicis Pharmaceutical Corp., Scottsdale, Arizona, USA) and Juvéderm Ultra Plus® (Allergan Inc., Irvine, California, USA).

common bacteria, mycobacteria, or other organisms. Wound culture may help to guide therapy. The discussion of biofilms below adds an interesting dimension to our understanding of infections. A previous history of Herpes simplex virus infection warrants the use of antiviral prophylaxis. Where an abscess is suspected, it must be drained. Sterile abscesses may also rarely occur and require drainage.

Injector-Dependent Adverse Outcomes Some injector-dependent adverse outcomes include asymmetry, overcorrection, undercorrection, and unsightly facial shape, amongst others. Each of these complications may be avoided by careful assessment before and after treatment. Local edema may make it difficult to accurately assess the degree of correction once the first few injections are carried out. Thus, it is important to note pre-existing asymmetry and to pay close attention to the amount of product injected into each area. A follow-up visit and touch-up injection may be necessary where undercorrection is noted. Overcorrection may lead to unattractive facial contours. This can often be improved by gentle manual moulding and/or massaging of the treated area. Care must be exercised so as to avoid creation of a concavity with massage. Where there is a very focal area of overcorrection in a delicate area such as the tear trough, it may be treated with gentle manipulation using a cotton-tipped applicator. A gentle rolling movement of the cotton tip often suffices. When overcorrection doesn’t respond to gentle manipulation, use of hyaluronidase is a suitable treatment alternative (12). This technique is more completely described below in the discussion of ischemia and necrosis with HA fillers.

Inflammatory Reactions Inflammatory reactions are uncommon and range from transient erythematous papules lasting a few days to prolonged granulomatous reactions lasting from months to years. Allergic and hypersensitivity reactions are rare. Findings may include focal erythema, edema, pruritus, induration and rarely dyspnea, and generalized angioedema. Some collagen-containing fillers such as Zyderm® and Zyplast® require skin prick testing prior to treatment to detect allergy. Treatment of hypersensitivity reactions includes oral antihistamines and systemic steroids. True granulomatous reactions are uncommon, especially with shorter lasting temporary fillers such as HAs. However, with the proliferation of longer lasting fillers, such reactions are more commonly seen. Granulomatous reactions typically occur months to years after injection, and are characterized by tenderness, swelling, and possibly suppuration (16). Granulomas with permanent agents may be more resistant to treatment. The concept of biofilms as a cause of chronic granulomas has gained increasing attention in recent years (17). A biofilm can be defined as a structured community of bacterial cells enclosed in a self-produced polymeric matrix and adherent to an inert or living surface (18). The biofilm protects organisms from the host’s immune response, promoting antibiotic resistance, and prolonged survival. Given the role of bacteria in the development of biofilms and possibly in granulomatous reactions, prevention is of utmost importance. Use of a simple alcohol swab may not be sufficient to prevent biofilms. As more information becomes available, we may find that a more stringent antiseptic preparation is in order, especially when using permanent or long-lasting fillers. Once a granuloma forms, management consists of oral antibiotics such as minocycline or clarithromycin, often for weeks or longer

Nodules Nodules may occur with any injectable filler product. Unlike true granulomas, which represent an inflammatory response to the foreign substance, nodules typically represent focal product accumulation or focal excessive fibrosis as a result of stimulation by the product. Focal product accumulation may sometimes be related to too much product injection into a focal area, injection into areas of dynamic muscle movement, inadequate volume when reconstituting the filler (such as with PLLA), and failure to massage after treatment. Massage is especially important with PLLA (13) and Evolence. Where nodules represent focal product “clumping,” they may sometimes be dispersed with sterile saline in the case of PLLA and manually massaged or extracted with a needle or #11 blade in the case of HA fillers. Sometimes, intralesional steroids may be effective, and in rare cases, surgical excision may be necessary, especially in the case of permanent products (Fig. 13.2). Tyndall Effect The Tyndall effect refers to a bluish discoloration that occurs when fillers are injected too superficially. This complication may be avoided by not injecting into the epidermis or superficial dermis. When this effect is seen with HA fillers, resolution may be achieved by using either a #11 blade (14) or a needle (25 or 27 gauge) to manually drain the product, or by injection of hyaluronidase into the affected area. Hirsch and colleagues also described cases where the Q-switched 1064 nm ND-YAG laser was effective in treating HA-induced Tyndall effect (15). For non-HA products, treatment is difficult and there is no simple solution, other than to wait for spontaneous resolution with temporary fillers or, in the case of a long-lasting product, excise the problem area. Infection Infection is only rarely seen with injectable fillers. Early infections are often secondary to Staphylococcus aureus and sometimes Streptococcus species. Treatment of these organisms is discussed in the section on laser complications. Delayed onset infections may be due to less

Figure 13.2 Polymethylmethacrylate (Artecoll) nodules are visible 3 years after superficial injection.

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depending on the response to therapy (19). Incision and drainage with culture should be considered for fluctuant lesions. For late onset inflammatory lesions, biopsy, and culture should be done. Corticosteroids (typically intralesional, but possibly systemic depending on the severity of the case) may be considered but are best used in conjunction with antibiotics to prevent biofilm activation. Surgical excision may be considered if other measures are ineffective, especially with permanent fillers. Product Migration Product migration refers to filler movement beyond the site of original placement. This may occur as a result of poor injection technique or placement along a plane where muscle movement allows the product to shift (e.g., perioral and infraorbital areas). Use of the serial microdroplet technique with silicone will minimize the risk of migration. Temporary products such as HA fillers may be manually repositioned in some cases or drained manually as described above. Correction of migration with permanent implants such as silicone may require disfiguring surgical resection with complicated reconstructions (20). Vascular Compromise One of the most worrisome, but luckily very rare, complications associated with fillers is vascular compromise, leading to ischemia and necrosis or blindness. With its limited vascular supply, the glabella is the most commonly reported site of necrosis but this complication may occur in other regions such as the nasolabial fold, nose, lips, and along the

(A)

labio-mental line (Fig. 13.3 A–E). Possible etiologic factors include intravascular injection, external vascular compression, and vasospasm. Blindness is thought to occur secondarily to intravascular injection into the supratrochlear artery which connects to the ophthalmic artery (21). Clinically, ischemia manifests as a sometimes painful, violaceousblue–gray discoloration with slow refill, typically in the distribution of the affected vessel. A reticulate pattern may also be seen. This must be distinguished from ecchymosis, which appears as non-blanchable discoloration. Persistent ischemic changes may be followed by erosion and ulceration. Although ischemia may manifest shortly after injection, a delayed onset of one to two days may sometimes occur. The risk of vascular compromise may be reduced by drawing back the plunger prior to injecting so as to insure that the needle is not intravascular. Because of the viscosity of many filler products, this is not always helpful. Injecting slowly, carefully avoiding known vessels and not overfilling will help to minimize the risk of necrosis. Many physicians prefer to use a HA with smaller particle size in the glabellar region to minimize the risk of ischemia. Examples include Restylane® and Juvéderm Ultra®. The author finds it helpful to pull the skin up and away from the underlying structures when injecting the glabellar and marionette regions. By doing so, one creates a potential space where product may be slowly injected, away from underlying vessels. Prompt diagnosis and treatment of ischemia is mandatory so as to maximize the chances of reperfusion and reduce the risks of permanent sequelae such as scarring or deformity. Management algorithms have been detailed elsewhere (22–24) and consist of application of

(B)

(D)

(C)

(E)

Figure 13.3 Ischemia after hyaluronic acid filler injections into lips. (A) Pre-treatment. (B) Immediately after lip injection, a reticulate violaceous-gray discoloration is noted over the left upper lip region, associated with pain. Treatment with topical nitroglycerin paste, warm compresses, hyaluronidase injections, and massage was instituted immediately. (C) At 9 hours, the ischemic pattern appears slightly worse. (D) At 4 days, the skin color has significantly improved. (E) At 6 weeks, the ischemic changes have completely resolved without any visible sequelae.

COMPLICATIONS A TO Z nitroglycerin paste, warm compresses (to promote vasodilation), gentle local massage to dissipate the filler and, for HA fillers, injection of hyaluronidase. The latter, which is available both commercially and as a compounded product, is used to dissolve HA. Hypersensitivity reactions to hyaluronidase have been rarely reported, prompting some physicians to do skin prick testing prior to use so as to prevent this serious adverse effect. Should ulceration develop, local wound care is critical so as to minimize scarring. Finally, once healing is complete, one may consider various modalities for residual scarring, including, but not limited to, ablative and non-ablative laser resurfacing, pulseddye laser, and dermabrasion. Neovascularization Neovascularization refers to the development of telangiectasia at the site of filler injections. Amongst other sites, potential areas of involvement include the superior nasolabial fold. This rare event may be treated with intense pulsed light, pulsed dye laser and 532 or 1064 nm lasers (25). LASER COMPLICATIONS

The array of lasers and light sources available has rapidly multiplied over the last 15 to 20 years. Today we have numerous technologies to treat a plethora of concerns including vascular lesions, scars, tattoos, pigmented lesions, rhytides, skin laxity, and more. A discussion of laser complications is a topic, which could easily fill a chapter of its own, but, because of space constraints, I shall limit my discussion to an overview of laser and light complications using examples of how these complications may occur, rather than describing complications associated with specific laser and light devices. In many cases, an understanding of laser principles and mechanism of action can help to predict potential complications. Lasers generally work by delivering very high energy within a very short period of time to the targeted tissue while sparing surrounding structures. Anderson and Parrish’s theory of selective photothermolysis (26) has prompted the development of laser systems that target a specific chromophore, such as melanin, while sparing surrounding tissue. Lasers that adhere to this principal are generally safe and effective because of their ability to minimize the amount of thermal damage to adjacent tissue. Nonetheless, complications may occur despite attempts to improve laser and light safety. As with all cosmetic procedures, it is imperative that the physician acquire a thorough understanding of laser physics, laser-tissue interactions, and laser safety issues prior to practicing laser surgery. Because each laser system has unique features and parameters, hands-on training is highly valuable. Laser and light complications often arise due to a combination of device issues and operator inexperience or error. Careful management of complications can often prevent permanent adverse effects. Safe operation of laser and light devices is the cornerstone of patient and operator safety. Protective equipment such as goggles specific to the laser device must be worn by the laser operator. Eye shields are mandatory for the patient to reduce the risk of ocular damage and blindness. Because laser plume is known to transmit infectious particles such as the human papilloma virus, appropriate masks, and a smoke evacuator should be used where appropriate. If tissue splatter is a concern, gloves and protective gowns should be worn. Reflective surfaces such as mirrors should be eliminated or covered during laser procedures. Windows should be covered so as to prevent laser light from inadvertently injuring someone outside the room. Appropriate signage outside the laser room must warn individuals to refrain from entering the room. Edema and erythema are common with most laser and light systems. The duration and intensity varies with the device used, being

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longest for ablative resurfacing lasers (up to 12 months), less for nonablative fractional lasers and even less for most hair removal devices. In a study of 20 patients, Alster and Wanitphakdeedecha reported that post-fractional laser erythema may be reduced with light-emitting diode photomodulation immediately after fractional laser skin resurfacing (27). Blistering and crusting may occur with most laser and light systems but may be prevented in many cases with appropriate choice of settings, epidermal cooling and post-operative care. Pigmentary changes secondary to laser and light treatment include both hyper- and hypopigmentation (Fig. 13.4). Although typically temporary, these complications may occasionally be permanent. Hyperpigmentation tends to occur more commonly in individuals with Fitzpatrick skin types III–VI. Prophylactic use of skin lightening agents such as those containing hydroquinone or tretinoin should be considered 1 to 2 weeks preoperatively in these individuals. Avoiding a tan before and after treatment will reduce the risk of hyperpigmentation. Additionally, fluence settings should generally be adjusted downward in darker-skinned individuals. Use of cryogen spray may help to prevent hyperpigmentation but, used aggressively, may also cause hyperpigmentation. If significant inflammation is noted after laser or light treatment, immediate use of a potent topical corticosteroid may help to reduce the likelihood of hyperpigmentation. Broad spectrum sunscreens and reduced sun exposure will also help to minimize post-inflammatory hyperpigmentation. Topical bleaching agents are the mainstay of therapy for hyperpigmentation. Hypopigmentation may be true hypopigmentation, which is generally due to over-aggressive therapy with ablative resurfacing lasers, devices that target pigment (e.g., Nd: YAG, Q-switched ruby, and alexandrite lasers) and intense pulsed light devices. Alternatively, one may see relative or pseudohypopigmentation when the treated skin reverts to its whiter, pre-photodamaged state compared to the surrounding untreated skin which retains its blotchy hyperpigmentation. Individuals with a tan or darker skin color are more susceptible to this preventable complication. Certain anatomic locations with less adipose tissue such as the shins and chest tend to be more prone to hypopigmentation, possibly related to the fact that the skin is thinner with less surrounding tissue available to dissipate the thermal energy. Adjustment of settings to minimize this risk is critical.

Figure 13.4 IPL-induced hyper- and hypopigmentation 6 months after a single back treatment.

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In the days when ablative CO2 laser resurfacing was common, delayed and often permanent hypopigmentation occurred not infrequently, eventually leading to a fall from favor for this technology. This prompted development of some of today’s lasers, which minimize this risk by utilizing longer pulse durations to spread the energy delivery over a longer time (e.g., long-pulsed Nd:YAG lasers), thus reducing melanocyte damage. Alternatively, fractional technology may be employed to spare tissue (e.g., fractional CO2 lasers), thus providing a repository of intact melanocytes that may be used to populate adjacent areas of damaged melanocytes. Hypopigmentation is difficult to treat. Luckily, in many cases it spontaneously resolves within a few months. If it persists, one may consider “feathering” the pigmentation with the surrounding skin, thus minimizing the contrast between treated and untreated skin. This can be done by gently treating the adjacent skin that is not hypopigmented. Purpura or bruising is an expected effect of some devices such as pulsed dye lasers when they are used aggressively to treat vascular lesions such as port wine stains. A discussion prior to treatment will allow the patient to select an appropriate time for treatment. Purpura duration varies from a few days to approximately two weeks. Newer lasers with longer pulse durations allow the operator to minimize the risk of purpura by spreading out the energy over a longer period of time. Although it occurs less commonly, other devices such as those utilizing intense pulsed light may also cause bruising, especially in individuals with prominent erythema, flushing or vasculature in the area of treatment. Paradoxical hypertrichosis has been reported in individuals undergoing laser hair removal. Although the mechanism is not fully understood, it may be may be that suboptimal fluences stimulate dormant hair follicles (28). While respecting skin type, use of optimal fluence settings may help to prevent and treat this problem. Infection may occur with any treatment that affects skin barrier integrity, but is more common with ablative laser resurfacing because of the significant interruption of the skin barrier, providing a portal of entry for organisms. Signs of infection include delayed healing, focal erythema, honey-colored crusting, pustules, and pain. Although many would agree that prophylactic antibiotics are not necessary for non-ablative laser procedures, debate continues for

ablative resurfacing procedures. Some physicians do not recommend prophylactic use of antibiotics with ablative resurfacing citing the fact that the wounds created are typically classified as class I clean wounds. Others argue that the benefits of prophylaxis outweigh the risk of prophylaxis and thus they err on the side of prophylactic antibiotics. Factors such as underlying disorders that predispose to infection (e.g., diabetes, immunosuppression) may influence the decision-making process in favor of prophylaxis. The choice of prophylactic antibiotics for ablative laser resurfacing is based on the most likely causative organism, which is typically S. aureus and sometimes Streptococcus or Pseudomonas species. Thus, a good choice might include a first-generation cephalosporin, a penicillin such as cloxacillin or a fluoroquinolone such as ciprofloxacin. The goal of prophylaxis is to achieve adequate antibiotic levels at the wound site at the time of the laser procedure until the skin re-epithelializes. A typical regimen might start on the day prior to the procedure and continue until the skin has re-epithelialized, 5 to 10 days post-operatively. Use of prophylactic antivirals is recommended for ablative laser resurfacing as severe, significant scarring may result should infection with H. simplex develop. There is some degree of variability in timing, but dosing should generally begin 1 day pre-operatively and continue for 5 to 10 days post-operatively until re-epithelialization is complete. If infection is clinically apparent despite use of prophylactic antibiotics and antivirals, cultures must be done to identify the causative organism. Empiric oral antifungal as well as gram-positive and gram-negative coverage should be instituted pending culture results. Fungal infections of the skin may occur after ablative resurfacing procedures. They are generally easily treated with oral antifungal agents such as fluconazole. Perhaps the most severe complication after a laser procedure is scarring and textural change (Figs. 13.5 and 13.6). Scarring may occur with any laser device and is often the result of patient, physician, and device factors. It is more likely with over-aggressive treatment and post-operative infection, although other factors may also play a role. Prevention is the treatment of choice. Amongst other things, a careful history should ascertain delayed or abnormal healing (e.g., keloids), previous surgery in the areas to be treated that may interfere with laser treatment (e.g., face lift, blepharoplasty), conditions that

Figure 13.5 Four days after laser hair removal, an erosion is noted over the right upper lip of this 28 year old woman with skin phototype 5. Superficial eschars are noted over the remainder of the upper lip. The patient described a burning and stinging sensation during treatment that was worse than with her previous treatment. This was followed by blister formation, redness, and pain.

Figure 13.6 A prominent keloid over the right upper lip is noted 9 months after laser treatment for hair removal. The patient described an initial “burn” with blister formation followed by crust. The elevated scar first became evident 2 to 3 months after laser treatment. The type of laser used was unknown to the patient.

COMPLICATIONS A TO Z may affect healing (e.g., diabetes, H. simplex virus), and medications that may delay or alter healing (e.g., isotretinoin, immunosuppressive agents). Careful attention to the tissue response is critical during treatment. In general, it is preferable to undertreat and later perform a “touchup” procedure than to overtreat and cause scarring. Treatment parameters that increase the risk of scarring include too much stacking of pulses, excessive fluence, and too many passes. The presence of white or grayish discoloration of the skin during laser treatment may signify excessive thermal tissue damage and should prompt the physician to reassess treatment parameters or discontinue treatment altogether. Management of scarring includes early recognition and intervention with ultrapotent topical steroids and pulsed dye laser therapy. The latter may help with erythema and scar texture. Hypertrophic or keloidal scarring often benefits from intralesional steroid therapy. CONCLUSION

Cosmetic enhancement procedures such as botulinum toxin, injectable fillers, and lasers have matured immensely over the years and have the potential to greatly improve the quality of life of our patients. Optimal results are obtained when, amongst other things, the physician has a thorough understanding of potential complications. Careful attention to preventive measures, prompt recognition of complications, and rapid institution of treatment will minimize the risk of prolonged or permanent sequelae while maximizing desirable patient outcomes. REFERENCES

1. Flynn TC, Carruthers A, Carruthers J. Surgical pearl: the use of the ultra-fine II short needle 0.3 cc insulin syringe for botulinum toxin injections. J Am Acad Dermatol 2002; 46: 931–3. 2. Alam M, Arndt KA, Dover JS. Severe, intractable headache after injection with botulinum A exotoxin: report of 5 cases. J Am Acad Dermatol 2002; 46: 62–5. 3. Alam M, Dover JS, Klein AW, Arndt KA. Botulinum A exotoxin for hyperfunctional facial lines: where not to inject. Arch Dermatol 2002; 138: 1180–5. 4. Spiegel JH. Treatment of periorbital rhytids with botulinum toxin type A: maximizing safety and results. Arch Facial Plast Surg 2005; 7: 198–202. 5. Klein AW. Contraindications and complications with the use of botulinum toxin. Clin Dermatol 2004; 22: 66–75. 6. Levy PM. The ‘Nefertiti lift’: a new technique for specific re-contouring of the jalwine. J Cosmet Laser Ther 2007; 9: 249–52. 7. Carruthers J, Carruthers A. Botulinum toxin A in the mid and lower face and neck. Dermatol Clin 2004; 22: 151–8. 8. U.S. Food and Drug Administration website. Accessed July 26, 2009. [Available from http://www.fda.gov/Drugs/Drug Safety/PostmarketDrugSafetyInformationforPatientsand Providers/DrugSafetyInformationforHeathcareProfessionals/ ucm143819.htm] 9. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg 2006; 118: 741–56.

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10. Cohen JL. Understanding, avoiding and managing dermal fillers complications. Dermatol Surg 2008; 34: S92–S99. 11. Glogau RG, Kane MA. Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid get dermal fillers. Dermatol Surg, 2008; 34: S105–S109. 12. Andre P, Levy PM. Hyaluronidase offers an efficacious treatment for inaesthetic hyaluronic acid overcorrection. J Cosmet Dermatol 2007; 6: 159–62. 13. Fitzgerald R, Vleggaar D, Burgess C. Facial dermal fillers. Aesth Surg J 2008. 28(6): 699–701. 14. Douse-Dean T, Jacob CI. Fast and easy treatment for reduction of the tyndall effect secondary to cosmetic use of hyaluronic acid. J Drugs Dermatol 2009; 7(3): 281–3. 15. Hirsch RJ, Narurkar V, Carruthers J. Management of injected hyaluronic acid induced Tyndall effects. Lasers Surg Med 2006; 38:202–4. 16. Monheit GD, Rohrich RJ. The nature of long-term fillers and the risk of complications. Dermatol Surg 2009; 35: 1598–604. 17. Christensen L, Breiting V, Janssen M, et al. Adverse reactions to injectable soft tissue permanent fillers. Aesth Plast Surg 2005; 29: 34–48. 18. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science 1999; 284: 1318–22. 19. Narins RS, Coleman WP, Glogau RG. Recommendations and treatment options for nodules and other filler complications. Dermatol Surg 2009; 35: 1667–71. 20. Hirsch R, Stier M. Complications and their management in cosmetic dermatology. Dermatol Clin 2009; 27: 507–20. 21. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg 2006; 118: 92S–107S. 22. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase. Dermatol Surg 2007; 33: 357–60 23. Hirsch RJ, Lupo M, Cohen JL, Duffy D. Delayed presentation of impending necrosis following soft tissue augmentation with hyaluronic acid and successful management with hyaluronidase. J Drugs Dermatol 2007; 6: 325–8. 24. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32: 276–81. 25. Sclafani AP, Fagien S. Treatment of injectable soft tissue filler complications. Dermatol Surg 2009; 35: 1672–80. 26. Anderson, RR, Parrish, JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220: 524–7. 27. Alster TS, Wanitphakdeedecha R. Improvement of postfractional laser erythema with light-emitting diode photomodulation. Dermatol Surg 2009; 35(5): 813–5. 28. Moreno-Arias GA, Castelo-Cranco C, Ferrrando J. Side-effects after IPL photodepilation. Dermatol Surg 2002; 28: 1131–4.

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Botulinum toxins type A: Advanced techniques Andreas Boker and Fredric S. Brandt

Since its discovery in 1895, botulinum toxin (BTX) has evolved from a poison to a versatile clinical tool with an expanding list of uses. The broad applicability of BTX results from its unique properties such as its transient duration and reversible effect, easy mode of application, and the fact that its effects can be localized to the target areas and their degree controlled with varying doses. Following its approval for cosmetic use by the Food and Drug Administration (FDA) in 2002, the use of BTX type A has revolutionized the facial rejuvenation market and has become the most popular cosmetic procedure performed in the United States every year since. In 2007 alone, the American Society for Aesthetic Plastic Surgery reported that out of the 11.7 million cosmetic surgical and nonsurgical procedures performed in the United States that year, 2.8 million (24%) procedures were BTX injections, making it the no. 1 non-surgical intervention by a large margin (1). With an ever-increasing demand for the procedure and the number of treated patients steadily growing, so is the experience and knowledge of the physicians that perform this procedure. PHARMACOLOGY

The cellular action of BTX eventually results in flaccid paralysis of the muscle by inhibiting the release of acetylcholine from nerve terminals. This process involves four steps (2): binding to receptor sites, internalization of the receptor complex, membrane translocation, and protease activity. The target of BTX type A (BTX-A) is the synaptosomeassociated protein of 25 kD molecular mass, commonly abbreviated SNAP-25 (3), while BTX types B and E cleave the vesicle-associated membrane protein (VAMP or synaptobrevin) (Fig. 14.1) (4). The action of BTXs on cholinergic synapses is reversed via the formation of an extensive network of accessory terminal sprouts from the damaged presynaptic axon. Moreover, vesicle turnover and restoration of cholinergic function is probably also mediated by synthesis of new, intact SNAP-25 (5). After approximately 90 days or more, a length of time that correlates well with that of the clinically observed duration of effect, recovery is essentially complete. Single-fiber EMG studies indicate abnormal neuromuscular transmission in muscles distant from the site of injection, despite the absence of clinical weakness, undermining the potential for spread of the toxin, particularly at higher doses (6).

factor ranging from three to six (7). This may be due to different concentrations of both botulinum neurotoxin and albumin. The higher albumin content of BOTOX® appears to prevent non-specific binding of neurotoxin to glass and plastic surfaces much more effectively than DYSPORT® whose protein content is much lower. Unless otherwise specified, material discussed in this review pertains to the use of BTX A under the trade name BOTOX® (Allergan, Inc., Irvine, California, USA) which the authors have most clinical experience with. DOSING, TOXICITY, AND IMMUNOLOGY

The toxicity of BTX-A is expressed in biologic mouse units, in which one unit (U) equals the median lethal dose (LD50) of a group of Swiss Webster mice that weigh 18 to 22 g each (8,9). The estimated lethal dose for a 70 kg person has been calculated to be approximately 40 U/kg (about 2500–3000 U), making poisoning by accidental overdosing with doses used for cosmetic procedures (typically less than 100 U per treatment session) highly unlikely. The concentration of BTX-A can be varied according to the physicians’ needs but in general the preferred dilution is 1 to 3 ml of normal saline without preservatives placed into a vial of 100 U of crystalline toxin. My personal preference is diluting with 2 ml of saline, which yields a solution containing 50 U/ml or 5 U of BTX-A per 0.1 ml. The clinical effect of BTX-A is dose related, which allows treatment to be modified according to the needs of the individual patient. The onset of muscle weakness occurs anywhere from 48 to 72 hours after injection of BTX-A and it can take up to 4 weeks for its maximum effect to develop. The development of immunoresistance seems to occur more often in patients treated with large doses and in which shorter intervals elapse between injections (10). It is important to avoid eliciting an immune response strong enough to induce the development of neutralizing immunoglobulin G (IgG) anti-BTX A antibodies to ensure future benefit from therapy. If they occur, the patient becomes unresponsive to future treatments with BTX-A. However, only a low number of patients actually develop this kind of antibodies and furthermore, the presence of antibody does not consistently correlate with absence of clinical effect. CONTRAINDICATIONS AND PRECAUTIONS

AVAILABLE PREPARATIONS OF BTX-A

There are two commercially available BTX-A toxins in the United States: BTX-A (BOTOX Cosmetic®, Allergan, Inc., Irvine, California, USA) which was developed in the United States and gained FDA approval for treatment of glabellar lines in 2002, and abobotulinumtoxin A (DYSPORT®, Medicis Aesthetics Inc., Scottsdale, Arizona, USA) which was approved by the FDA for cervical dystonia and moderate to severe glabellar lines in 2009. The latter, which was developed in the United Kingdom, has been used clinically in Europe and other parts for the world since 1990. One vial of DYSPORT® contains 300 U of toxin, 125 μg of albumin, and 2.5 mg of lactose, whereas one vial of BOTOX® contains 100 U of toxin, 500 μg of albumin, and 0.9 mg NaCl. Although the products differ in their composition with respect to contained units of neurotoxin they should be equal in potency. However, in the clinical setting, BOTOX® is alleged to vary from the potency of DYSPORT® by a

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A detailed medical history should be obtained in every patient prior to treatment, including concomitant medication use and allergies. Individuals with pre-existing neuromuscular disease should be advised to be cautious when receiving BTX-A treatment for cosmetic purposes and remain a relative contraindication since there are reports of exacerbation of underlying conditions following treatment with BTX (11,12). Aminoglycoside antibiotics and calcium channel blockers interfere with neuromuscular transmission and may potentiate the effect of BTX-A, thus making their use a contraindication for BTX therapy. Similarly, BTX should not be administered to patients with known allergic reactions to any of its molecular component or to human albumin. Other relative contraindications for the use of BTX-A include patients that are psychologically unstable or who have unrealistic expectations from treatment. Special care should be taken when treating people who are dependent on facial animation and expression for their livelihood (e.g., actors, musicians, and politicians).

BOTULINUM TOXINS TYPE A: ADVANCED TECHNIQUES

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Light chain cleaves Specific SNARE proteins Botulinum toxin endocytosed

Types B, D, F, G Types A, C, E

Light chain

SNARE complex does not form

Types C Heavy chain

Botulinum toxin

Membranes do not fuse

Neurotransmitter not released

Muscle cell Muscle fiber paralyzed Figure 14.1 Pharmacological action of botulinum toxin (BTX).

Although the safety of BTX-A on pregnancy has not been established, it remains classified as a category C drug by the U.S. FDA and its teratogenic effect needs to be studied further. CLINICAL USE OF BOTULINUM TOXIN A

The Upper Face The Fronto-glabellar Complex Even though the forehead “worry lines” and glabellar “frown lines” are frequently treated independently, these two regions must be approached as a distinct anatomical unit when attempting rejuvenation of the upper face using BTX. The justification for this lays in the intricate anatomical and inter-dependent functional relationship between these two regions of the face. Furthermore, the 3 cm radial spread of the toxin makes the involvement of adjacent structures of both areas practically inevitable and therefore obligates them to be considered conjunctly. Treating forehead wrinkles with BTX should be performed with due caution, and special attention needs to be directed at the degree of muscle paralysis achieved in the different regions. Excessive muscle weakness of the forehead musculature will leave the action of the brow depressors unopposed and lead to ptosis of the brow resulting in a “tired” look. This untoward outcome may even interfere with upward gaze. Moreover, there should be concern for the patient whose hyper functioning frontalis muscle actually supports a ptotic upper eyelid since relaxation of the forehead will result in eyelid ptosis (13). For that reason, it is exceedingly important to leave a proper degree of muscle function to avoid such complications. Accordingly, the important role of the glabellar or frown region in the facial expression of a variety of human emotions makes it another area where caution must be exercised when using botulinum toxin for facial rejuvenation purposes. Paralyzing the underlying musculature will hinder the overuse of these muscles during facial expression and even during everyday activities such as concentrating, reading or walking outside during bright daylight. Hence, the furrows will cease to be formed and the wrinkles disappear. Anatomy and Physiology Forehead. The main muscle of the forehead, the frontalis, originates in the tendinous galae aponeurotica near the coronal suture of the scull and inserts on the superciliary ridge of the frontal bone as well as onto

fibers of the procerus, corrugator and orbicularis oculi muscles (14) (Fig. 14.2). Typically, the frontalis muscle may have only one central tendinous sheath with little muscle fibers within the midline of the forehead. Therefore, less amount of BTX-A is required to induce paralysis in this region of the forehead. The frontalis muscle is responsible for the horizontal wrinkles of the forehead caused by elevation of the brows and forehead skin during various facial expressions (15). Its function is to oppose the effect of the depressor muscles of the glabella and brows. Glabella. Fibers from three muscle groups, the corrugator supercilii, the frontalis, and the procerus contribute to the motion in this area of the face. In addition fibers from the medial orbital portion of the orbicularis oculli contribute to the muscular bundle of the glabellar region. The corrugator muscle, which is the main target of BTX treatment lies deep in both the frontalis and procerus muscles and has its origin on the nasal process of the frontal bone just above the superomedial orbital rim. It extends laterally and upward and passes through the galeal fat pad to insert into the dermis superior to the middle third of the eyebrow (Fig. 14.2). Its function is brow adduction, moving the eyebrow and skin downward and medially giving rise to the glabellar crease (13,16). The direction of these creases and wrinkles appear usually perpendicular to the direction of the muscle fibers creating them. One beneficial effect of paralyzing the corrugator muscular group with BTX-A is the resulting unopposed action of the frontalis muscle, which will produce an upward pull of the eyebrows leading to an “opened-eyed” look (17). However, due to the complex intertwining of these muscle group fibers, targeting the corrugator muscle alone will somewhat affect the activity of both the frontalis and procerus muscles. Moreover, knowing that the medial fibers of the frontalis muscle aid in the lifting of the brows it is important to take caution not to paralyze these too when aiming at the corrugator muscle since this would conversely result in a brow droop and cancel out the desired result of the injection. Injection Technique The most important area of treatment on the forehead is the glabellar complex, for this not only alleviates frown lines but also elevates the brow. It is important to treat this area completely. The amount of BTX necessary to paralyze this complex varies depending upon the muscular

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Frontalis

Corrugator supracilli

Procerus

Orbicularis oculi

Figure 14.2 Anatomy of the upper face.

(B)

(A)

Figure 14.3 Injection sites for glabellar frown lines: (A) arched female brow, (B) horizontal male brow.

mass of the individual, but generally speaking, 20 to 40 U are necessary. The variation in muscular mass is evident in the different approach when treating the female versus the male brow. The female brow is usually more arched compared to the more horizontal or flattering appearance in males (Fig. 14.3). Also, 5 to 10 U are injected in a single shot into the procerus muscle (Fig. 14.4). Each corrugator is then treated with 4 to 6 U placed at the inferior and superior belly of the muscle (Fig. 14.5) and lastly, 2 to 3 U are injected into the medial fibers of the orbital portion of the orbicularis oculi muscle as these also contribute to the frowning mechanism (Fig. 14.6). By performing this technique one should see complete paralysis of the glabellar complex as well as elevation of the medial brow (Fig. 14.7). With the diffusion properties of the toxin, one should also see partial or complete paralysis of the inferior portion of the frontalis muscle.

Nonetheless, some considerations need to be taken into account; if the patient has a very heavy brow, I would not further treat the forehead at the first treatment visit. The patient can return in two weeks time and be re-evaluated. At this point, if the frontalis muscle is minimally frozen, 2 to 3 U of toxin can be added at the upper portion of the muscle at 1.5 cm intervals for an additional total dose of 8 to 12 U (Fig. 14.8). In the case of the patient whose brow is not ptotic the entire frontoglabellar complex can be treated in one visit. In this case after treatment of the glabellar complex, 2 to 3 U can be added at 1.5 cm intervals on the mid-frontalis. Complications As mentioned earlier, the major cosmetic complication resulting from complete paralysis of the frontalis muscle is loss of expression of the

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Figure 14.6 Injection sites into orbital portion of orbicularis oculi muscle. Figure 14.4 Injection sites into the procerus muscle.

The wrinkles usually radiate outward and laterally from the lateral ocular canthus and are perpendicular to the direction of the fibers of the orbicularis oculi muscle. Weakening the muscles responsible for these dynamic lines will impede their further contraction during common activities like squinting of the eyes and as a result smooth out the overlaying skin. Flynn et al. demonstrated that subdermal injection of 2 U of BOTOX® into the lower eyelid together with treatment of the lateral ocular canthus resulted in a significant improvement of lower eyelid wrinkles and further prompted the opening of the palpebral aperture (23). It is important to remember that a snap test should always be performed before injecting the lower eyelids with BTX to test for the retraction of the skin, as patients with a delayed retraction of the lower eyelid may experience ectropion of the injected eye when the periocular muscles are rendered inactive by the toxin. Figure 14.5 Injection sites into the corrugator muscle.

upper face, marked by the inability to lift the brows and sometimes even the dropping of the eyelids. This should be avoided at all costs since patients will complain of a “mask-like” appearance and may even have trouble with upward vision. To circumvent this problem, it has been proposed to either inject the toxin subcutaneously instead of into the muscle itself or to inject multiple small doses of toxin at 1 to 2.0 cm intervals across the forehead (18). In the frown region, the main concern when injecting BTX-A into the corrugator muscle is upper eyelid ptosis and diplopia caused by diffusion of the toxin through the orbital septum to the levator palpebrae superioris and extraocular muscles from the injection site (19,20). This can be avoided to some extent by always staying superior to the medial orbital rim when injecting BTX-A around the eye (21). Other complications unrelated to the action of the toxin include headache and pain and/or bruising at the injection site. These are usually mild and last no longer than 24 hours post-injection (22). The Lateral Ocular Canthi Much of the wrinkling in the area around the eyes is the result of facial chronologic aging and superimposed extrinsic photodamage. But a significant component can also be attributed to the hyperactivity of the musculature underlying the skin around the eyes, making this the target for therapy with BTX.

Anatomy and Physiology The principal muscle in the area around the eye is the orbicularis oculi muscle. With its two components, the orbital and the palpebral, it encircles the periorbital region and inserts onto the medial and lateral canthal tendons as well as onto fibers of the frontalis, procerus, and corrugator supercilii muscles (Fig. 14.2) (13). Its combined functions are the forceful closure of the eyes and the depression of the brow and eyelids. Injection Technique Injection of BTX into this region should be directed at the lateral fibers of the orbital portion of the orbicularis oculi, which can be easily accessed by placing the injection 1 cm lateral to the orbital rim (19,21). Three to five units are injected at three points in a vertical line (Figs. 14.9 and 14.10). These injections can be made intramuscularly or intradermally if bruising is a concern. If the patient has a good snap test, 2 to 4 U can be placed 3 mm below the mid-papillary line for the correction infraorbital wrinkles (Fig. 14.11). Complications Complete paralysis of the orbicularis oculi not only is impossible but due to its important role in closing the eye, even unwanted. Inducing excessive weakness by either injecting too much toxin into the orbicularis oculi muscle or by it diffusing to neighboring muscles such as the frontalis muscle could result in improper eye closure or may cause the lateral brow to droop, respectively (13). Although very rare, paralysis of the lateral rectus muscle may cause diplopia (18,24) and accidentally

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(A)

(B) Figure 14.7 Before and after photographs of fronto-glabellar complex (female).

Figure 14.8 Injection sites into the frontalis muscle.

weakening the levator labii superioris muscles when injection is aimed at the lower periorbital wrinkles can cause the upper lip to droop and as a consequence prevent a normal smile (25). Other reported adverse reactions include worsening of preexisting fat herniations of the lower eyelid (26) and skin redundancy beneath it. It is important to recognize patients with excessive lower eyelid skin or lower fat pads prior to treatment, since these will benefit the least from treatment with BTX alone and may need adjunctive cosmetic procedures like blepharoplasty, or laser resurfacing for optimal results. Similarly, patients who have swollen or puffy lower eyelids due to fluid accumulation prior to treatment may see their condition worsened if injected with BTX since the toxin’s paralytic effect may interfere with regional lymphatic drainage and accentuate fluid retention even more. Midface Nasolabial Fold Due to its multifactorial etiology and complex anatomical composition, the nasolabial fold poses a challenge for both the patient and the physician when attempting rejuvenation of the midface. The crucial physiologic and aesthetic activity of the various muscles that contribute to it makes the correction of the nasolabial furrow with BTX-A a difficult task. Inducing excessive paralysis in certain muscular components can easily lead to unwanted cosmetic and functional defects and is therefore critical to avoid. In general it is understood that BTX achieves limited improvement in this region of the face compared to high degree of complications.

Figure 14.9 Injection point into the lateral fibers of the orbital portion of the orbicularis oculi muscle.

Anatomy and Physiology A prominent nasolabial fold is the result of diverse factors that play a role in the development of the aging face, such as loss of subcutaneous fat, gravitational ptosis and laxity of the skin, and overuse of the muscles of facial expression. It is composed of subcutaneous fat and dense fibrous tissue, muscle fibers from the lip elevators and their fascia, and excess skin hanging over the cutaneous attachment of the zygomaticus major and minor, levator labii superioris and levator labii superioris alaeque nasi muscles (Fig. 14.12) (27). The combined activity of this muscular group is responsible for the wide range of motion associated with the movement of the mouth and lips. Since talking, smiling, and a broad array of facial expressions involve the use of the mouth and other structures of the midface, the nasolabial furrow is a common feature of the aging face, especially in very expressive people. The crease deepens with time as the effects of aging take their toll. This ultimately causes the breakup of the even biconvex contour of the face and an unwanted cosmetic appearance. Injection Technique One to two units of botulinum exotoxin are injected at the upper portion of the nasolabial fold 2 to 3 mm lateral to its intersection with the nose (Fig. 14.13). This will help flatten out the muscular prominence caused by the levator labii superioris alaeque nasi muscle pull.

BOTULINUM TOXINS TYPE A: ADVANCED TECHNIQUES

1 cm

Figure 14.10 Injection sites for crow’s feet: lateral view.

Figure 14.11 Injection point into inferior fibers of orbicularis oculi muscle.

Nonetheless, the cosmetic improvement is usually so subtle that it is not worth incurring in the risks associated with injection into this area. Complications As noted before, causing complete relaxation of the muscles of this area can result in cosmetically unacceptable results. The most commonly observed complication is ptosis of the upper lip, giving the patient a sad appearance (28). In addition, the compound bilateral muscular control of the lips makes it very easy to induce disproportionate kinesis of the lips if one side is paralyzed more than its counterpart. Furthermore, a resulting asymmetric smile or an incompetent mouth is an untoward effect that should be avoided at all cost. Thus, it is generally understood that the primary attempt at correction of the nasolabial fold should consider other means and leave the use of BTX-A as an adjuvant to, for example, soft tissue augmentation. It is known that weakening the fibers of the lip elevators before injecting the nasolabial folds with a filler material will enhance its effect and longevity by reducing supposed muscle atrophy and preventing immediate microextrusion from injection sites by repetitive muscular action (29). The Lower Face Perioral Region In the perioral region, fine vertical lines extending above and below the vermillion border on the upper and lower lips are an evident sign of aging, particularity in women, and are therefore a common reason for patients to seek medical advice for treating them. They result from a combination of long-term use of the underlying musculature and

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actinic damage to the overlying skin. In addition, certain activities like smoking accentuates their depth and makes them even more apparent. Various treatment options including soft tissue augmentation with filling agents and abrasive resurfacing procedures yield satisfactory results in most of the cases. However, the injection of low doses of botulinum A exotoxin into the underlying muscular layer has also proven to effectively eliminate and smoothen out multiple fine rhytids (30). Anatomy and Physiology The muscular anatomy of the perioral region is complex and includes fibers from various muscle groups (Fig. 14.12). However, the principal muscle responsible for contracting the lips is the orbicularis oris muscle. It consists in part of fibers derived from other facial muscles (i.e., buccinator, caninus, and triangularis muscles) which are inserted into the lips, and partly of fibers proper to the lips. It originates from the alveolar border of the maxilla and the mandible and its fibers run circumferentially around mouth onto its cutaneous insertions. The main functions of this muscular group are opposition and protrusion of the lips. Another important muscle group involved in the kinesis of the mouth is the depressor anguli oris muscle, also called the triangularis. It arises from the oblique line of the mandible and its fibers then converge to be inserted by a narrow fasciculus into the angle of the mouth. At its origin it is continuous with the platysma muscle, and at its insertion with the orbicularis oris muscle. Its action is depression of the angles of the mouth. The mentalis muscle originates from the incisive fossa of the mandible and descends to be inserted into the integument of the chin. It raises and protrudes the lower lip, and at the same time wrinkles the skin of the chin (18). Injection Technique The upper lip is injected with 0.5 to 1 U at four points 2 to 3 mm above the vermillion border (Fig. 14.14). This can then be massaged gently after the injection. The same technique can be applied to the lower lip. The depressor anguli oris muscles are injected at the most inferior portion with 2 to 4 U placed on either side on an imaginary line drawn as a continuation of the nasolabial fold. This is usually done at about 1 cm above the intersection of this line and the angle of the jaw (Fig. 14.15). The injection of 5 to 10 U of BTX into the inferior portion of the midchin (mentalis muscle) will smoothen out the dimpling of the chin (Fig. 14.16) (31,32). Complications Due to the complex structure of the musculature in this area and its critical role in the proper function of the mouth and lips, the perioral region should be approached with care when attempting muscular paralysis with BTX for cosmetic purposes. Difficulties with certain facial expressions and even trouble with speech could ensue if the normal oral physiology is hindered. Cosmetic defects may include an asymmetric smile or the inability to properly close the mouth. As such, the lateral angles of the mouth should be spared entirely to avoid lip droop and all other injection sites should be injected with low doses and more superficially rather than deeply. When treating the chin, if done properly, complications are rare unless the toxin is injected too high into the chin where it could cause paralysis of the levator anguli oris and compromise the ability to elevate the corner of the mouth. The Neck The senescent neck is a common cosmetic concern to many patients as they age, especially in over expressive individuals that use this muscle

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT Zygomaticus major and minor Levator labii superioris Orbiculatis oris Depressor anguli oris Mentalis Platysma

Figure 14.12 Anatomy of the lower face and neck.

Figure 14.15 Injection sites into the depressor anguli oris muscle.

Figure 14.13 Injection points into zygomaticus major and minor muscles.

Figure 14.16 Injection sites into the mentalis muscle.

Figure 14.14 Injection sites into the orbicularis oris muscle.

frequently during facial animation. The platysma muscle has a direct influence on the looseness and tonicity of the skin of the neck. Its central bands actually thicken and contract with time, becoming visibly apparent with advancing age. This combined with actinic damage accumulated over the years makes the neck region a particularly apparent sign aging that needs to be addressed. Until recently, the only option available for correcting the resulting cosmetic traits was

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(A)

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(B) Figure 14.17 Before and after photographs of the neck on treatment with BTX-A.

Complications It is generally understood that this is a safe and minimally invasive procedure. Complications are minimal and have included transient edema, ecchymoses, hematoma formation, muscle soreness, and neck discomfort. Some patients also developed headaches and some degree of neck weakness while lifting their head off a pillow (33). Most of these side effects lasted 1 to 2 weeks and resolved completely. More serious complications such as laryngeal muscle weakness, hoarseness, or dysphagia are rare and should be avoided.

REFERENCES

Figure 14.18 Injection sites into the platysma muscle complex.

undergoing rhytidectomy and other plastic surgery procedures. Nevertheless, the use of BTX-A for rejuvenating the aging neck has proven effective and well tolerated (Fig. 14.17) (33,34). Anatomy and Physiology The platysma muscle complex is a broad muscular sheet that comprises the anterolateral aspect of the neck. It has its origin on the fascia covering the upper parts of the pectoralis major and deltoid muscles including clavicular and acromial subcutaneous insertions. Its fibers cross the clavicle, and proceed obliquely upward and medially along the side of the neck. Some fibers are then inserted into the mandibular bone below the oblique line, others into the skin and subcutaneous tissue of the lower part of the face. Many of these fibers blend in with the perioral muscles about the angle and lower part of the mouth (Fig. 14.12). When the entire platysma complex is contracted, it produces a slight wrinkling of the skin of the neck in an oblique direction. Its anterior portion, the thickest part of the muscle, depresses the lower jaw and also serves in a small extent to depress the lower lip and angle of the mouth (35). Injection Technique The neck can be injected with as little as 20 U to as much as 100 U of BTX depending upon of the muscular mass present. First, the platysmal bands need to be identified having the patient clench their teeth. Each platysmal band is firmly held between the thumb and index finger and 2 to 5 U of toxin can then be injected from the superior to the inferior portion of each platysmal band at 1 to 1.5 cm intervals (Fig. 14.18). This usually comes out to four to five injection points per band.

1. http://www.surgery.org/download/2007stats.pdf 2. Aoki KR, Guyer B. Botulinum toxin type A and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions. Eur J Neurol 2001; 8(Suppl 5): 21–9. 3. Graham ME, Washbourne P, Wilson MC, Burgoyne RD. Molecular analysis of SNAP-25 function in exocytosis. Ann N Y Acad Sci 2002; 971: 210–21. 4. Shiavo G, Benfenati F, Poulain B, et al. Tetanus and botulinum-B neurotoxins block transmitter release by proteolytic cleavage of synaptobrevin. Nature 1992; 359: 832–5. 5. dePaiva A, Meunier FA, Molgo J, Aoki KR, Dolly JO. Functional repair of motor endplates after botulinum neurotoxin type A poisoning: biphasic switch of synaptic activity between nerve sprouts and their parent terminals. Proc Natl Acad Sci 1999; 96: 3200–5. 6. Sanders DB, Massey W, Buckley EG. Botulinum toxin for blepharospasm: single-fiber EMG studies. Neurology 1986; 36: 545–7. 7. Klein AW, Carruthers A, Fagien S, Lowe NJ. Comparisons among botulinum toxins: an evidence-based review. Plast Reconstr Surg 2008; 121(6): 413e–22e. 8. Pearce LB, Borodic GE, First ER, et al. Measurement of botulinum toxin activity: evaluation of the lethality assay. Toxicol Appl Pharmacol 1994; 128: 69–77. 9. McLellan K, Das RE, Ekong TA, et al. Therapeutic botulinum type A toxin: factors affecting potency. Toxicon 1996; 34: 975–85. 10. Jankovic J, Schwartz K. Response and immunoresistance to botulinum toxin injections. Neurology 1995; 45: 1743–46. 11. Erbguth F, Claus D, Engelhardt A, et al. Systemic effects of botulinum toxin injections unmasks subclinical Lambert–Eaton myasthenic syndrome [letter]. J Neurol Neurosurg Psychiatry 1993; 56: 1235–36. 12. Hara K, Matsuda A, Kitsukawa Y, Tanaka K, et al. Botulinum toxin treatment for blepharospasm associated with myasthenia gravis. Mov Disord 2007; 15: 22(9):1363–4.

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13. Wieder JM, Moy RL. Understanding botulinum toxin: surgical anatomy of the frown, forehead and periocular region. Dermatol Surg 1998; 24: 1172–4. 14. Gray H. In: Warren HL, ed. Anatomy of the Human Body. Philadelphia, PA: Lea & Febiger, 1918. 15. Stennert E. Why does the frontalis muscle “never come back”? Functional organization of the mimic musculature. Eur Arch Otorhinolaryngol 1994; Suppl: S91–5. 16. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS. An anatomical approach to glabellar rhytids. Arch Otolaryngol Head Neck Surg 1998; 124: 1315–20. 17. Huang W, Rogachefsky A, Foster J. Browlift with botulinum toxin. Dermatol Surg 2000; 26: 55–60. 18. Matrasso, SL. Complications of botulinum A exotoxin for hyperfunctional lines. Dermatol Surg 1998; 24: 1249–54. 19. Carruthers JDA, Carruthers A. Botulinum A exotoxin in clinical ophthalmology. Can J Ophtlamol 1996; 31: 389–400. 20. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996; 97: 1321–33. 21. Carruthers A, Carruthers J. Cosmetic uses of botulinum A exotoxin. In: Klein AW, ed. Tissue Augmentation in Clinical Practice: Procedures and Techniques. New York: Marcel Dekker, 1998. 22. Carruthers A, Carruthers J. Botulinum toxin in the treatment of glabellar frown lines and other facial wrinkles In: Jankovic J, Hallet M, eds. Therapy with Botulinum Toxin. New York: Marcel Dekker, 1994. 23. Flynn TC, Carruthers JA, Carruthers JA. Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye. Dermatol Surg 2001; 27: 703–8. 24. Garcia, A, Fulton JE. Cosmetic denervation of muscles of facial expression with botulinum toxin: A dose–response study. Dermatol Surg 1996; 22: 39.

25. Matarasso SL, Matarasso A. Treatment guidelines for botulinum toxin type A for the periocular region and a report on partial upper lip ptosis following injections to the lateral canthal rhytids. Plast Reconstr Surg 2001; 108: 208–14. 26. Ascher B, Klap P, Marion MH, et al. La toxine boutulinique dans le treatment des rides fronto-glabellaires et de la region orbitaire. Ann Chir Plast Esthet 1995; 40: 67–76. 27. Carruthers A, Carruthers J. Cosmetic uses of botulinum A exotoxin. Adv Dermatol 1997; 12: 325–47. 28. Blitzer A, Binder WJ, Aviv JE, Keen MD, Brin MF. The management of hyperfunctional facial lines with botulinum toxin. A collaborative study of 210 injection sites in 162 patients. Arch Otolaryngol Head Neck Surg 1997; 123: 389–92. 29. Carruthers JD, Glogau RG, Blitzer A. Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies— consensus recommendations. Plast Reconstr Surg. 2008; 121 (5 Suppl): 5S–30S. 30. Carruthers A, Carruthers J. Clinical indications and injection technique for the cosmetic use of botulinum A exotoxin. Dermatol Surg 1998; 24: 1189–94. 31. Papel ID, Capone RB. Botulinum toxin A for mentalis muscle dysfunction. Arch Facial Plast Surg 2001; 3: 268–9. 32. Le Louarn C. Botulinum toxin A and facial lines: the variable concentration. Aesthetic Plast Surg 2001; 25: 73–84. 33. Brandt FS, Bellman B. Cosmetic use of botulinum A exotoxin for the aging neck. Dermatol Surg 1998; 24: 1232–4. 34. Kane AC. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg 1999; 103: 656–65. 35. Hoefflin SM. Anatomy of the platysma and lip depressor muscles. A simplified mnemonic approach. Dermatol Surg 1998; 24: 1225–31.

15

Botulinum toxin in the management of focal hyperhidrosis Dee Anna Glaser

Botulinum toxins can be used to treat secretory problems such as hyperhidrosis, chromhidrosis, sialorrhea, and Frey’s syndrome. This chapter will focus on the rationale for and the practical application of using botulinum toxins to treat patients with such problems.

Sweating is a normal physiological response to increased body temperature and is an important mechanism in releasing heat produced from endogenous as well as exogenous sources. The heat regulatory center is located within the hypothalamus, particularly involving the preoptic and anterior nuclei. Sweating is controlled by the sympathetic nervous system (1). Nerve fibers exit the preoptic or anterior nuclei and descend ipsilaterally through the spinal cord until they reach the intermediolateral column, where they exit the cord and enter the sympathetic chain. Although the neurotransmitter for the sympathetic nervous system is generally norepinephrine, acetylcholine is the neurotransmitter mainly involved in the sweating response. Other chemical mediators found in periglandular nerves include vasoactive intestinal peptide (VIP), atrial natriuretic peptide (ANP), galanin, and calcitonin gene peptide (CGP) (2). The eccrine glands, responsible for producing sweat, are distributed around the body, with high concentrations in areas such as the palms, soles, and forehead (Table 15.1). They are located at the junction of the dermis and subcutaneous fat and their function is to secrete water while conserving sodium chloride for electrolyte maintenance. Although they continually produce secretions, they are stimulated by heat, exercise, anxiety, and stress (3,4). Under severe heat stress, up to 10 l of sweat can be produced in a day; however, the normal rate is 0.5 to 1.0 ml/min. While rates vary among individuals, men generally sweat more than women (5). The apocrine gland opens into the hair follicle and is located mostly in the axillae and perineum. They become functional around puberty and are not important for thermoregulation. The scant viscous secretions are thought to function as chemical attractants or signals, as an odor is produced when the secretions reach the skin surface and interact with bacteria (1,3). The apocrine glands respond to adrenergic stimuli, epinephrine more than norepinephrine.

secondary process including lesions or tumors of the central or peripheral nervous system (9,10). More commonly however, it is idiopathic (primary) focal and is usually referred to simply as “hyperhidrosis.” It is characterized by excessive sweating of small areas of the skin, usually the axilla, palms, soles, face, or groin (Fig. 15.1) (11). The onset is usually in adolescence to early adulthood but can begin in early childhood, especially the palmar-plantar variants (7) (Table 15.3). The differential diagnosis for excessive sweating is extensive, and an underlying cause must be considered, especially when the hyperhidrosis is generalized, asymmetrically distributed, or has a late onset (6,12). A detailed history with comprehensive review of symptoms and thorough physical examination is the first step to identifying the type and cause of hyperhidrosis of a patient presenting with excessive sweating. The types or extent of further testing is based on the findings from the history and physical exam. This chapter will focus on primary focal hyperhidrosis henceforth identified simply as hyperhidrosis (HH). The prevalence of HH is reported to be 2.8% although it may be higher. It most commonly presents in the second or third decade of life and a family history has been reported in 30 to 50% of patients (13). The prevalence is similar for men and women, although interestingly, women are more likely to seek evaluation and treatment (11). Patients may sweat on a continuous basis throughout the day, but more commonly, there are episodes of profuse sweating with a sudden onset. Trigger factors include emotional stress, stress at work or in the public, higher environmental temperatures, and stimulants such as caffeine and exercise. However, patients also often have episodes of HH without a known initiating factor or trigger when they are cool, comfortable, and calm. Hyperhidrosis has a negative impact on many aspects of patients’ daily living: physically, psychologically, and occupationally (14–16). There is limited and mixed information on any real increase in cutaneous infections or other problems such as skin maceration with idiopathic hyperhidrosis (17,18). The greatest impact of HH is the significant reduction in the quality of life and the alterations it has on daily functioning (19). Patients report a lack of confidence, feeling depressed, refraining from meeting new people, and avoiding intimate activities. Work limitations are reported because of excessive sweating and patients describe having to change clothes during the day.

HYPERHIDROSIS

MEASURING HYPERHIDROSIS

Hyperhidrosis simply describes excess sweating beyond that necessary for physiological thermoregulation and homeostasis (6). Problems can occur within any portion of the system: from the hypothalamus to the sweat gland or duct (2). The amount of sweat necessary to be considered “excessive” is not well-defined and is variable between individuals. Patients with hyperhidrosis do not demonstrate any histopathologic changes in their sweat glands, nor are there any changes in the numbers of sweat glands (7). Hyperhidrosis may be generalized or focal, bilateral or unilateral, symmetric or asymmetric, primary or secondary in origin. Generalized hyperhidrosis affects the entire body whereas focal hyperhidrosis occurs in discrete sections of the body (8). Generalized hyperhidrosis is usually secondary in nature, and the differential diagnosis is extensive ( Table 15.2). Focal or localized hyperhidrosis may result from a

The Minor’s iodine-starch test is a simple way to detect the presence of sweat (Fig. 15.2). The hyperhidrotic area to be treated is dried thoroughly, an iodine solution is painted over the area and when thoroughly dried, a starch powder such as corn starch is sprinkled on the surface. With the interaction of sweat, a purple to black color develops. Decolorized iodine solutions do not perform the colorimetric change properly and should not be used for this test. Many physicians today use surgical preparations such as Betadine™ solution or swabs to perform the iodine-starch test. A plain corn starch that is used for cooking is readily available and inexpensive. The starch may be applied with a brush, cottonball, sifter or loose gauze. The iodine-starch test is useful in localizing the areas of sweat production but is not a quantitative test. For iodine-sensitive patients, Alizarin or Ponceau red dye and starch can be used. The pink powder turns to a bright red color when wet.

SWEATING

This chapter adapted from Botulinum Toxins in Clinical Aesthetic Practice, Second Edition, (Benedetto A, ed.), Informa Healthcare, New York, London, 2011.

115

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Table 15.1 Eccrine Sweat Glands: Area and Quantity

Table 15.3 Criteria for Establishing the Diagnosis of Primary Focal Hyperhidrosis (6)

2

Area

Quantity (cm )

Sole of foot Forehead Palms Axillae Thigh Scrotum Back Lips Nail bed Nipple Inner preputial surface Labia majora Glans penis Glans clitoridis

620 360 300 300 120 80 65 None None None None None None None

Focal, visible excessive sweating of at least 6 months No apparent secondary cause At least two of the following characteristics • • • • • •

Source: From Ref. 68, p. 263.

Table 15.2 Forms of Hyperhidrosis Generalized

Focal/Localized

Fever Infections Malignancy Tumors Thyrotoxicosis Pheochromocytoma Diabetes mellitus Diabetes insipidus Hypoglycemia Hypopituitiarism Endocarditis Gout Medications Menopause Anxiety Drug withdrawal

Primary focal hyperhidrosis Intrathoracic tumors Rheumatoid arthritis Spinal cord disease or injury Stroke Syringomelia Ross syndrome Atrioventricular fistula Gustatory sweating Frey’s syndrome Localized unilateral hyperhidrosisa Cold-induced hyperhidrosis Eccrine nevus Social anxiety disorder Granulosis Rubra Nasi

Bilateral and relatively symmetric Age on onset <25 years Positive family history of primary focal hyperhidrosis Cessation of focal sweating during sleep Frequency of at least one episode per week Impairs daily activities

validated quantity that separates hyperhidrosis from euhidrosis, although it can exceed 30 times that of normal nonhyperhidrotic individuals. Hund suggests a minimum of 100 mg/5 min for men and 50 mg/5 min for women will identify axillary hyperhidrosis (5). A study of 60 patients demonstrated that the mean axillary sweat production was 346 mg/5 min for men and 186 mg/5 min for women with HH (healthy control subjects had values of 72 and 46, respectively). Likewise, the mean palmar gravimetric measurement was 300 mg/5 min (23). Gravimetric evaluation is typically reserved for research purposes and is not routinely used in clinical practices. A third method used to measure disease severity is with questionnaires and quality of life scales. Several such tools are available, including the Dermatology Life Quality Index (DLQI), the Hyperhidrosis Impact Questionnaire (HHIQ), and the Hyperhidrosis Disease Severity Scale (HDSS). The DLQI has 10 items that form six domains such that a total score of zero is best and 30 demonstrates the worst quality of life. The HHIQ has items for a baseline evaluation and ten items used to assess treatment follow-up. It too is most commonly used in clinical trials (24). The HDSS is based on one question that the patient can answer in the office (Table 15.4). The HDSS is a simple tool to use in the clinical setting and is responsive to treatment with a one-point HDSS improvement corresponding with approximately a 50% reduction in sweat. This validated scale can aid in selecting patients appropriate for therapy and for assessing effectiveness of treatment (25).

a

Also referred to as unilateral circumscribed idiopathic hyperhidrosis.

THERAPY

r

oin

he Ot

/sc Fa

ce

Gr

alp

tar an Pl

lm Pa

Ax

illa

ry

ar

80 70 60 50 40 30 20 10 0

Figure 15.1 Sites of hyperhidrosis in patients seeking medical evaluation. Source : From Ref. 11, p. 263.

Ninhydrin is another variant, but regardless of which variant is used, they all achieve a colorimetric outline of the sweating area (20–22). Gravimetric testing measures the amount of sweat produced during a given time. It can be performed using a preweighed filter paper that is placed on the affected area (typically for 5 minutes) and then reweighing the paper. Evaporation must be prevented. There is no standard or

Many treatments are available for HH, and therapy should be tailored to the needs of the individual based on factors such as age and health status, location, and severity of the disease, occupation, and lifestyle (Table 15.5). Antiperspirants are used as first-line therapy and function by decreasing sweat secretion through blockage of the distal eccrine ducts. Over-the-counter (OTC) products very rarely control patients with severe disease (HDSS 3 or 4) (see above) (7,11,26,27). Prescription strength products containing high concentrations of metal salts, most commonly aluminum chloride, are more effective than OTC preparations (28). Efficacy is still limited, and side effects are frequent with skin irritation, erythema, dryness, and pruritus. Systemic anticholinergic drugs such as glycopyrrolate, atropine, or oxbutynin provide a generalized acetylcholine blockade (Table 15.6) (26,29,30,31). Adverse effects such as dry eyes, dry mouth, and urinary retention are frequently encountered at the doses required to achieve symptom relief. Additionally, the generalized reduction in sweat production can be dangerous in individuals who engage in exercise, sports, or work in hot environments. Iontophoresis is an electrical device that uses direct current and tap water. The mechanism of action is unknown but may change the ability of the pores to secrete sweat, or physically block the release of sweat via ions that enter the ducts. It is most suited for treatment of the hands and feet. Anticholinergic agents can also be added to the tap water (32).

BOTULINUM TOXIN IN THE MANAGEMENT OF FOCAL HYPERHIDROSIS

(A)

(B)

(C)

(D)

117

(E) Figure 15.2 Performance of the Minor’s iodine-starch test. The hyperhidrotic area is doused with iodine solution (A) and after drying covered with starch powder (B). The hyperhidrotic area becomes clearly demarcated as a purple surface. Then the hyperhidrotic area is outlined (C). After removing the excess purple color from the center of the outline each injection site can be marked with gentian violet (D) to achieve the best results; (E) shows how the injections are placed. Source: From Ref. 68, p. 276.

Table 15.4 Hyperhidrosis Disease Severity Scale “Which best describes the impact of sweating on your daily activity?” 1 2 3 4

My (underarm) sweating is never noticeable and never interferes with my daily activity My (underarm) sweating is tolerable but sometimes interferes with my daily activity My (underarm) sweating is barely tolerable and frequently interferes with my daily activity My (underarm) sweating is intolerable and always interferes with my daily activity

Source: From Ref. 25.

Side effects are relatively minimal but is relatively time-consuming, limiting its use for many patients (Fig. 15.3) (33). Local surgical excision and liposuction or curettage techniques can be used to remove eccrine units (34). The outcome is technique dependant and is typically limited to the axilla. Endoscopic thoracic sympathectomy (ETS) offers long-term improvement but is not universally accepted. The sympathetic chain is interrupted at the T2, T3, and sometimes the T4 ganglion (35,36). Success rates for palmar disease approximate 95% but is less for axillary HH. Surgical and anesthetic-related adverse events are relatively rare, but the major issue with ETS surgery for HH is the potential for patients to develop compensatory sweating (Fig. 15.4) (37).

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Table 15.5 Therapies Most Commonly Used for Hyperhidrosis Antiperspirants, over the counter Antiperspirants, prescription strength Iontophoresis Oral medications BoNTA or BoNTB Local excision of eccrine glands Liposuction and/or curettage Endoscopic transthoracic sympathectomy

Table 15.6 Anticholinergics Commonly Used to Suppress Hyperhidrosis Medication

Dosage

Glycopyrrolate 1% cream Glycopyrrolate (1 mg tablet) Oxybutnin Propantheline bromide

Apply 1% solution to affected area once daily 1–2 mg PO bid/tid, titrate to effect 5 mg PO bid/tid; not to exceed 5 mg qid 15 mg PO bid/tid 30 min ac initially; gradually titrate to effect 1–2 mg/day PO; not to exceed 6 mg/day

Benzotropine

Figure 15.4 Increased sweating of the entire trunk after mild exercise or even after mental stress as a result of severe compensatory hyperhidrosis occurring after endoscopic thoracic sympathectomy for hyperhidrosis of the head. Source : From Ref. 68, p. 271.

Source: From Ref. 68, p. 268.

neurotoxin type A (BoNTA) has been most extensively studied and used clinically to treat HH, but botulinum neurotoxin type B (BoNTB) has also been reported to work. The basic principle for using BoNTs to treat excessive sweating is to treat any underlying etiology as already discussed. Then the area of sweating should be identified using a colorimetric test such as the Minor’s iodine-starch test (Fig. 15.2). Since the sweat glands are typically located at the junction of the dermis and subcutaneous fat, BoNT is usually placed as a deep intradermal injection. It is important to avoid injecting deeper structures such as muscle to prevent unwanted affects on the underlying muscles and for optimal BoNT interaction at the neuron–eccrine interface. Injections are generally placed 1 to 2 cm apart to allow for diffusion to the entire area. Although this basic technique is used to treat all areas of the body, the more commonly treated sites will be covered in more detail. Due to the differences using the different BoNTA products, the newly assigned nonproprietary names will be listed when necessary. AXILLARY HYPERHIDROSIS

Figure 15.3 Iontophoresis procedure for palmar hyperhidrosis. To achieve satisfactory anhidrosis on both hands, it is important that both hands are treated in the anodal bath (red current). Therefore, after 10 minutes the red current plug has to be switched from one hand to the other and the treatment has to be repeated in the same manner. For palmoplantar therapy the treatment principles remain the same, but both hands are bathed in one and the feet in the other pan. Source : From Ref. 68, p. 270.

The incidence varies, but approximately 60 to 70% of patients seem to develop it, with its occurrence and severity being unpredictable (35,38,39). BOTULINUM TOXIN THERAPY

Since sweating is mediated by acetylcholine the use of botulinum neurotoxin (BoNT) to treat focal HH is a logical choice. The chemodenervation is localized, reversible, and yet long-lasting. Botulinum

No area has been as extensively studied as the axilla (14,40–45) with numerous studies showing the benefit of BoNTA, including large multicenter randomized, placebo-controlled trials in Europe and the United States. Naumann et al. reported on 320 patients with axillary HH that received 50 U of BoNTA (BOTOX® or onabotulinumtoxinA) per axilla or placebo (44). At 4 weeks, 94% of the onabotulinumtoxinA group had responded compared with 36% of the placebo group as measured by ≥50% reduction of sweat production from baseline. By 16 weeks, the response rates were 82% and 21%, respectively. Repeated injections with onabotulinumtoxinA over 16 months continued to produce similar results (40). The mean duration between onabotulinumtoxinA treatments was approximately 7 months and patient satisfaction was high. Similar results were published in a large phase III double-blind trial in North America (45). Subjects with axillary HH were randomized to receive placebo, 50 U, or 75 U onabotulinumtoxinA into each axilla. The HDSS was the primary efficacy in this study with gravimetric measurements being secondary. Successful response was seen in 75% of patients in both treatment groups compared with 25% in the placebo group (defined as ≥2 point reduction in HDSS) while 80 to 85% of the treated subjects had >75% reduction in sweat production. No significant differences were noted between the two

BOTULINUM TOXIN IN THE MANAGEMENT OF FOCAL HYPERHIDROSIS doses of onabotulinumtoxinA and the durability of therapy was approximately 7 months for both. A 3-year open label extension study revealed continued effectiveness and with similar duration of results (46). Specifically, the researchers were able to show a significant sustained improvement in the quality of life of subjects. The DLQI revealed significant improvement in overall quality of life and occupation and work-specific improvements were noted as well. The efficacy of Dysport® (abobotulinumtoxinA) has been shown in several studies. A multicenter trial of 145 subjects was performed with 200 U abobotulinumtoxinA in one axilla while the contralateral axilla was injected with placebo (41). After 2 weeks, the placebo-treated axilla was injected with 100 U abobotulinumtoxinA. Axillary sweating decreased within 2 weeks in both treatment sides and results were maintained for 6 months. There were no significant differences gravimetrically between the two doses used. Therapy was well-tolerated and 98% of subjects said they would recommend the therapy to others. Although studies have consistently shown that 50 U onabotulinumtoxinA per axilla provides safe and durable results (averaging ∼7 months), there is some debate whether higher doses of onabotulinumtoxinA can provide prolonged efficacy (47,48). One small open label study of 200 U onabotulinumtoxinA per axilla in 47 patients found prolonged results (over 19 months) in half of the patients, although the methodology was very different from other studies; starch iodine and telephone calls were used to assess patients (47). Likewise, 250 U of abobotulinumtoxinA (42) in each axilla resulted in prolonged benefit in a small study of 12 patients. Half remained symptom-free for 12 months and 9 months was achieved for 25% of the subjects (42). Currently the standard dose in the United States, and that listed in the package insert for onabotulinumtoxinA is 50 U per axilla. This achieves excellent results, high patient satisfaction, and helps to keep costs down. There is no such dosing consensus on other brands of BoNTA products. To optimize treatment, the area of axillary involvement should be identified before treatment by a Minor’s iodine-starch test (as previously reviewed) so that the BoNTA can be concentrated into the affected area. The key to performing a high-quality iodine-starch test is to thoroughly dry the region before beginning the test (Fig. 15.2). The axilla does not need to be shaved prior to performing an iodinestarch test or to injecting BoNTA. The BoNTA is injected into the deep dermis at the dermal subcutaneous level and placed 1.5 to 2 cm apart. Because the axillary skin is thin, a wheal should be seen with each injection. An average of 10 to 15 injections per axilla are required, but will depend on the size of the axilla and hyperhidrodic area (49). In the event that an iodine-starch test cannot be performed prior to treatment or is equivocal, the physician should treat the hair-bearing areas as descried above. Should symptoms fail to be alleviated within 2 weeks, the patient can return to the office and an iodine-starch test performed to identify any “active” eccrine glands. The skin should be injected with 3 to 5 u of onabotulinumtoxinA for each 1 cm surface area identified. Pain is minimal and the procedure is well tolerated. Although the package insert describes the use of unpreserved saline to reconstitute BoNTA, many physicians have found that the use of preserved saline reduces pain without altering efficacy (50,51). The use of 2% lidocaine to reconstitute BoNTA has been reported in one small study to be less painful than the use of unpreserved saline when injecting axillary HH and with equal efficacy (52). Side effects noted in studies include pain, hematoma, bruising, headache, muscle soreness, increased facial sweating, perceived compensatory sweating, and axillary pruritus. Treatment intervals are mandated by the longevity of an individual’s treatment response but will average every 6 to 7 months. Some clinicians have advocated that patients use a topical therapy twice a week when the sweating starts to return to try and extend the time interval between injections and help to keep costs to a minimum (53).

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PALMAR HYPERHIDROSIS

BoNT injections are useful in the treatment of palmar HH. No largescale studies have been published but multiple small studies have demonstrated the ability of BoNT to establish clinical improvement in patients’ symptoms (23,54,55). Several challenges exist when treating hands such as choosing optimal doses, control of pain during injection, and side effects which include muscle weakness (23,56–60). The optimum dose of BoNTA to control palmar HH is unknown and the issue is complicated by large variations in hand size (Fig. 15.5). Published data report doses as low as 50 U per hand and as high as 200 U onabotulinumtoxinA per hand (55,61). Doses of abobotulinumtoxinA have ranged from 120 U per hand to 500 U per hand (22,54,62). Some authors have suggested using a defined dose per injection, with Swartling’s group using 0.8 U/cm2, and Naumann’s group using 2 U onabotulinumtoxinA injected every 1.5 cm on the palm but 3 injections per fingertip and two injections into each of the middle and proximal phalanx using 1 to 2 U per injection (55,63). The Canadian advisory committee recommends 1.5 to 2 u/cm2 with a mean dose of 100 U onabotulinumtoxinA per palm (7). It is unclear whether or not larger doses add to the duration of symptom relief or increase the risk of developing muscle weakness. When Wollina used 200 U of onabotulinumtoxinA per hand in 10 patients, his relapse time varied from 3 to 22 months (61). Saadia studied 24 patients: 11 received 50 U onabotulinumtoxinA per hand and 13 received 100 U/ hand. There was higher patient satisfaction reported in the high-dose group, but no difference in terms of duration (measured as a percentage of the palm area sweating) for the two doses. There were more patients with hand and finger weakness in the high-dose treatment group (55). Until larger studies

Figure 15.5 Variations in hand size. The larger hand is that of a 17-year-old male while the smaller hand is that of a 16-year-old girl. Hand size variations need to be taken into consideration when dosing BoNTA for palmar hyperhidrosis.

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are available to address this issue, 75 to 100 U onabotulinumtoxinA per hand is a good starting point with adjustments being made as needed based on the size of the hand and past responses (27). Another challenge with palmar BoNT therapy is an apparent shorter duration of response when compared with axillary injections (56). Responses range from 3 to 12 months (64). Aghaei found that anhidrosis lasted up to 5 months for his patients treated with 500 U abobotulinumtoxinA per hand (62), although he observed hypohidrosis lasting an average of 10 months (62). The reason for this shorter duration is unknown but may be (64) related to a smaller diffusion radius in the thicker palm skin and compartmentalized areas of the phalanges, a higher number of cholinergic nerve endings or a differential recovery rate of the nerves in the hands compared with the axilla. Backflow of the BoNT solution upon injection can be an issue with palmar injections and perhaps this plays a role as well (65). Injection of the hand can be quite painful due to the density of nerve receptors and the large numbers of injections that are required. Pain during injection of the palm has been rated an average 68.1 ± 31.8 compared to 29.9 ± 24.5 for axillary treatment (using a visual analogue scale 1–100) (15). Several methods of pain control have been tried (Table 15.7), although a rare patient will not require anesthesia. Topical anesthetic containing lidocaine and cold packs tend not to provide adequate pain control. More intensive cold exposure can be helpful: the use of dichlorotetrafluoroethane or liquid nitrogen, submersion of the hand in an ice bath, direct exposure of an ice cube or ice pack (66,67). Machines that emit chilled air or utilize a chilled tip can be beneficial but more expensive. Kreyden describes a technique of iontophoresis with 2% lidocaine for 30 minutes, followed by a light spray of liquid nitrogen just prior to inserting the needle to inject BoNTA (68). The use of a dermojet to inject BoNTA was found to be less painful than standard needle injections, but was much less effective in controlling the sweating and thus not recommended as a useful tool to treat the palms (69). Benohanian has described the used of a pressure unit to inject lidocaine into the palms and soles without the use of needles, before injecting BoNTA (70). The Med-JetMBX II (MIT Canada) (71) device system consists of a CO2-powered variable dose injector to which a 12 cc disposable syringe is attached containing lidocaine. When the trigger is pulled, a volume of 0.02 to 0.3 cc anesthesia is injected to the targeted depth within the skin. The starting pressure is typically around 130 psi (with a range of 1 to 350 psi) depending on the epidermal thickness. The device is approved by Health Canada and the European Union. After the anesthetic wheals appear, BoNT can be administered with a standard needle system. Nerve blocks are effective and can be performed in the office (63,72–74). The palm is innervated by three nerves, median, ulnar and radial nerves. All can be anesthetized at the level of the wrist using 1% or 2% lidocaine (Fig. 15.6). Risks of a nerve block include infiltration of the nerve with subsequent nerve injury and vascular puncture. In addition, temporary hand weakness after the nerve blocks may limit the patients’ activities and ability to have both hands treated at one session.

A 30G 0.5-inch needle should be used to minimize any nerve trauma. Approximately 2 cc of 1% or 2% lidocaine is injected around each of the nerves. If the patient feels any unusual tingling or sensation during the injection, the needle should be withdrawn slightly. Twenty minutes or more may be necessary for the full effect to develop. Intravenous regional anesthesia (IVRA), also known as a Bier’s block is effective (75,76). An anesthetic such as prilocaine is injected intravenously following the application of a tourniquet cuff on the forearm. Exsanguination of the extremity is performed and an electronic double cuff is applied. Complete anesthesia is obtained in 20 minutes using 40 to 60 ml of 0.5% prilocaine. The total tourniquet time for IVRA ranges from 50 to 80 minutes and is well-tolerated. Due to the risk of toxic cardiovascular and central nervous system reactions, blood pressure and electrocardiogram are monitored during the IVRA and for about 30 minutes after the procedure. Vibratory anesthesia is gaining popularity (77). The theory is that the nervous system is unable to perceive fully two different types of sensory inputs simultaneously. A handheld vibrator is applied to the volar and dorsal surface of the hand near the site of BoNTA injection. This requires an assistant and there is some movement of the patient’s hand, which can make injections challenging. The use of one vibrator to the volar aspect does not diminish pain as much as the use of two vibrators (personal experience). Neither technique results in a painfree injection, but rather a diminishment of perceived pain. A study by Sherer found that pain threshold is significantly higher during vibration compare to pre- or postvibration, and that vibration applied distal to the site of pain provided better analgesia than vibration applied proximal to the site of pain (78). The author most commonly uses ice with pressure at this time for palmar injections. An ice cube is applied firmly to the planned injection site for 7 to 10 seconds (Fig. 15.7). If the patient requires additional pain control, a combination of ice and vibration is used. Ice is applied firmly to the area for 7 to 10 seconds and then the vibrator is firmly applied immediately adjacent to the injection site simultaneous to the injection (no more than 2–3 seconds). This technique does require an assistant and coordinated timing to optimize pain control. A 30G 0.5-inch needle with a leur lock syringe or insulin type syringe is especially helpful because of the thicker skin and higher pressures needed to inject the palm. Injections should be placed every 1 to 1.5 cm but the digits will usually need two to three injection sites per phalangeal unit (Fig. 15.8). Bruising is common with injections into the palm, but it is temporary. Weakness of the hand or fingers is possible but is usually minor

Radial nerve distribution

Radial injection site

Median nerve distribution

Table 15.7 Anesthesia Techniques Used for Palmar Injections Topical anesthesia Nerve blocks Cryoanalgesia

Dichloretetrafluoroethane Liquid nitrogen spray Ice cubes, ice pack, or ice bath Cold packs Machine-assisted cold air

Vibration Intravenous regional anesthesia (Bier’s block) General anesthesia or sedation anesthesia

Median injection site

Ulnar nerve distribution Ulnar injection site

Figure 15.6 The palm is innervated by the ulnar, median, and radial nerves. Nerve blocks are usually performed at the wrist.

BOTULINUM TOXIN IN THE MANAGEMENT OF FOCAL HYPERHIDROSIS

121

Children with palmar hyperhidrosis can be treated with BoNTs but pain control remains the biggest challenge. Less is known about the dosing, duration, and adverse events associated with pediatric use. Coutinho dos Santos published a series of nine children aged 6.5 to 15 years with palmar HH successfully treated with onabotulinumtoxinA. Nerve blocks were used for pain control and doses of 75 to 150 units were given per palm (83). PLANTAR HYPERHIDROSIS

Figure 15.7 Ice is firmly applied to the palm for 7–10 seconds before injection of botulinum toxin.

Figure 15.8 Typical injection pattern of palm and digits.

and of limited duration. The incidence varies in published series, but ranges from 0 to 77% (23,55–57,79). The most commonly affected area of weakness is the thenar eminence and can be measured in the thumbindex finger pinch, whereas gross strength or grip strength of the hand is not usually affected (55,58). Rarely, patients report numbness, tingling, or decreased dexterity. Injections of BoNTA should be in the dermal layer, especially over the thenar eminence to limit the chance that the drug will come in contact with the muscle layer. Subepidermal injections may increase the incidence of hematoma (57). There is one report of atrophy of the intrinsic musculature of the hands with “debilitating” weakness associated with BoNTA injections for palmar HH, after five treatment sessions using 500 U abobotulinumtoxinA per palmar basin every nine months (80). Patients should be adequately counseled on the risks of weakness, which is usually mild and transient. In an attempt to prevent muscle weakness, Zaiac advocates the use of the ADG® needle, a device designed for the injection of collagen (81). He found the average depth of the eccrine glands in 10 consecutive palmar biopsies to be 2.6 mm. By adjusting the needle to a length of 2.6 mm and using a total of 60 to 70 U onabotulinumtoxinA per palm, he had no weakness in a series of 10 patients. Likewise, Almeida uses an adapter to shorten her 7 mm 30G needle to measure 2.5 to 3.0 mm for palmar injections (60,82).

Very little has been published on BoNT therapy for plantar HH. Like the palms, there is no consensus on the optimal dose, the duration is variable and the injections are painful. Naumann used 42 and 48 units of onabotulinumtoxinA to treat two soles by injecting 3 U onabotulinumtoxinA (0.15 ml) into each 2 × 2 cm squares (84). Blaheta’s group used 100 U onabotulinumtoxinA per sole (100 U/5 ml saline) in a study of eight patients with severe plantar hyperhidrosis (85). Campanati studied 10 patients with plantar hyperhidrosis using 100 U onabotulinumtoxinA per foot. All patients had an improvement in symptoms and a “significant decrease of Minor’s test” for 12 weeks without significant side effects (86). An iodine-starch test will delineate the hyperhidrotic area, which can extend up the sides and onto the dorsum of the foot. BoNTA should be evenly distributed every 1 to 2 cm using small gauge needles and injecting into the deep dermis. Injections of the plantar surface can be technically more challenging due to the thickness of the stratum corneum in some areas, especially if calloused. The physician has to adjust for the variation in depth to accurately place BoNTA into the appropriate cutaneous level. The need for pain control has to be addressed like with palmar injections. IVRA can provide sufficient anesthesia for the sole and has been reported to be effective when administering BoNTA. In a small series of eight patients, IVRA was found to be more effective than nerve blocks in reducing the pain of BoNTA injections (87). However, nerve blocks can also be used and are generally performed at the level of the ankle (Fig. 15.9). The tibial and sural nerves need to be blocked, and if the dorsum of the foot must be injected, the superficial peroneal nerve can be anesthetized (82). Vadoud-Seyedi reported on using the Dermojet to inject BoNTA for plantar HH. Ten patients were treated with 50 U onabotulinumtoxinA/5 ml saline per foot. Fifteen to twenty points were injected per foot and no analgesia was used. The injections were tolerated well by all patients, although one developed a localized hematoma. The duration of benefit lasted 3 to 6 months, however, 20% of patients reported the treatment had no effect on their condition (88). At this time, the author’s preferred method of pain control is ice combined with vibration as described earlier (Fig. 15.10). Doses of 100 to 200 U onabotulinumtoxinA per foot are typically required. Bruising and pain with injection are the most common side effects. In the published literature, one patient reported weakness of plantar flexor muscles in both feet following BoNTA injections, with resolution in 10 days (89). FACIAL HYPERHIDROSIS

Primary facial HH has several patterns, but most commonly involves the forehead plus or minus the scalp. Patients with craniofacial HH may present with involvement of the forehead, scalp perimeter, entire scalp, cheeks, nose, upper lip, chin, or a combination of the areas (Fig. 15.11). Gustatory sweating is a relatively common complication after surgery or injury in the region of the parotid gland and will be discussed later in the chapter. All forms of facial HH can respond to BoNTA, with gustatory sweating responding for very long periods of time. There is a paucity of literature published on craniofacial hyperhidrosis. Kinkelin’s group injected a mean of 86 U onabotulinumtoxinA

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(A)

(C)

(B) Figure 15.9 The injection point of tibialis. (A) Saphenous block, 1 = medial malleolus, 2 = posterior tibialis artery, 3 = injection points for tibialis block, 4 = area of subcutaneous infiltration for saphenous block; (B) Fibularis block, 1 = lateralis malleolus, 2 = area of subcutaneous infiltration for saphenous block; (C) Profundus block, 1 = dorsalis pedis artery, 2= injection points for fibularis profundus block. Source : From Ref. 68, p. 282.

Figure 15.10 When ice and vibration is combined, ice is applied with firm pressure for 7–10 seconds before applying vibration to the immediate treatment area.

(3 U BoNTA per injection site) over the forehead at equidistant locations (1–1.5 cm) in 10 men with frontal hyperhidrosis (90). The injections were kept 1 cm superior to the eyebrow to help prevent drooping of the eyelid; injections were intracutaneous. Five of 10 patients had partial disability in frowning of the forehead, but was limited to a maximum of 8 weeks. There was no ptosis noted and satisfaction was good or

excellent in 90% of the subjects. The benefits were maintained for 5 months in 90% of patients. Similarly, Tan and Solish report that symptoms return on average 4 1 2 months after treatment of the forehead (15). Böger treated 12 men suffering from bilateral craniofacial hyperhidrosis with abobotulinumtoxinA 0.1 ng per injection (91). Half of the forehead was treated using a total of 2.5 to 4 ng injected equidistantly with a total of 25 to 40 injections given. Decreased sweating was seen within 1 to 7 days after injection and lasted a minimum of 3 months, but one patient experienced anhidrosis for 27 months. Side effects were limited to temporary weakness of the frontalis muscle (100%), and brow asymmetry that lasted 1 to 12 months in 17% of subjects. It is the observation of the author that patients typically present with forehead sweating that may be combined with scalp sweating in a diffuse pattern or in an ophiasis pattern. OnabotulinumtoxinA injections are performed with 2 to 3 U every 1 to 2 cm avoiding the inferior 1 to 2 cm of the forehead to reduce the risk of brow ptosis (92) (Figs. 15.12 and 15.13) The forehead can be treated more inferiorly if the response is not sufficient and the patient is willing to accept brow ptosis. Doses range from 50 U (forehead) to 250 to 300 U for the forehead and entire scalp (92). GUSTATORY SWEATING (FREY’S SYNDROME)

Gustatory sweating occurs on the cheek in response to salivation or anticipation of food. It may result from misdirection of autonomic nerve fibers after surgery and is frequently observed in diseases of the parotid gland and in diabetes.

BOTULINUM TOXIN IN THE MANAGEMENT OF FOCAL HYPERHIDROSIS

(A)

123

(C)

(B) Figure 15.11 Cranio-facial hyperhidrosis. Right side of face Minor’s iodine-starch test prior to treatment. (A) Right side of face, (B) forehead, and (C) left side of face. Source : Photographs courtesy of Anthony V. Benedetto, DO, FACP.

Figure 15.12 Injection pattern for craniofacial hyperhidrosis. Injections should be intradermal to avoid muscular affect.

BoNT is a highly effective treatment option for gustatory sweating as shown by several uncontrolled studies (93–97) (Table 15.8). In a large open study of 45 patients, there was a significant reduction of local facial sweating after injection of onabotulinumtoxinA using a mean dose of 21 U (range 5–72 U) and no recurrence of sweating was observed during the follow-up period of 6 months. A marked long-lasting benefit of 11 to 36 months was also observed in three other open studies (95–97). Thus, BoNT appears to have a particularly long-lasting effect on gustatory sweating. The reason for this is unclear. In clinical practice, the Minor’s iodine-starch test should be performed before injection to visualize the affected area that has to be injected (Fig. 15.14). After the iodine and starch have been applied to the area, the patient should chew on a piece of candy or food to stimulate the facial sweating. Injections with 2 to 3 U onabotulinumtoxinA or 8 U abobotulinumtoxinA are given intradermally at sites 2.0 to 2.5 cm apart and evenly distributed over the affected area. Specific side-effects of the injection of BoNT include pain on injection, local hematomas, and local

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Figure 15.13 Injection into the hairline for therapy of forehead hyperhidrosis.

Table 15.8 Selected Studies on BoNTA Treatment of Gustatory Sweating Author

Year

Design

n

Dose (mean)

Naumann et al. (94)

1997

Open

45

Bjerkhoel and Trobbe (95)

1997

Open

15

Laskawi et al. (96)

1998

Open

19

Laccourreye et al. (97)

1999

Open

33

21 mu onabotulinumtoxinA 37 mu onabotulinumtoxinA 31 mu onabotulinumtoxinA 86 mu abobotulinumtoxinA

Figure 15.14 Patient with Frey syndrome. Distinct hyperhidrosis of a confined area of the cheek during or after eating due to misdirected re-sprouting of postsynaptic salivomotor parasympathetic fibers after parotid gland surgery or infection. Source : From Ref. 68, p. 288.

Duration (mo) 6

13

11–27

12–36

muscle weakness due to diffusion of the toxin to adjacent muscles (particularly, the zygomatic muscle). OTHER SWEATING DISORDERS

Inguinal HH affects 2 to 10% of individuals with primary HH (14). It usually develops in adolescence and can be associated with excessive sweating at other body sites. Intradermal injections of BoNTA can control symptoms for 6 months or more. Identifying the surface areas that needs injection by the iodine-starch test can be technically challenging due to the body location, but is valuable (Fig. 15.15). Two to three units onabotulinumtoxinA are injected every 1 to 2 cm within the affected area; typical doses range from 60 to 100 U per side (98). Compensatory sweating is the most common complication of endoscopic transthoracic sympathectomy (ETS), ranging from 44% to 91% (99) (Figs. 15.4 and 15.16) Treatment has been particularly difficult but a couple of reports noted success using BoNTA. Huh used 300 U abobotulinumtoxinA to treat the chest and abdomen after identifying the area with an iodine-starch test (99). He diluted each 100 U of onabotulinumtoxinA with 10 ml saline and injected 0.1 ml into each square centimeter. The effects gradually reduced but were reported to remain for 8 months. Belin and Polo reported good results treating the upper abdomen with onabotulinumtoxinA, but unfortunately their patient’s compensatory sweating was from the nipple line down to his knees and the entire area was not treated (37). Kim and colleagues

Figure 15.15 Hyperhidrosis of the left groin area after a Minor’s iodine-starch test. As shown the affected area can be extensive, which has to be considered before treatment. Source : From Ref. 68, p. 290.

reported on 17 patients with severe compensatory hyperhidrosis being treated with BoNTA (100). One hundred to 500 units of onabotulinumtoxinA were used, administering 2 units every 1.5 cm. The injections were well-tolerated, but the authors noted incomplete resolution of the sweating due to insufficient dosing, and the duration lasted only 4 months. Chromhidrosis is a rare disorder characterized by the excretion of colored or pigmented sweat. It is most commonly confined to the face or axilla but has been noted elsewhere on the body. Matarasso used 15 U onabotulinumtoxinA into the affected area of each cheek which measured 3 cm in diameter. Within 48 hours, the patient had a marked reduction in the amount of discharged black sweat (101).

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125

Figure 15.16 Typical Minor’s iodine-starch test of a patient with compensatory hyperhidrosis after endoscopic thoracic sympathectomy for hyperhidrosis of the forehead. Note the anhidrotic area of the upper trunk (no coloration) and the (compensatory) hyperhidrotic purple area of the chest. Source: From Ref. 68, p. 290.

Figure 15.18 Patient with localized unilateral hyperhidrosis on his right wrist, showing the dripping hyperhidrosis after the Minor’s iodine-starch test. Source: From Ref. 68, p. 291.

colon (103). The pathogenesis of Ross syndrome is unknown. Multiple neuropathies of the autonomic nervous system or a failure in the synthesis or release of neurotransmitters have been suggested as possible causes (102). There is no histologic evidence of nerve fiber destruction. Therefore Ross postulated a defect in acetylcholine cholinesterase activity, rather than the degeneration of sweat glands. The progression of Ross syndrome is very slow. There is no therapy for the segmental progressive anhidrosis. The bothersome compensatory hyperhidrosis can be improved, however, with systemic antimuscarinic drugs or with injections of BoNTA into the affected areas, usually the face. In 1992 Itin et al. (104) presented a case study of a patient suffering from Ross syndrome with a defined area of anhidrosis in the right hand, the right axilla, and the right side of the face. In follow-up, after 11 years, the patient presented with additional anhidrotic areas in the right hemithorax and the underside of the left arm (Fig. 15.17). Unfortunately the patient refused treatment with onabotulinumtoxinA, even though the hyperhidrosis was so severe that electrolyte replacement was necessary (unpublished data). Figure 15.17 Patient with Ross syndrome characterized by progressive segmental anhidrosis with a compensatory band of excessive perspiration leading the patient to the physician. This is the very same patient 11 years after Itin et al. (46) first published their case study, showing extensive progression of the disease (unpublished data). Source: From Ref. 68, p. 289.

ROSS SYNDROME

Ross syndrome was first described by the neurologist Alexander T. Ross in 1958 (102). It is characterized by the triad of unilateral tonic pupils, generalized areflexia (Holmes–Adie syndrome), and progressive segmental anhidrosis with a compensatory band of excessive perspiration. Patients suffering from Ross syndrome usually do not perceive the hypohidrosis; instead, it is the compensatory segmental hyperhidrosis that is bothersome. In addition, many patients suffer from several symptoms of vegetative dysfunction, such as palpitation, stenocardia, orthostatic hypotonia, and irritable

Localized Unilateral Hyperhidrosis Localized unilateral hyperhidrosis (LUH) is a rare form of idiopathic localized hyperhidrosis and is defined as a confined area of hyperhidrosis of less than 10 × 10 cm, mainly found on the forehead or the forearm, whose pathogenesis is unknown (Fig. 15.18). Beside the unusual localization, the major difference from essential hyperhidrosis is that LUH has no typical triggering factor and occurs even while patients are asleep. The etiology of LUH is unknown but may be due to a misdirected reconnection of the sympathetic nerve fiber network after injury, similar to the Frey syndrome (105). Before onabotulinumtoxinA, no treatment was available for this distinctive but enigmatic skin disorder. However, excellent results have been experienced following injection of 30 U onabotulinumtoxinA in a patient suffering from LUH (105). USE OF BOTULINUM TOXIN TYPE B FOR HYPERHIDROSIS

Botulinum neurotoxin type B (BoNTB) use has been primarily limited to treatment of cervical dystonia, but there are a few reports of its use

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for treating HH. Injection of BoNTB can induce focal anhidrosis in a dose-dependant fashion. Birklein found that a threshold dose of 8 U Neurobloc®/Myobloc® (rimabotulinumtoxinB) led to anhidrotic skin areas greater than 4 cm after 3 weeks. The duration was prolonged for 3 months when 15 U BoNT-B were injected, and for 6 months when 125 U were injected (106). Despite its ability to induce anhidrosis, the use of BoNTB is limited by the occurrence of systemic adverse events (107). Dressler reported that 100 U onabotulinumtoxinA, 2000 U rimabotulinumtoxinB, and 4000 U rimabotulinumtoxinB were equally effective in blocking axillary sweating when studying 19 HH patients (108). The extent of improvement was similar (16 weeks) in all groups, but the onset of action was earlier with the rimabotulinumtoxinB and there was greater discomfort with the rimabotulinumtoxinB compared with onabotulinumtoxinA. One patient developed severe dryness of the mouth starting 1 week after injection, lasting 5 weeks as well as accommodation difficulties and conjunctival irritation that lasted 3 weeks. Likewise, patients treated with 5000 U rimabotulinumtoxinB in each axilla achieved excellent reduction in sweating, but the incidence of side effects was high and included dry mouth, headache, and sensory motor symptoms of the hand (109). A patient treated with 2500 U BoNTB to each palm for HH developed bilateral blurred vision, indigestion, dry sore throat, and dysphagia (110). The largest published study to date on BoNTB to treat palmar HH included 20 subjects used 5000 U per palm (111). Adverse events were common: dry mouth or throat (90%), indigestion (60%), excessively dry hands (60%), muscle weakness (60%), and decreased grip strength (50%). Lower dosing may be the key to reducing the high incidence of side effects (112). However, because of the incidence of systemic side effects using BoNTB and the high safety profile using BoNTA to treat focal hyperhidrosis, to date, BoNTA is the neurotoxin of choice. FUTURE DIRECTIONS

The use of botulinum toxins has revolutionized the treatment of HH and other secretory disorders. Compared with other treatments, it is unmatched in its efficacy, ease of administration, and patient satisfaction. Development of quick, safe, and effective pain control is needed for the treatment of more tender areas such as the palms and soles. New delivery devices are already being researched to help provide the most comfortable and efficient therapy. Kavanagh and colleagues have successfully used a small iontophoresis machine to deliver BoNTA to two patients with severe palmar hyperhidrosis, sparing them the injections (113). Glogau demonstrated that onabotulinumtoxinA can be successfully delivered into the axillary skin when combined with a proprietary transport peptide molecule (114). Research is ongoing looking at the clinical applications of different BoNT serotypes. Another area of potential research is with combination therapy. For the present, BoNT therapy is a valuable, well-tolerated therapy and can provide meaningful improvement in the quality of life of patients with HH and other secretory disorders. REFERENCES

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64.

65. 66.

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79. 80.

81. 82.

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT treatment in palmar hyperhidrosis. J Am Acad Dermatol 2004; 50: 61–2. Perez BA, Avalos-Peralta P, Moreno-Ramirez D, Camacho F. Treatment of palmar hyperhidrosis with botulinum toxin type A: 44 months of experience. J Cosmetic Dermatol 2005; 4: 163–6. Glogau R. Treatment of hyperhidrosis with botulinum toxin. Dermatologic Clinics 2004; 22: 177–85. Kontochristopoulos G, Gregoriou S, Zakopoulou N, Rigopoulos D. Cryoanalgesia with dichlorotetrafluoroethane spray versus ice packs in patients treated with botulinum toxin a for palmar hyperhidrosis: self-controlled study. Dermatol Surg 2006; 32(6): 873–4. Smith K, Comite SL, Storwick GS. Ice minimizes discomfort associated with injection of botulinum toxin type A for the treatment of palmar and plantar hyperhidrosis. Dermatol Surg 2007; 33: S88–91. Kreyden OP. Botulinum Toxin in the Management of Focal Hyperhidrosis. In: Benedetto, AV, ed. Botulinum Toxin in Clinical Dermatology. Taylor & Francis, 2006; Chapter 10: pp. 281–285. Naumann M, Bergmann I, Hofmann U, Hamm H, Reiners K. Botulinum toxin for focal hyperhidrosis: technical considerations and improvements in application. Br J Dermatol 1998; 139: 1123–4. Benohanian A. Needle-free anaesthesia prior to botulinum toxin type A injection treatment of palmar and plantar hyperhidrosis. Br J Dermatol 2007; 156(3): 593–6. Benohanian A. What stands in the way of treating palmar hyperhidrosis as effectively as axillary hyperhidrosis with botulinum toxin type A. Dermatol Online J 2009; 15(4): 12. Trindade de Almeida AR, Kandunc BV, Martins de Oliveira. Improving botulinum toxin therapy for palmar hyperhidrosis. Derm Surg 2001; 27: 34–36. Hayton MJ, Stanley JK, Lowe, NJ. A review of peripheral nerve blockade as local anaesthesia in the treatment of palmar hyperhidrosis. Br J Dermatol. 2003; 149: 447–451. Campanati A, Lagalla G, Penna L, Gesuita R, Offidani A. Local neural block at the wrist for treatment of palmar hyperhidrosis with botulinum toxin: technical improvements. JAAD 2004; 51(3): 345–348. Vollert B, Blaheta H, Moehrle E, Juenger M, Rassner G. Intravenous regional anaesthesia for treatment of palmar hyperhidrosis with botulinum toxin type A. Br J Dermatol 2001; 144: 632–3. Ponce-Olivera RM, Tirado-Sanchez A, Arellano-Mendoza MI, Leon-Dorantes G, Kassian-Rank S. Palmar hyperhidrosis. Safety efficacy of two anaesthetic techniques for botulinum toxin therapy. Dermatology Online J 2006; 12(2): 9. Reed M. Surgical pearl: mechanoanesthesia to reduce the pain of local injections. J Am Acad Dermatol 2001; 44: 671–2. Scherer C, Clelland J, O’Sullivan P, Doleys D, Canan B. The effect of two sites of high frequency vibration on cutaneous pain threshold. Pain 1986; 25(1): 133–8. Solomon B, Hayman R. Botulinum toxin type A therapy for palmar and digital hyperhidrosis. J Am Acad Dermatol 2000; 42: 1026–9. Glass GE, Hussain M, Fleming AN, Powell BW. Atrophy of the intrinsic musculature of the hands associated with the use of botulinum toxin-A injections for hyperhidrosis: a case report and review of the literature. J Plastic Reconstr Aesthetic Surg 2009; 62(8): 274–6. Zaiac M, Weiss E, Elgart G. Botulinum toxin therapy for palmar hyperhidrosis with ADG needle. Dermatol Surg 2000; 26: 230. Trindade de Almeida A, Boraso R. Palmar hyperhidrosis. In: Trindade de Almeida A, Hexsel D, eds. Hyperhidrosis and Botulinum Toxin. Sao Paulo: Know-how Editorial Ltd, 2004: 155–62.

83. Coutinho dos Santos C, Gomes A, Giraldi S, Abagge K, Marinoni L. Palmar hyperhidrosis: long-term follow-up of nine children and adolescents treated with botulinum toxin type A. Pediatr Dermatol 2009; 26(4): 439–44. 84. Naumann M, Hofmann U, Bergmann I, et al. Focal hyperhidrosis: effective treatment with intracutaneous botulinum toxin. Arch Dermatol 1998; 134(3): 301–4. 85. Blaheta H, Deusch H, Rasner G, Vollert B. Intravenous regional anesthesia (Bier’s block) is superior to a peripheral nerve block for painless treatment of plantar hyperhidrosis with botulinum toxin. J Am Acad Dermatol 2003; 48(2): 302–4. 86. Campanati A, Bernardini M, Gesuita R, Offidani A. Plantar focal idiopathic hyperhidrosis and botulinum toxin: a pilot study. Eur J Dermatol 2007; 17(1): 52–4. 87. Blaheta H, Deusch H, Rassner G, Vollert B. Intravenous regional anesthesia (Bier’s block) is superior to a peripheral nerve block for painless treatment of plantar hyperhidrosis. J Am Acad Dermatol 2003; 48(2): 301–3. 88. Vadoud-Seyedi J. Treatment of plantar hyperhidrosis with botulinum toxin type A. Int J Dermatol 2004; 43: 969–71. 89. Sevim S, Dogu O, Kaleagasi H. Botulinum toxin-A therapy for palmar and plantar hyperhidrosis. Acta Neurol Belg 2002; 102: 167–70. 90. Kinkelin I, Hund M, Naumann M, Hamm H. Effective treatment of frontal hyperhidrosis with botulinum toxin A. Br J Dermatol 2000; 143: 824–7. 91. Boger A, Herath H, Rompel R, Ferbert A. Botulinum toxin for treatment of craniofacial hyperhidrosis. J Neurol 2000; 247(11): 857–61. 92. Glaser DA, Herbert AA, Pariser DM, Solish N. Facial hyperhidrosis: best practice recommendations and special considerations. Cutis 2007; 79(5 Suppl): 29–32. 93. Drobik C, Laskawi R. Frey’s syndrome: treatment with botulinum toxin. Acta Otolaryngol (Stockh) 1995; 115: 459–61. 94. Naumann M, Zellner M, Toyka K, Reiners K. Treatment of gustatory sweating with botulinum toxin. Ann Neurol 1997; 42(6): 973–75. 95. Bjerkhoel A, Trobbe O. Frey’s syndrome: treatment with botulinum toxin. J Laryngol Otol 1997; 111(9): 839–44. 96. Laskawi R, Drobik C, Schonebeck C. Up-to-date report of botulinum toxin type A treatment in patients with gustatory sweating (Frey’s syndrome). Laryngoscope 1998; 108: 381–4. 97. Laccourreye O, Akl E, Gutierrez-Fonseca R, et al. Recurrent gustatory sweating (Frey syndrome) after intracutaneous injection of botulinum toxin type A: incidence, management, and outcome. Arch Otolaryngol Head Neck Surg 1999; 125: 283–6. 98. Hexsel D, Dal’forno T, Hexsel C. Inguinal, or Hexsel’s hyperhidrosis. Clin Dermatol 2004; 22(1): 53–9. 99. Huh C, Han K, Deo K, Eun H. Botulinum toxin treatment fore compensatory hyperhidrosis subsequent to an upper thoracic sympathectomy. J Dermatol Treat 2002; 13: 91–3. 100. Kim W, Kil H, Yoon K, Noh K. Botulinum toxin: a treatment for compensatory hyperhidrosis in the trunk. Dermatol Surg 2009; 35(5): 833–8. 101. Matarasso S. Treatment of facial chromhidrosis with botulinum toxin type A. J Am Acad Dermatol 2005; 52(1): 89–91. 102. Ross AT. Progressive selective sudomotordenervation. Neurology 1958; 8: 808–17. 103. Kreyden OP. Rare forms of hyperhidrosis. In: Kreyden OP, et al., eds. Hyperhidrosis and Botulinum Toxin in Dermatology. Basel: Karger, 2002; 30: 178–87. 104. Itin P, Hirsbrunner P, Rufli T, et al. Das Ross Syndrom. Hautarzt 1992; 43: 359–60. 105. Kreyden OP, Schmid-Grendelmeier P, Burg G. Idiopathic localized unilateral hyperhidrosis. Case report of successful treatment

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106.

107.

108.

109.

with botulinum toxin type A and review of the literature. Arch Dermatology 2001; 137: 1622–5. Birklein F, Eisenbarth G, Erbguth F, Winterholler M. Botulinum toxin type B blocks sudomotor function effectively: a 6 month follow up. J Invest Dermatol 2003; 121(6): 1312–6. Schlereth T, Mouka I, Eisenbarth G, Winterholler M, Birklein F. Botulinum toxin A (Botox) and sweating-dose efficacy and comparison to other BoNT preparations. Autonom Neurosci 2005; 117: 120–6. Dressler D, Abid Saberi F, Benecke R. Botulinum toxin type B for treatment of axillary hyperhidrosis. J Neurol 2002; 249: 1729–32. Nelson L, Bachoo P, Holmes J. Botulinum toxin type B: a new therapy for axillary hyperhidrosis. Br J Plastic Surg 2005; 58: 228–32.

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110. Baumann L, Halem M. Systemic adverse effects after botulinum toxin type B (myobloc) injections for the treatment of palmar hyperhidrosis. Arch Dermatol 2003; 139: 226–7. 111. Baumann L, Slezinger A, Halem M, et al. Double-blind, randomized placebo-controlled pilot study of the safety and efficacy of myobloc (botulinum toxin type B) for the treatment of palmar hyperhidrosis. Dermatol Surg 2005; 31: 263–70. 112. Hecht M, Birklein F, Winterholler M. Successful treatment of axillary hyperhidrosis with very low doses of botulinum toxin B: a pilot study. Arch Dermatol 2003; 295: 318–9. 113. Kavanagh G, Oh C, Shams K. BOTOX delivery by iontophoresis. Br J Dermatol 2004; 151: 1093–5. 114. Glogau R. Topically applied botulinum toxin type a for the treatment of primary axillary hyperhidrosis: results of a randomized, blinded, vehicle-controlled study. Dermatol Surg 2007; 33: S76–80.

16

One syringe wonder Mary P. Lupo

The art and science of injectable dermal fillers are continuing to evolve as techniques improve and safer, more durable, and more versatile fillers are brought to market. The science of dermal filler results has been documented in numerous double-blinded, controlled studies (1–3). Many articles have outlined off-label uses found to be safe and effective (4–7). Complications have been documented to help practicing physicians prevent and effectively treat the untoward result and prevent significant sequelae (8–14). The artistry of fillers is visible in the natural enhancement and augmentation that is possible by using good clinical judgment and meticulous injection technique. Economics for doctor and patients is an important, yet often neglected aspect of a filler practice in educational books, journals, and at meetings. This chapter will discuss the importance of optimal use of small amounts of filler in order to give patients who are either on a budget or simply apprehensive the ability to try one syringe and still get results. The emphasis will be on clinical judgment and the strategy needed during patient consultation, how to stretch one syringe, product choices, and injection tips. This premise was the result of my hearing so many complaints at live demonstrations that attendees could not relate to patient results that were based on four or more syringes being injected. They expressed dismay that they were not learning techniques they could reasonably use in their practices. Practicing in a somewhat economically depressed city, yet having a thriving filler practice I felt uniquely qualified to discuss this issue. I presented this lecture at several meetings, including American Society for Dermatologic Surgery (ASDS) and the Cosmetic Boot Camp and now in this textbook. WHEN TO SAY “NO,” HOW TO SAY “THAT IS ALL I CAN DO,” WHY TO SAY “YOU NEED IT HERE INSTEAD”

There are patients to whom one syringe will be a waste of money. To those patients, it is best to do nothing rather than have a patient waste their money. The truth is that this is very rare however, if you can make the patient understand exactly what only one syringe can realistically do. The 80-year old may want to look 50, but when they understand that it would take thousands of dollars of filler (and likely several laser sessions and a facelift), they may just settle for a syringe of filler around the lips to reduce lipstick bleeding (Figs. 16.1 and 16.2). The point is that communication is the key to success with fillers whether the patient is 30 or 80, and it is the one thing that will determine if you succeed in pleasing the patient. Remember, this is an elective procedure and your success will depend on whether the patient elects to do the procedure, and then you must deliver on their understood expectation for them to return a second time. I often show patients while he/she may need nasolabial, marionette, and cheeks done, with just one syringe, I can really only do the marionette well. So the first rule for a one syringe wonder is “Do a very good job with one syringe, and the patient will return for more.” Of course the corollary of this rule is if you do a poor job, you will never see them again. Never, therefore, take one syringe and spread it over multiple areas of need. That will result in a dilution of effect and no real visible improvement. The second rule therefore is “Use one syringe effectively in one area to maximize its impact.” Another very important tip is to complement the filler with botulinum toxin to enhance the effect. For example, I almost always throw

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in, at no charge on the first filler visit to treat the marionette area, 9 U to 15 U of botulinum toxin type A into the mentalis and depressor angularis oris to modulate the pull of these muscles that accentuate the marionette fold and pre-jowl sulcus (Figs. 16.3 and 16.4). Using a little toxin (4–10 U) into the obicularis oris makes one syringe of filler placed into lipstick lines work much better. Rule three: “Complement the benefit of one syringe with neurotoxin for greater effect.” PRODUCT SELECTION

There are several Food and Drug Administration (FDA) approved fillers available for injection. Hyaluronic acid (HA) fillers are the most popular. This is likely because of the documented safety of this filler, as well as the fact that it is reversible with hyaluronidase. In my practice, however, it is not the reason that it is my workhorse dermal filler. I have found great safety and effectiveness in all currently available fillers. The major advantage of HA is that it can go into the lips and others cannot. When I have a younger patient in need of a little softening of the nasolabial fold, they inevitably want “just a little in the lips” (Figs. 16.5 and 16.6). This means I cannot safely inject calcium hydroxy apatite, poly-L-lactic acid, or the current formulation of porcine collagen. These products have well-known problems with nodules when injected into the lips. For this reason, the fourth rule of one syringe wonder is “Hyaluronic acid fillers are the most versatile and can be stretched the easiest.” The large volume of material in and the stiffness of the product within the syringe actually make calcium hydroxy apetite one of the best options for a one syringe wonder, if the patient requires or desires no lip augmentation (Figs. 16.7 and 16.8). Finally, it is often very important to understand that the area of concern may not be where you actually should inject. The nasolabial fold should not be injected if there is mid-cheek lipoatrophy. This will result in a “monkey” look to the face by building up the fold when the patient would look more natural with cheek augmentation instead (Figs. 16.9 and 16.10). STRETCH THE ONE SYRINGE

There are some definite tricks to stretch the effectiveness of one syringe of dermal filler. The results of HA filler have the longest duration in the nasolabial fold when injected into the dermis. Non-HA fillers can, however, get a “woody,” indurated texture when injected into the dermis, so they should be injected just beneath the dermis for best results (Fig. 16.11). When injected beneath the muscle, long duration is also achieved. When the filler is injected into the subcutaneous tissue, much so the fifth rule is “When injecting dermal fillers, the least dramatic effect will be achieved if you are in the subcutaneous plane.” The angle of placing the needle for injection is also very important. When injecting cheeks, I recommend going in at 90° and placing the needle tip under the muscle above the periosteum, then pivoting the needle up toward the skin for injection in order to give the most dramatic lift of the cheeks. Deep bolus injections above the bone and beneath the muscle give very effective long-lasting correction with less material (Fig. 16.12). When injecting into the dermis, use the needle to scrape along the dermis and “subsize” the tissue. This will result in greater long-term

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Figure 16.1 Eighty-year old before 1 cc hyaluronic acid (HA) filler.

Figure 16.2 Eighty-year old after 1 cc hyaluronic acid (HA) filler.

Figure 16.3 Before 1.3 cc calcium hydroxyapatite and 15 U botulinum toxin.

Figure 16.4 After 1.3 cc calcium hydroxyapatite and 15 U botulinum toxin.

Figure 16.5 Seven months before 0.8 cc hyaluronic acid (HA) filler into scar, nasolabial fold, and lips of 32-year-old female.

Figure 16.6 Seven months after 0.8 cc hyaluronic acid (HA) filler into scar, nasolabial fold, and lips of 32-year-old female.

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Figure 16.7 Before 1.3 cc CaHA into nasolabial and marionette of 52-year-old

Figure 16.8 After 1.3 cc CaHA into nasolabial and marionette of 52-year-old female.

female.

Figure 16.9 Before 0.8 cc hyaluronic acid (HA) filler into cheeks of 38-year-old

Figure 16.10 After 0.8 cc hyaluronic acid (HA) filler into cheeks of 38-year-old

female.

female.

Figure 16.12 Cheek augmentation. The dots represent the needle’s point of entry at

Figure 16.11 Fifty-eight-year-old female treated with CaHA too superficially.

90° to a depth under the muscle above the bone (i.e., it goes straight in and down). The arrow represents where the needle is then pivoted up; the bolus is injected at the tip of needle and there is then retrograde threading of filler as the needle is slowly withdrawn.

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Figure 16.13 Result 4 years before regular one syringe of 1.0 cc hyaluronic acid (HA)

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filler using the “subsizing” technique.

Figure 16.14 Result 4 years after regular one syringe of 1.0 cc hyaluronic acid (HA) filler using the “subsizing” technique.

Figure 16.15 Before treating top third of defects 0.8 cc hyaluronic acid (HA) filler in

Figure 16.16 After treating top third of defects 0.8 cc hyaluronic acid (HA) filler in

43-year-old female.

43-year-old female.

collagen stimulation (Figs. 16.13 and 16.14). Another trick to improve the nasolabial and marionette folds with one syringe is to correct the top one-third of these folds only (Figs. 16.15 and 16.16). Using the “bridging” (crosshatching) technique of perpendicular dermal

injections helps build this area up rather than just filling along the line (Fig. 16.17). When injecting only the lips, add little boluses into the lip tubercles for a natural enhancement that allows just one syringe to go further (Figs. 16.18 and 16.19).

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Figure 16.17 “Bridging” or linear crosshatching of perpendicular threads: the arrows show the direction of injections (both antegrade and retrograde threading).

Figure 16.18 Before 1.0 cc hyaluronic acid (HA) filler into tubercles of lips.

SUMMARY

One syringe can do wonders if a good product is placed correctly into a well-informed patient. When patients understand the limitations of one syringe, but see measurable benefit, it will translate into a happy patient who returns for more. REFERENCES

1. Narins RS, Brandt F, Leyden J, et al. A randomized, double-blinded, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg 2003; 29: 588–95. 2. Baumann LS, Shamban AT, Lupo MP, et al. Comparison of smoothgel hyaluronic acid fillers with cross-linked bovine collagen: a multi-center, double-masked, randomized, within-subject study. Dermatol Surg 2007; 33: S128–S135. 3. Monstrey SJ, Pitaru S, Hamdi M, et al. A two-stage phase I trial of Evolence30 collagen for soft-tissue contour correction. Plast Reconstr Surg. 2007; 120: 303–11. 4. Lupo MP. Hyaluronic acid fillers in facial rejuvenation. Semin Cutan Med Surg. 2006; 25: 122–6. 5. Vleggaar D. Soft-tissue augmentation and the role of poly-L-lactic acid. Plast Reconstr Surg 2006; 118(Suppl 3): 46S–54S. 6. Jacovella PF, Peiretti CB, Cunille D, et al. Long-lasting results with hydroxylapatite (Radiesse) facial filler. Plast Reconstr Surg 2006; 118(Suppl 3): 15S–21S.

Figure 16.19 After 1.0 cc hyaluronic acid (HA) filler into tubercles of lips.

7. Lupo MP, Thomas JA, Murphy DK, Walker PS. Effectiveness of next generation hyaluronic acid dermal fillers in the treatment of severe nasolabial folds [abstract]. J Am Acad Dermatol. 2007; 56: AB199. Abstract P 2909. 8. Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to dermal fillers: review. Dermatol Surg. 2005; 31: 1616–25. 9. Hirsch RJ, Lupo M, Cohen JL, Duffy D. Delayed presentation of impending necrosis following soft tissue augmentation with hyaluronic acid and successful management with hyaluronidase. J Drugs Dermatol 2007; 6: 325–8. 10. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr Surg 2007; 120: 98S–105S. 11. Glogau RG, Kane MC. Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers. Dermatol Surg 2008; 34: S105–S109. 12. Hirsch RJ, Brody HJ, Carruthers JDA. Hyaluronidase in the office: a necessity for every dermasurgeon that injects hyaluronic acid. J Cosmet Laser Ther 2007; 9: 182–5. 13. Hirsch RJ, Narurkar V, Carruthers J. Management of injected hyaluronic acid induced Tyndall effects. Lasers Surg Med. 2006; 38: 202–4. 14. Brody HJ. Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement. Dermatol Surg 2005; 31: 893–7.

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Hyaluronic acid fillers Mary P. Lupo

INTRODUCTION

Nonsurgical rejuvenation has become the cornerstone of cosmetic dermatology practices. The art of combining lasers, botulinum toxins, and dermal fillers is replacing cold steel surgery. Since dermatologists first pioneered the concept of office-based dermabrasion in the 1960s and lunchtime fillers and peel procedures in the 1980s, there has been a continued growth of innovations to improve aging skin without the need for radical plastic surgery. Softer, more natural corrections are replacing pulled and plastic alterations. Dermal fillers are critical to this style of patient care. Bovine collagen was first approved by FDA in 1981. For over 20 years, it was the only filler option in the United States to efface lines and wrinkles of the face. But there were barriers to success. Poor duration, allergenicity, and inability to deliver volumetric correction of the aging face made bovine collagen an important, but inadequate “first step.” Finally in 2003, the United States saw its first new dermal filler: non-animal stabilized hyaluronic acid (HA). This delayed, but important, second step was quickly followed by other dermal filler innovations. Although there are newer and different fillers now available, HA remains the workhorse filler in most practices. The reasons for this are the effectiveness, versatility, and safety of HA products. SCIENCE OF HYALURONIC ACID FILLERS

HA is a glycosaminoglycan found in connective tissue of cartilage, bone, synovial fluid, and skin. It is identical in all mammals. Its viscoelastic properties, lack of immune variances between species, and prevalence in the dermis make it an ideal substance for cosmetic skin augmentation. HA decreases with intrinsic, chronological aging and is impacted by photoaging, or extrinsic aging. This senescence and loss of tissue causes reduction in dermal hydration and volume and is a factor in formation of lines, folds, and wrinkles. HA is a polysaccharide of repeating units of D-glucuronic acid and N-acetyl-glucosamine. Uncrosslinked HA has a very short dwell time in the dermis before it is completely eliminated by the lymphatics and metabolized in the liver into carbon dioxide and water. Chemical crosslinking is necessary to improve duration and utility as a dermal filler. HA is highly hydrophilic and binds water in proportion to its concentration, and these factors make it an ideal material to lift and fill the aging face. Other parameters that affect the final performance and utility of an HA filler are molecular weight, particle size, and the degree of crosslinking percentage of the HA. All these factors combine to give a final product which will have very specific physical properties that impact the usefulness of the HA in varying situations, the ease or difficulty of injection, and the likelihood of various complications such as swelling. There are currently several proprietary versions of HA fillers available in the United States. HYALURONIC ACID FILLERS: OPTIONS

HA fillers are approved as devices, not drugs. Safety and efficacy have been established for improvement of facial lines and folds such as the nasolabial fold. Many other HA dermal fillers are available outside the United States and likely several will eventually appear in the U.S. marketplace. For purposes of this discussion, only those FDA approved in the United States as of this writing will be included. Restylane (Medicis Aesthetics Inc., Scottsdale, Arizona, USA) was the first to be approved in December 2003. In the original pivotal trial, it

was found to have significant duration of correction when compared to Zyplast (1). Restylane is 20 mg/ml concentration, approximately 330 to 430 μm particle-size, of medium viscosity and designed for mid-todeep dermal injection. The source of the HA is non-animal, from streptococcal fermentation. Like all HA products to follow, no skin testing was required before administration. Hylaform was approved in April 2004 and Hylaform Plus (both from Inamed) in October 2004. These are derived from avian rooster combs and are particles sized. These HA products are of higher molecular weight than Restylane, but much lower concentration (5.5 mg/ml). The particle size of Hylaform is 500 μm, and Hylaform Plus is 750 μm. In a comparative trial, Restylane Perlane had better duration of effect (2). Perlane, released by Medicis in May 2007, has a concentration of 20 mg/ml and is a larger particlesized HA (750– 1000 μm) but its duration has not been found to be greater than Restylane (3). After Allergan’s acquisition of Inamed, the Hylaform line was phased out. Captique (also from Inamed) was the second HA approved derived from a bacterial source. Its approval came in December 2004. This product was similar to Hylaform in concentration (5.5 mg/ml) and particle size (500 μm) but lower in molecular weight like Restylane. When Inamed was acquired by Allergan, it too was phased out, but re-emerged in 2008 to be the first dermal filler available with lidocaine. Renamed Prevelle, it is available from Mentor Corporation (Santa Barbara, California, USA). Although Elevess from Anika Therapeutics, Bedford, Massachusetts, USA,. was the first HA–lidocaine combination product to get an FDA approval in 2007, it has only recently become available again since Artes, its distributing company went bankrupt. Re-emerging in July 2009, as Hydrelle from Coapt Systems Inc., Palo Alto, California, USA, it is the highest concentration of HA (28 mg/ml) on the market to date in the United States (4). Like Juvederm, it is not particle sized. Juvederm Ultra and Ultra Plus became available in June 2006. The manufacturer (Allergan Inc., Irvine, California, USA) uses a proprietary process that results in a “smooth cohesive gel” rather than being a uniformly particle-sized suspension. Both products are 24 mg/ml, but the higher degree of crosslinking of the Ultra Plus version results in a more robust and longer lasting dermal filler (5). PRACTICAL APPLICATIONS

The most important variable in patient outcome from HA fillers is the injecting physician. The level of training and experience, innate artistry, and the level of familiarity with the product all impact the final result of dermal filler injections. I have given lectures entitled: “It’s not the filler, it’s the Filler” reviewing the fact that experienced dermatologists and other core aesthetic physicians can get great results when using any filler and inexperience can result in disastrous results even with safe dermal fillers (Fig.17.1). HA fillers are very versatile in that many areas can be injected and various depths can be injected (6). Exciting new research suggests that the mechanical stretching of aging skin with HA filler can result in activation of fibroblasts and subsequent de-novo collagen production in vivo (7). Layering HA filler into the subcutaneous or sub-muscular planes as well as deep and middermal levels can result in more natural correction of greater durability (Figs. 17.2 and 17.3). HA fillers can be used in any area on the face with excellent results. The nasolabial fold is the primary area for correction, but experienced aesthetic physicians understand the importance of cheek enhancement

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to lift a deflated cheek and reposition it to give a lift to the nasolabial fold (Figs. 17.4 and 17.5). By injecting both areas, less material is needed in the nasolabial fold and this helps prevent over-filing of this area and a resulting “muzzle” look to the face. HA fillers are particularly good for cheek and nasolabial correction because of the molding capabilities of the product (8). Deeper injections beneath the obicularis oculi in the upper cheek often improve atrophy along the arcus marginalis (Figs. 17.6 and 17.7) as well as the extended orbital-malar groves that are the result of volume loss in the cheek area and add to the redundancy of the nasolabial fold (Figs. 17.8 and 17.9). The marionette fold can result in a droopy, sad, or angry look and can accentuate the jowls when the marionette and pre-jowl sulcus converge. The use of filler deep into these areas can re-sculpt the chin, lift the mouth corner, and reshape an aging jaw line. The complementing

action of botulinum toxin into the mentalis and depressor angularis oris muscles can improve the overall result (Figs. 17.10 and 17.11) (9). HA fillers, especially the less viscous and less crosslinked types, can be used in fine lines around the eyes and mouth and to complement the action of botulinum toxin in the glabellar lines when these lines are deeply etched into photoaged skin. The glabellar area must be injected into the upper dermis to prevent inadvertent vascular injection and catastrophic complications from occlusion and skin necrosis. The earlobes are the popular new area for HA filling as well, to improve the position of earring studs. Loss of volume from age results in thin, elongated earlobes. The replacement of volume plumps the lobe and shortens it, allowing the earring to point forward rather than down. By far the most popular use of HA filler is for lip augmentation (Figs. 17.12 and 17.13). As we age, the loss of lip volume from intrinsic aging and photoaging as well as the dynamic wrinkles and lines that develop as a result of talking, lip pursing, and smoking result in an aged, “pinched” appearance. The distance between the nose and the upper lip increases as the distance from the lower lip to the chin decreases. Ptosis of the mouth corners adds to the sad and aged look of the mouth. While no filler is FDA approved for lip augmentation, HA has been used safely “off-label” for years (10). In contrast, calcium hydroxylapatite and poly-L-lactic acid are not recommended in the lips because of the high incidence of nodule formation (Fig. 17.14). COMPLICATIONS

Figure 17.1 Fifty-three-year-old female 1 year after injection of 1 cc Hylaform Plus by nurse practitioner.

Figure 17.2 Sixty-three-year old female prior to injection.

No medical procedure is without risks. Dermal filling with HA, however, has a long track record of safety when used by experienced, board certified core aesthetic physicians. The fact that HA fillers are temporary usually translates into temporary side effects. Transient and selflimiting complications of redness and swelling are not uncommon with any filler. Because of the hydrophilic nature of HA, higher concentration products will naturally be associated with greater incidence of swelling (11). Over-correction should, therefore, be avoided. Granuloma formation can occur with any filler as well, but is less common

Figure 17.3 3.5 years after repeated injection with 1 cc hyaluronic acid (HA) filler into deep submuscular plane and dermis, showing good long-term effect.

HYALURONIC ACID FILLERS

Figure 17.4 Before treatment with 0.8 cc hyaluronic acid (HA) filler into the cheek.

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Figure 17.5 After treatment with 0.8 cc hyaluronic acid (HA) filler into the cheek.

Figure 17.6 Before treatment with 0.2 cc hyaluronic acid (HA) filler.

Figure 17.7 After treatment with 0.2 cc hyaluronic acid (HA) filler.

Figure 17.8 Before treatment under the obicularis oculi muscle for correction of the malar groove.

Figure 17.9 After treatment under the obicularis oculi muscle for correction of the malar groove.

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Figure 17.10 Fifty-six-year-old female before treatment.

Figure 17.11 After treatment of hyaluronic acid (HA) and botulinum toxin type A.

Figure 17.12 Thirty-year-old female before treatment with 0.8 cc hyaluronic acid

Figure 17.13 Nine months post-treatment.

(HA) filler.

with HA than semi-permanent fillers such as poly-L-lactic acid and calcium hydroxy apetite and permanent fillers such as polymethylmethacrylate (12). Complaints of asymmetry or lumpiness can be very long lasting with other dermal fillers, but because of the availability of hyaluronidase, these problems are quickly reversed with HA fillers. Other fillers must be allowed to gradually diminish over time. Nodules or “lumps” are best managed as quickly as possible. Gentle massage between the thumb and forefinger immediately after injection can usually smooth out minor irregularities. Any nodule or lump present for more than 1 week should be addressed. Sometimes a slight nick into the skin can result in the ability to milk the excess material out of the skin (Figs. 17.15 and 17.16). If not, hyaluronidase should be considered. I use FDA-approved Vitrase, diluted to 75 mg/ml. About 10 to 30 mg is injected per lump. The patient is seen back in 24 to 72 hours for possible re-treatment as needed (Figs. 17.17 and 17.18). Bruising is a common but very disturbing complication of HA filler injections. While other common side effects like redness and swelling typically last less than 24 hours, bruising often worsens over 24 hours and can last one week. This has significant impact on social “downtime” and may give the patient hesitation to repeat the procedure in the future. HA has structural similarities to heparin. The after-production addition of lidocaine with or without epinephrine into the HA syringe by the treating physician may decrease bruising because of the vasoconstrictive action of the epinephrine. Plain lidocaine is not

Figure 17.14 Two years after injection of CaHA into lips.

vasoconstrictive, but studies with HA and added lidocaine without epinephrine has not demonstrated increased bruising (13). Bruising may also be reduced by decreasing the number of needle sticks, by avoiding the fanning technique of injection and by slowing the rate of the injection to reduce tissue trauma (14). Various reports of the

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Figure 17.15 Patient with hyaluronic acid (HA) filler injected too superficially,

Figure 17.16 After extrusion of hyaluronic acid (HA) through a lancet nick into

resulting in blue hue from the Tindle effect.

the skin.

Figure 17.17 Patient one year after hyaluronic acid (HA) filler caused nodules.

Figure 17.18 One week after injection with hyaluronidase.

Figure 17.19 Forty-eight hours after injection with 0.4 cc hyaluronic acid (HA) filler into nasolabial fold, showing reticulated pattern characteristic of vascular compromise.

Figure 17.20 One week after use of hyaluronidase to dissolve hyaluronic acid (HA) compressing vasculature.

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benefits of Arnica and a proprietary lotion derived from a witch hazel extract used for two weeks prior to injection may reduce bruising (15). Finally, a high concentration glycerin product was found to decrease bruising by 65% when applied immediately post injection (16). Pain management during the injection session will result in happier patients, more likely to return for future injections. Topical anesthetics, ice, vibration therapy, nerve blocks, superficial gingival blocks, post-production addition of lidocaine, and “talkasthesia” have all been reported to help improve the patient experience (17). The addition of lidocaine by physicians at the time of injection has been found to decrease pain, improve patient tolerability without affecting the correction (18). The most disastrous and potentially permanent complication of HA filler injection is necrosis or blindness from inadvertent injection into the arterial circulation. The occlusion of the arteriole from the particulate material, or the compression of the arterial vasculature from the filler, can significantly compromise circulation to the skin and result in loss of tissue and permanent scarring. For this reason, the injecting physician should inject slowly and watch for any sign of vascular compromise such as a skin color change (blue or blanched) and immediately stop injection if this occurs. It would be advised to also massage the area, use topical nitroglycerin paste, and give the patient a full dose of aspirin. With HA, the use of hyaluronidase to dissolve the filler has been found to help prevent continued sequelae from vascular compression (Figs. 17.19 and 17.20) (19). The patient should be closely monitored if tissue breakdown occurs and meticulous wound care implemented. Any scars can later be addressed with laser or dermabrasion. SUMMARY

Hyaluronic acid fillers are the most popular fillers in the United States because of efficacy, safety, duration of result, versatility, and reversibility. These factors can give the treating physician confidence and the patient peace of mind. As with all medical procedures, the best results are achieved when an experienced physician chooses a safe dermal filler for an informed, prepared, and appropriate patient. REFERENCES

1. Narins R, Brandt F, Leyden J, et al. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial fold. Dermatol Surg 2003; 29: 588–95. 2. Carruthers A, Wayne C, de Lorenzi C, et al. Randomized, doubleblind comparison of the efficacy of two hyaluronic acid derivatives, Restylane Perlane and Hylaform in the treatment of nasolabial folds. Dermatol Surg 2005; 31: 1591–600. 3. Perlane package insert, Medicis Aesthetics, Inc. Scottsdale, Az. 4. http://news.prnewswire.com/DisplayReleaseContent.aspx? ACCT=ind_focus.story&STORY=/www/story/07-06-2009/ 0005054929&EDATE=(july 25,2009.

5. Lupo MP, Smith SR, Thomas JA, et al. Effectiveness of Juvederm Ultra Plus dermal filler in the treatment of severe nasolabial folds. Plast Reconstruc Surg 2008; 121: 289–97. 6. Lupo MP. Hyaluronic acid fillers in facial Rejuvenation. Semin Cutan Med Surg 2006; 25: 122–6. 7. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol 2007; 143: 155–63. 8. Carruthers J, Carruthers A. Hyaluronic acid gel in skin rejuvenation. J Drugs Dermatol 2006; 5(10): 959–64. 9. Carruthers J, Glogau R, Blitzer A, et al. Advances in facial rejuvenation: botulinum toxin type A, hyaluronic acid dermal fillers, and combination therapies—consensus recommendations. Plast Reconstruct Surg 2008; 121(Suppl): 5S–30S. 10. Bosniak S, Cantisano-Zilkha M, Glavas IP. Nonanimal stabilized hyaluronic acid for lip augmentation and facial rhytids ablation. Arch Facial Plast Surg 2004; 6: 379–83. 11. Clark CP. Animal-based hyaluronic acid fillers: scientific and technical considerations. Plast Reconstr Surg 2007; 120(Suppl): 27S–31S. 12. Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to dermal fillers: review. Dermatol Surg. 2005; 31: 1616–25. 13. Weinkle SH, Bank DE, Boyd CM, et al. Safety and Effectiveness of a 24 mg/mL hyaluronic acid injectable gel with and without lidocaine. In: Poster Exhibit. 5th Annual Cosmetic Boot Camp. Aspen Co., June, 2009. 14. Glogau RG, Kane MC. Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers. Dermatol Surg 2008; 34: S105–9. 15. Hagège JC. Prevention of edemas and bruises after facelift and rhinoplasty. Presented at 23rd International Congress of the French Society of Aesthetic Surgery, Paris, 2006. 16. Lupo MP. A double-blinded, randomized, placebo-controlled split faced within subject evaluation of a bruise reduction serum. Poster Exhibit, 5th Annual Cosmetic Boot Camp, Aspen Co., June 2009. 17. Smith K, Niamtu J, Carruthers J. Pain control in cosmetic facial surgery. In: Carruthers J and Carruthers A, eds. Soft Tissue Augmentation Philadelphia, PA: Saunders Elsevier, 2008: 127–41. 18. Svetman G, Lupo MP, Waller W. Comparison of the efficacy and tolerability of non-animal stabilized hyaluronic acid filler with and without lidocaine hydrochloride 2% for the correction of nasolabial folds. Poster Exhibit, 5th Annual Cosmetic Boot Camp. Aspen Co., June 2009. 19. Hirsch RJ, Lupo M, Cohen JL, Duffy D. Delayed presentation of impending necrosis following soft tissue augmentation with hyaluronic acid and successful management with hyaluronidase. J Drugs Dermatol 2007; 6: 325–8.

18

Calcium hydroxylapatite dermal filler for aesthetic correction of face and hands Roberta D. Sengelmann

INTRODUCTION

As the boomer population ages, the quest for a more youthful appearance has generated safe, painless, efficacious, and long-lasting solutions to the loss of elasticity, gradual subcutaneous atrophy, and muscular weakening that are most obviously but not exclusively perceived in the face. The injection of soft tissue filler has met this need, with an array of available permanent and semi-permanent dermal fillers. A relative newcomer to semi-permanent soft tissue filler solutions, Radiesse® Dermal Filler (Merz Aesthetics, San Mateo, California, USA) has received increased attention from practitioners worldwide since its clinical introduction early in this decade. Easily administered during one office visit in well under an hour, Radiesse, a longer-lasting, semi-permanent, non-allergenic soft tissue filler, involves little to no patient downtime and produces immediate results with minimal injection dosage without significant adverse events (1). The biocompatibility of Radiesse renders the filler a durable, safe restorative for moderate to severe facial wrinkles and folds, including nasolabial folds (NLFs), and for HIV-associated facial lipoatrophy. Both of these applications received FDA approval in 2006. Radiesse has also been approved as a corrective for vocal cord insufficiency due to neurological impairment, oral/maxillofacial defects, and as a radiographic tissue marker. In addition to its approved uses, Radiesse has performed effectively in a number of documented off-label clinical applications. These include marionette line and oral commissure correction, chin and lip support, acne scar fill, brow elevation, midface volume restoration, pre-jowl sulcus correction, ear lobe repair, nasal sculpting, and dorsal hand augmentation (1–4). In its current formulation, Radiesse is not appropriate for injection into the lips. COMPOSITION AND MECHANISM OF ACTION

Radiesse is composed of 30% synthetic CaHA microspheres (25–45 µm in diameter) suspended in a 70% aqueous carrier gel of sodium, carboxymethylcellulose, glycerin, and water. Formulated in 1.5, 1.3, 0.8, and 0.3 ml syringes, the tiny CaHA particles and gel can be injected with a fine-gauge needle as small as 28 gauge. On the other hand, the viscosity of Radiesse is substantial enough that oftentimes one syringe during one treatment session suffices—depending upon the degree of volume loss. Upon subdermal injection, the material instantly adds volume to the targeted soft tissue of the skin and requires no overcorrection (5). Within 8 to 12 weeks, the gel carrier is absorbed by the body (6). The biodegradable CaHA microspheres left behind serve as a matrix for new collagen development. These subdermally scattered microspheres are progressively enveloped by collagen, preventing particle migration while enabling longer lasting corrective durability and a smooth, natural appearance and feel (7). The CaHA spherules are eventually metabolized into calcium and phosphate ions and excreted by the body’s urinary system. Multiple safety and efficacy studies have shown the inherent biocompatibility of CaHA. In a pilot study conducted to evaluate the clinical, histologic, and in vivo ultrastructural behavior of Radiesse in human skin, injected CaHA microspherules exhibited minimal cellular inflammation or fibrosis under electron or light microscopy (7). While post-injection soreness and some edema have been reported, Radiesse has caused no allergic, toxic, or irritating response among tested

subjects. Furthermore, the compound’s biocompatibility precludes testing for patient sensitivity prior to injection (1,8). In addition, Radiesse presents no threat of calcification because CaHA contains neither osteo-progenitor cells nor bone morphogenic proteins. CaHA will not interfere with the interpretation of X-rays or CT scans. While not always apparent on X-rays, CaHA is clearly distinguishable from surrounding bone on CT scans, permitting unobstructed scrutiny of adjacent structures. In a study of 58 patients treated for either HIV-related facial lipoatrophy or nasolabial fold correction, images taken from 1 to 426 days following Radiesse injection showed that CaHA was unlikely to be confused with serious radiographic anomalies (9). DURABILITY, EFFICACY, AND COMPARABILITY

When used for augmenting moderate-to-severe nasolabial folds, a relatively small amount of Radiesse (1.0–2.0 ml) is required to induce optimal results visible from 10 to 36 months (10,11). Depending upon the application and the patient, cosmetic enhancement generated by Radiesse persists for approximately 1 year. While comparable to other semi-permanent soft tissue fillers as an alternative to corrective surgical intervention, Radiesse has distinguished itself in a number of studies aimed at evaluating the performance of CaHA, collagen, and hyaluronic acid derivatives. Collagen In a pivotal, multi-centered, prospective, split-face 6-month study to evaluate the long-term efficacy and safety of Radiesse, 117 randomly selected subjects with moderate-to-severe NLFs were injected with Radiesse and the human collagen (HC) filler Cosmoplast (Inamed, Santa Barbara, California, USA). During the time of initial treatment, subjects were injected with a total mean volume of 1.2 ml of Radiesse and 2.4 ml of HC. Graded on the Lemperle Rating Scale, folds treated with Radiesse were rated superior (84.6% at 3 months, 78.6% at 6 months) to those treated with HC (12.8% at 3 months, 16.2% at 6 months) (12). On the Global Aesthetic Improvement Scale (GAIS), 94.6% of Radiessetreated folds garnered at minimum an “improved” grade in comparison with 2.7% for HC. No significant adverse effects were reported. A 39-month post-marketing, follow-up study involving 90% of the original subjects showed that nearly half the CaHA-treated folds were deemed at least “improved” (Figs. 18.13) (13,14). Hyaluronic Acids In two randomized, blinded, multi-center trials designed to assess the efficacy, durability and safety of CaHA versus hyaluronic acids (Juvederm, Allergan, Irvine, California, USA; Perlane, Medicis, Scottsdale, Arizona, USA; Restylane, Medicis, Scottsdale, Arizona, USA) for the correction of NLFs, the fillers compared favorably in safety results. Noteworthy was the considerably smaller volume of CaHA necessary to achieve full correction, representing a cost-effective choice for physicians. CaHA was rated highest in patient satisfaction and likelihood to return for treatment in the future. In both trials, NLFs treated with CaHA received higher ratings on the GAIS in duration of effect (15,16). Radiesse and Persons of Color To determine the efficacy of Radiesse when subdermally injected into the NLFs of people with dark skin, investigators treated NLFs of

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100 patients (African–American, Hispanic, Asian and other) in a randomized, open-label, prospective, five-center trial. Study results provided investigators with evidence that Radiesse does not incite scarring, keloidal formation, or altered pigmentation (17). INDICATIONS

While currently FDA-approved for injection in moderate-to-severe wrinkles and folds (including NLFs) and for HIV-related lipoatrophy, Radiesse has proved an effective corrective option in a number of applications for which general guidelines regarding injection technique, amount of filler, patient indications, and expected longevity of results may be modified. PATIENT COUNSELING AND EVALUATION

Although skin pre-testing is deemed unnecessary for Radiesse, a physician should examine the chart for evidence of past hypersensitivity. Given the potential risk of adverse reaction, physicians will want to be cautious about injecting any filler into persons with a history of bleeding disorder, keloidal formation, hypertrophic scarring, collagen disease, or acute or chronic infections. For 5 to 10 days prior to treatment candidates should be instructed to refrain from taking anticoagulants, anti-inflammatories, vitamin E or other medicines, or nutritional supplements that may inhibit clotting or otherwise interfere with the healing process. Antiviral prophylaxis is rarely needed, except in patients who suffer from frequent herpes simplex virus outbreaks on their face. Some patients may be taking blood thinners such as warfarin, clopidogrel, aspirin, herbal medications, or supplements; discontinuation of these medications may help prevent bruising. However, medications should not be discontinued without permission of the prescribing physician. Informed consent is recommended for all procedures and off-label usage needs to be discussed. Given the potentially overwhelming choice of approved fillers and their applications, the physician should ensure that patients are aware of corrective options available to them for specific aesthetic purposes. A candid discussion to calibrate patient and physician expectations may reduce patient anxiety regarding safety and discomfort while providing insight regarding post-treatment care, down time, and treatment durability. Pre- and post-treatment photographs of the affected area(s) should be taken on the day of treatment and then ideally at a one-month posttreatment visit. PRETREATMENT ANESTHESIA AND RADIESSE-LIDOCAINE MIXING

A number of protocols may be utilized for administering anesthesia depending upon the individual patient and the area being treated. Traditionally, anesthetizing the area with ice, vibration, topical anesthetic, local or regional anesthesia (infraorbital and mini-nerve blocks) has been known to facilitate a nearly pain-free experience for the patient (1). The author prefers infraorbital and mental nerve blocks using 0.5% lidocaine with epinephrine 1:200,000 for perioral treatment, e.g., nasolabial folds, marionette lines, tear-trough, and, for filling elsewhere, e.g., hands, temples, cheek bones, prejowl sulcus, angle of mouth, Radiesse mixed with lidocaine. A 2008 investigation confirmed the viability of administering a mixture of Radiesse and lidocaine in treating the sensitive dorsum of the hand (18). The study bore out the investigators’ hypothesis that such an admixture might minimize the need for nerve blocks and, given the reduced viscosity of the newly constituted filler, mitigate the shortterm swelling commonly witnessed. Approved in July 2009 by the FDA, the lidocaine/Radiesse filler mixture requires the connection of one 1.3 ml/1.5 ml syringe of Radiesse to a 3.0 ml syringe containing <0.5 ml of lidocaine via a Rapid Fill™ Luer-Lok-to-Luer-Lok adapter (Baxa; Engelwood, Colorado, USA).

Figure 18.1 Creating an admixture of Radiesse and lidocaine, using female-to female connector.

The process begins with the introduction of filler into the syringe filled with anesthetic. The materials are pushed back and forth approximately 20 times between syringes or until the substance is fully mixed. Slowly injected into the skin, the filler combined with lidocaine has proved subdermally pliant (18,19). Appropriate for both face and hands, the Radiesse/lidocaine regimen has been clinically assessed as a more comfortable alternative for anesthesia administration, in addition to abbreviating the time spent in treatment (Fig.18.1) (20). GENERAL GUIDELINES FOR RADIESSE INJECTION TECHNIQUES

Injection techniques vary according to the area targeted for treatment, motility of the tissue, and amount of filler required for correction. Radiesse is classically injected in a retrograde manner via linear, threading, and/or crosshatching technique. A 1.25-inch, 25- to 28-gauge needle should be inserted at the dermal/subcutaneous junction while the physician advances and withdraws approximately 0.5 ml per pass of filler into the fold (1). A 0.5-inch needle is indicated for areas requiring less volume, e.g., marionette lines, radial lip lines, acne scars, glabella, nose, and ear lobules. As a nuance in technique, the author prefers to inject both on advance and withdrawal of the needle in much smaller volumes, closer to 0.05 to 0.1 ml per pass, for a smooth, natural outcome. Importantly, Radiesse must be injected slowly, so that small amounts are deposited at this level in the tissue; to avoid, palpability and irregularity. The depot or deep threading techniques are recommended for deep supraperiostal injections. This involves 0.1 to 0.15 ml of filler per pass. The material is subsequently molded for maximum dispersal. Areas that this technique is used include over the maxillary bone (cheek, tear trough), frontal bone (eyebrows), mandibular bone (jawline and prejowl sulcus), and in the dorsal hand. Again, Radiesse is injected quite slowly and methodically (Fig. 18.2). TIPS FOR SUCCESSFUL TREATMENT

Physicians may want to keep in mind certain “rules of thumb” regarding the administration of Radiesse.

• •

Filler should be injected for 1:1 correction. Touch-ups can be made at subsequent visits. A 25- to 28-gauge needle is recommended with a 1.25-inch length for NLFs, cheeks, chin, pre-jowl sulcus, labiomental crease, tail of brow, jawline, temples or with a ½-inch length for the marionette lines, radial lip lines, acne scars, glabella, nose, ear lobules, and dorsal hands.

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Epidermis

Dermis

Subcutis Muscle Supraperiosteal injection Periosteum

Deep dermis

Bone

Dermal/SQ junction Figure 18.2 Radiesse is placed at or below the dermal/subcutaneous junction.

Figure 18.3 Threading and fanning for nasolabial folds.

NASOLABIAL FOLDS

Appropriate candidates for nasolabial fold correction are generally men and women over 40 years of age with some degree of facial ptosis and malar fat pad descent. Radiesse works best for convexities in the area of the upper nasolabial fold and isthmus of the upper lip. It also nicely treats deep creasing. An infraorbital nerve block may be used to anesthetize the area from lower lids to the upper lip and as far lateral as the oral commissure. The physician should guide a 27-gauge, 28-bore, 1¼ -inch Radiesse needle deep into the dermal plane of the crease, staying medial to the fold, to provide volume fill and structural support to the line or fold.

Some injectors prefer a ½-inch needle for more control. In this case, it is important to overlap threaded areas for a smooth contour (see Fig. 18.1). Tiny aliquots (0.05–0.1 ml) of product are injected on advance and withdrawal for a smooth, natural look. Filling occurs so slowly that it should not be evident to the injector. With any given pass, mid-dermal threads address coarse rhytids whilst deeper threads into deep dermis and superficial subcutis serve to elevate tissue and correct the folds. Full correction in this area does not mean obliterating the shadows; obliteration would give an unnatural appearance and a convexity to the upper cutaneous lip that is ape-like. This approach should be explained to the patient at the outset. While some degree of molding can occur immediately following injection, this cannot compensate for poor technique (usually too much volume deposited in one place, injection too high in skin, or lateral to the nasolabial fold causing added fullness). Additionally, fine superficial creasing cannot be completely corrected with Radiesse but can be improved. This also must be explained to the patient with this indication. To reduce post-treatment redness and swelling, the physician may wish to avoid over-massaging the skin during the procedure and limit the molding process as needed for post-injection correction (1). In the perialar area, filler should be deposited using a fanning technique with retrograde threading to lift and fill the concavity. Following injection, the physician should use both hands to palpate the area to achieve symmetrical contouring. Of note, the angular artery parallels the nasolabial fold as it courses upward from the oral commissures toward the nasal ala in the subcutaneous plane. To avoid cannulating this vessel, injections should be done high in the subcutis and slowly enough so that, if a vessel is injected, the volume of product is small enough so as to be ineffectual. Compromise of the angular artery, especially at the superior aspect of the fold, has been described with various fillers and can lead to tissue ischemia and subsequent scarring (Figs. 18.3 and 18.4).

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(A)

(B)

S/P 1.5 cc Radiesse per side (Mixed with 0.2 cc 2% lido)

(C) Figure 18.4 (A–C) Treatment of nasolabial folds and cheeks.

MIDFACE/CHEEKS

Changes in cheek ptosis arise from resorption and descent of cheek fat pad, remodeling and resorption of cartilaginous and bony structures, laxity in the zygomatic ligament, loss of skin elasticity, simple gravity, and an individual’s genetic makeup. The midface and cheeks have been good applications for Radiesse due to its volumizing properties. Pretreatment counseling with the patient includes the medical history already mentioned here, management of realistic expectations, and cautions to the patient against inadvertently manipulating the injected product through use of goggles, facials, microdermabrasion, and even large-framed and heavy glasses. Post-counseling, the patient is ready for midface/cheek augmentation. Prior to injection, the physician should properly mark the patient's face to determine structures of interest. First, palpate and mark the infraorbital rim on each side of the face. Should one infraorbital rim be lower than the other, the physician should follow the level of the lower rim to enhance symmetry. Product should never be placed above the orbital rim. The superior and inferior cheek borders are also marked, as is the zygomatic arch, to provide guidance in the correct placement of the cheek. In addition, a medial canthal line should be drawn parallel to the nasolabial folds. Product should stay lateral of this line to avoid injection into the angular artery. The medial canthal line, the infraorbital rim, and the infraorbital foramen form a medial lower lid triangle where injection should be approached only by injectors extremely comfortable with the anatomy of the area and their injection techniques. Anesthetic applications may include entry site anesthesia, ice, skin chilling, topical products, and vibration. Recently, Radiesse has been approved to be mixed with lidocaine prior to injection as an added anesthetic option. The infraorbital nerve should not be blocked when injecting the cheeks as this might mask compromise of the infraorbital nerve at the foramen during injection. Instead, entry site anesthesia

and mixing product with a small amount of lidocaine before injecting can comfort the patient without taking away this precaution. As a rule of thumb, injection should be supraperiosteal whenever possible (onlay implantation), especially when addressing the zygoma, the maxilla, and area below the infraorbital rim. This supraperiosteal placement is necessary to avoid lymphatic irritation and/or obstruction in this delicate area of the face. Subdermal injections should only be used for lateral zygoma enhancement when blending into the surrounding area. Subdermal injections should never be done in the medial aspect of the midface. Physicians will want to stay below the infraorbital rim, avoid injection of product on the infraorbital foramen and nerve, and inject lateral to the medial canthus. Onlay implantation will help avoid contact with the malar septum and therefore may aid in preventing some adverse events in this area. For zygoma and malar enhancement, the first insertion point is likely to be from the mid-zygomatic arch, parallel and inferior to the infraorbital rim. The needle should be slowly advanced to the periosteum, then lifted slighty above the periosteum, and repositioned in the supraperiosteal plane. Retrograde linear threads of 0.1 ml of Radiesse can be placed in the supraperiosteal plane, starting just below the infraorbital rim, and then progressing inferiorly in a fanning pattern. Care should be taken to stay superior and lateral to the infraorbital foramen when laying threads of product in this area. The index finger of the non-dominant hand can be placed right at the infraorbital rim to serve as a barrier to inadvertent product injection or migration above the orbital rim. If depot aliquots are to be used in addition to the deep threading technique described above, 0.2 ml aliquots can be used. Some physicians have found that serial puncture depots, with the needle held at a 90° angle to the malar eminence, are useful for injecting aliquots just over the bony prominence. Again, care should be taken to see that aliquots remain small and, when molded, do not encroach on the foramen.

CALCIUM HYDROXYLAPATITE DERMAL FILLER FOR AESTHETIC CORRECTION OF FACE AND HANDS Should a “shelf ” appear in the malar area as the result of aliquot injections, additional augmentation in the zygomatic-temporal zone may be needed for softening. For further refinement and blending, Radiesse injections of 0.05 ml may be placed in the subdermal plane, layered above the supraperiosteal injections. These injections should be lateral to the lateral canthus and deep in the subdermal plane to avoid vasculature and the orbital septum. To recap, when treating the midface, Radiesse is to be placed over the periosteum, especially in the lower lid and medial cheek areas. Small aliquots of product are recommended in the medial midface area to allow for exact placement of product and prevent placement of product near or on the infraorbital foramen/nerve. Aliquots should not exceed 0.2 ml anywhere in the cheeks. No more than 0.2 ml should be placed in the medial lower triangle described earlier (medial canthal line, infraorbital rim, and infraorbital foramen). Post-treatment, the patient should receive post-care instructions, including the admonition to avoid massaging the treated area. Photos should be taken two to four weeks post-injection. SUBMALAR CHEEK HOLLOWS

Caused by the loss or redistribution of subcutaneous fat, submalar cheek hollows may assume the form of concavities and lines lateral to nasolabial folds. Treatment is expected to provide volume replacement and stimulate fibroblasts to produce innate collagen. Once again, patients should be advised that etched lines will not be fully corrected, but contours will be greatly improved. If the malar area needs filling, this area should be addressed before the submalar area, to avoid adding undue weight to the area and facial imbalance. After pretreatment with regional or local anesthesia (the author prefers entry site anesthesia and mixing Radiesse with lidocaine), ice, cooling agent, topical anesthetic or vibration, the needle should be inserted into the subdermal subcutaneous plane with special care to avoid the orbicularis oris muscle inferiorly, and the parotid gland laterally. A higher risk of nodularity will occur if the needle injects the orbicularis oris due to perpetual movement in this area. The parotid gland extends irregularly from just below the zygomatic arch to the angle of the mandible. Passing through the parotid gland are the facial nerve and its branches. Above this, in the subcutaneous plane coursing over parrotid gland and running upward toward the temporal region is the superficial temporal artery. Trauma to it would cause significant ecchymoses. Preferably a 1¼-inch needle is used to administer Radiesse in this area. Once inserted, an easy glide is detected in the subdermal/subcutaneous plane. At this point, the needle is advanced and fine threads (0.05–0.10 ml each) are injected on advance and withdrawal although the bulk of the strand is likely laid down in a retrograde fashion as the needle is withdrawn. Linear threading, fanning, and crosshatching techniques at oblique angles are employed until full correction is obtained. Optimal correction requires 0.5 to 1.5 ml per side (more in the case of HIV lipoatrophy patients). Immediately following full correction, the area should be molded with thumb and forefinger as needed. Patients may benefit from a touch-up 1 to 3 months after initial treatment (Figs. 18.5). NASAL SCULPTING

The nose offers both opportunities and challenges for aesthetic correction. Defects that warrant correction include dorsal hump, “skier’s nose,” concavity (from trauma, chronic drug use, piercing), post-rhinoplasty or post-trauma deformity, nasal tip ptosis, or deep horizontal furrow over the nasal root. Especially indicated for patients interested in nasal contour correction with a desire to avoid surgical rhinoplasty, this application requires discussion of realistic expectations and follow-up care. Nasal sculpting may require more than one injection per session,

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Figure 18.5 Radiesse injection points in malar cheek and submalar region.

depending upon the correction. However, the physician must take care not to over-treat. Small, subtle changes go a long way due to the strong structural integrity of the nasal bone and cartilages. A maximum of 0.3 ml of Radiesse is advised per injection sitting. Before treatment, the patient should be apprised of nasal asymmetries and the estimated amount of product necessary to achieve correction. In addition to customary medical history, physicians should assess the effect upon the procedure of previous rhinoplasty or nose trauma. A surgically repaired tip can be corrected but may be less receptive to volume filling due to tissue scarification. Prior to anesthetizing, the area to be injected should be marked. Infraorbital nerve blocks are a nice way to achieve nasal sidewall anesthesia without distortion of nasal contours. An ethnoid block may also be helpful but may not provide sufficient anesthesia when lifting the nasal tip. If not adequate, a small amount of local anesthesia can be injected. This tends to be necessary to boost anesthesia of the nasal tip and columella, where small amounts are adequate. An intraoral approach is helpful when numbing the base of the columella. When treating the nose, small strands (approximately 0.1 ml each) are injected supraperiosteally/supraperichondrially. Because of the highly vascular nature of the nose, injections should be done carefully and slowly. For dorsal hump treatment, Radiesse is injected above and below the deformity and should be injected over the midline and bilaterally, to bridge and support the nose. It may be helpful to visualize administration in the form of a small “w”: one strand midline; one strand right of midline; one strand left of midline. Product may be corrected to a visual endpoint and molded lightly. To treat nasal tip ptosis, the needle should be inserted at a 90° angle at the base of columella in the supraperiosteal plane. Small boluses may be injected into the area to bolster the columella and lift the tip. If a small bolus is insufficient to lift the tip, an additional bolus can be placed immediately superior to the first injection in order to correct the problem. The bridge and tip of the nose present certain challenges that accompany treatment of any area with little to no potential space. Over-injection can cause compression of vasculature and possible occlusion and necrosis. While rare, minimizing total injection volume to 0.3 ml per session and 0.1 ml at injection site may be useful (Figs. 18.6 and 18.7). MARIONETTE LINES, ORAL COMMISSURE

Characterized by a mouth frown, marionette lines can be difficult to correct. Small volumes of locally administered anesthesia or mental nerve blocks are advised. Using a 0.5 to 2.75-inch needle, Radiesse is injected along the dermal/subcutaneous junction, starting at the most inferior aspect of the fold and working toward the oral commissures.

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(A)

(B) Figure 18.6 (A,B) Injection points for Radiesse treatment of nasal defects.

(A)

(B) Figure 18.7 (A) Before and after 0.3 ml Radiesse treatment in bridge and columella for dorsal hump camouflage. Photo: Hilton Becker, MD, Boca Raton, Florida, USA, courtesy of Merz Aesthetics. (B) Before and after 0.3 ml Radiesse to left dorsum and nasal tip. Photo: Brock Ridenour, MD, Creve Coeur, Missouri, USA.

CALCIUM HYDROXYLAPATITE DERMAL FILLER FOR AESTHETIC CORRECTION OF FACE AND HANDS Fanning and cross-hatching is used at the corner of the mouth to suspend the angle of the mouth. The entire area, which may include the lateral chin zone, should be treated and progressively brought to full correction. The physician may mold intermittently with forefinger and thumb to assess symmetry. Bimanual (one finger on the skin and one intraorally pushing out on the buccal mucosa) palpation is very helpful in this regard. Because this area bruises readily, a slow, methodical technique is optimal. If injections are placed too high in the skin, irregularities in contour will be evident for quite some time following treatment. It is important to stop injecting several millimeters prior to needle exit, lest product extrudes from the needle entry/exit site and collects there. These small

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collections of Radiesse look very much like milia but are not as easily evacuated and often require a small incision and extraction. If unavoidable, they can be treated on the day of injection (Figs. 18.8 and 18.9). PRE-JOWL SULCUS

With age, a perceptible hollowing of the area lateral to the chin develops due to bone resorption and soft tissue loss. This causes volume loss, deepening labiomental creases, and chin pad sagging. Amplifying this area with filler sculpts the chin while offering support for the sagging jaw line. Radiesse works famously here to restore contour in a durable fashion. While volumizing this area is not a substitute for face lifting in patients with significant jowling and facial descent, it may be all that is needed in middle-aged patients with early aging changes or in older patients who need the support despite a lift. The facial artery courses through the subcutaneous plane in this area. As such, a deep plane of injection overlying periosteum is used from a lateral or medial approach. Many physicians prefer a depot technique in this area, laying down 0.1 to 0.2 ml aliquots over bone and molding. Others prefer a slow, deep threading technique. The key is to place the product just along the edge of the mandibular border, in order to strengthen and provide a two-dimensional change in facial shape. Placement above the mandibular border will result in a threedimensional improvement in shadows. Bruising can be impressive in this area and the patients should be prepared for this (Fig. 18.10). CHIN RECESSION

Figure 18.8 Crosshatching for marionette lines and oral commissures.

(A)

Before Radiesse

Most of the time, when we treat the chin, treatment arises from a need for more projection and is related to heredity. While chin aging with

(B)

(C)

6 months after 2 cc Radiesse

12 months post Radiesse

Figure 18.9 (A,B) Treatment of marionette lines with 2 ml Radiesse.

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(A)

Before Radiesse to chin and lower face lift

(B)

2 months after 1.3 cc Radiesse to chin and lower face lift

Figure 18.10 (A,B) Treatment of chin before and after injection of 1.3 cc Radiesse.

bone and muscle resorption occurs to some degree, more commonly, facial aging, and ptosis are accentuated by lack of adequate chin volume. Improving chin projection can strengthen the jaw and neckline for a more balanced appearance. The area to be treated is marked prior to anesthesia. Pretreatment with ice, skin-cooling agent, topical anesthetic, or vibration is necessary if a mental nerve block is not going to be used (19). With the patient seated upright, head positioned at 90° to the body, the physician should palpate the mandibular rim at the midpoint of the chin before inserting the needle from below the chin. The injection plane is under mentalis muscle and over periosteum, using a depot or short-threading technique. This technique mitigates risk of injury to the mental nerve as it exits the cranium in the midpupillary line and courses toward the lip depressors. Injections can occur from one prejowl sulcus all the way across to the other or just in the midline, depending on need. Volumes range from 1.0 to 3.0 ml to attain maximal correction. In general, volume is placed both anteriorly and inferiorly. Pressure and molding along the boney ridge allows for proper product placement and contouring (Fig.18.11). CUTANEOUS LIP LINES

Fine rhytids appearing above the upper lip are bothersome to those wearing lipstick, as the color begins to bleed into the tiny lines. Nicknamed “smokers’ lines,” the cutaneous lip lines appear as innate hyaluronic acid collagen and subcutis and are depleted as the skin loses elasticity. Due to the delicacy of the area and superficial etching of the lines, patients should be prepared for more than one treatment approach for full correction. While Radiesse can nicely provide support to the soft tissues in the upper lip, it does not replace the need for skin resurfacing, fine line fillers, and/or botulinum toxin for prominent radiating lip rhytids caused by aging and sun damage. Nerve blocks at the infraorbital foramen are the best way to manage patient discomfort in this area. Injections here are performed at the subdermal but supramuscular level. There is a high risk of bruising in this location. As soon as any bruising is noticed, ice and compression must be used. Thinning Radiesse via reconstitution with lidocaine can be helpful to provide for the smooth outcome that is so critical here. Staying superior of the vermilion border and administering 0.05 ml Radiesse per thread using a 28-gauge needle, the physician should

Figure 18.11 Before and after 0.8 cc Radiesse for pre-Jowl sulcus.

insert the needle just above each oral commissure for retrograde thread placement into the immediate subdermal plane, in a long, transverse “v” or “w” pattern. This is a conservative technique that consumes an average volume of 0.2 ml on each side. The area should then be gently molded in a slight up and down, vertical manner (Fig. 18.12). HANDS

With the baby boomer population increasingly comfortable with facial nonsurgical aesthetic restoration, attention has turned to the hands, where the aging process is evidenced by a skeletonized appearance with visible bony architecture, tendons, and veins.

CALCIUM HYDROXYLAPATITE DERMAL FILLER FOR AESTHETIC CORRECTION OF FACE AND HANDS People with exceptionally thin skin may not be appropriate candidates for this procedure. In addition to the customary concerns, special attention should be paid to candidates with a history of breast cancer, lymphedema, or carpal tunnel syndrome. In addition, since treating the hands may provoke delayed swelling, patients engaged in occupations requiring fine motor skills where swelling would prohibit function need to be warned prior to treatment. Anesthesia generally includes local anesthesia at three to five injection sites and some form of comfort measure(s) for the rest of the hand—ice, chilling, topical anesthetic, or vibration. Radiesse is mixed with 1% or 2% plain lidocaine via a female-to-female adapter on a 3 ml syringe. Epinephrine is discouraged because it may cause vasoconstriction and increase the small risk of tissue ischemia.

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The physician may inject at one to five sites scattered over the hand dorsum and use vigorous massage to spread product. Injection points are generally spaced 2 to 4 cm apart and tend to occur in between the distal halves of the metacarpal heads. Using the noninjection hand to lift the skin away from the dorsal aspect of the hand being treated, the skin is tented up away from vessels, tendons, and fascia prior to injection. A bolus technique is used to deliver 0.3 to 0.5 ml of Radiesse (21). If a single injection site is selected, a retrograde injection bolus of the lidocaine–Radiesse mixture (0.5–1.3 ml) may be introduced in the areolar plane between the subcutaneous layer and superficial fascia (22). No more than 1.3 ml should be used per injection session for each hand.

Temple Eyebrow

Prejowl Chin

Figure 18.12 Radiesse injection points for cutaneous lip lines and other facial sites.

(A)

Before Radiesse

(B)

After 1.3 cc Radiesse

Figure 18.13 (A,B) Hand augmentation with Radiesse. Originally appeared in J Dermatol Ther; used by permission of physician, Mariano Busso, MD, and the J Dermatol Ther.

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Once injected, the Radiesse needs to be contoured. To do so, the patient makes a fist of the injected hand as the provider manipulates and massages the injected area, firmly massaging the dorsum until the filler has been evenly spread. Ice packs should be applied to prevent bruising. If the patient requires additional volume, refinement may be provided at a 6- to 8-week touch-up appointment. In addition to bruising, exquisite tenderness can occur post-treatment if fascia is accidentally injected or traumatized. This generally occurs 1 to 2 weeks later and manifests as an area of redness and swelling. The patient should be assessed to rule out infection and managed with NSAIDs and empiric antibiotics. Resolution of the affected area may take several weeks (Fig. 18.13). POST-OPERATIVE TREATMENT

Post-operative treatment includes gentle molding by the practitioner to assess symmetry. Ice packs applied to the treated area will mitigate swelling and bruising. However, patients may experience transitory redness, soreness, swelling, itching and bruising. While a few hours of rest are recommended, it is rare for patients injected with Radiesse to experience down time. The advantage of nonsurgical aesthetic intervention is its optimal impact on the patient’s self-confidence and its minimal impact on the quality of the patient’s daily life. OTHER APPLICATIONS

The versatility of Radiesse has paved the way for a number of applications in other areas of the face and head, including mental creases, glabella, lateral brow, temple, earlobes, and tear trough. Radiesse has been used in these off-label areas—alone and, in some cases, in combination with other soft tissue fillers. The applications are beyond the scope of this chapter but are options for physicians highly experienced in injection of dermal fillers. CONCLUSION

Gone are the days when cosmetic correction involved a considerable outlay of money, pain, significant bruising, and long recovery time. Radiesse is a contemporary product that provides real-time results with little pain and almost no post-treatment recovery periods. Peerreviewed studies cited here have clearly supported the safety, efficacy, and durability of Radiesse in midfacial and lower facial applications. Physicians can use Radiesse in their clinical settings, confident that the result of their injections will result in high satisfaction levels in their patients and relatively long-lasting improvements in appearance. ACKNOWLEDGMENTS

The author appreciates the editorial assistance provided by David J Howell, PhD, San Francisco, California, and Sally Sherwood, MA, New York, New York. REFERENCES

1. Graivier MH, Bass LS, Busso M, Jasin ME, Narins, RS, Tzikas TL. Calcium hydroxylapatite (Radiesse®) for correction of the mid- and lower face: consensus recommendations. Plast Recon Surg 2007; November (Suppl): 55S–66S. 2. Becker, H. Nasal augmentation with calcium hydroxylapatite in a carrier-based gel. Plast Recon Surg June 2008; 121(6): 2142–7. 3. Busso M, Karlsberg PL. Cheek augmentation and rejuvenation using injectable calclium hydroxylapatite (Radiesse®). Cosmetic Dermatol 2006; 19(6): 583–8.

4. Goldberg DJ, Amin S, Hussain M. Acne scar correction using calcium hydroxylapatite in a carrier-based gel. J Cosmet Laser Ther 2006; 8: 134–6. 5. Sadick NS, Katz BE, Roy D. A multicenter, 47-month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face. Dermatol Surg 2007; 33: S1222–127. 6. Tzikas TL. Evaluation of Radiance™ FN soft tissue filler for facial soft tissue augmentation. Arch Facial Plast Surg 2004; 6: 234–9. 7. Marmur ES, Phelps R, Goldberg DJ. Clinical, histologic, and electron microscopic findings after injection of a calcium hydroxylapatite filler. J Cosmet Laser Ther 2004; 6: 223–6. 8. Hubbard W. Bioform Implants: Biocompatibility. Franksville (WI): Bioform Inc., 2003. 9. Carruthers A, Liebeskind M, Carruthers J, Forster B. Radiographic and computed tomographic studies of calcium hydroxylapatite for treatment of HIV-associated facial lipoatrophy and correction of nasolabial folds. Dermatol Surg 2008; 34: S78–S84. 10. Alam M, Yoo SS. Technique for calcium hydroxylapatite injection for correction of nasolabial fold depression. J Am Acad Dermatol 2007; 56: 285–9. 11. Jones D. Semi-permanent and permanent injectable fillers. Dermatologic Clinics 2009; 27(4): 433–44. 12. Lemperle G, Holmes RE, Cohen S, Lemperle SM. A classification of facial wrinkles. Plast and Reconst Surg 2001; 108(6): 1735–50. 13. Smith S, Busso M, McClaren M, Bass LS. A randomized, bilateral, prospective comparison of calcium hydroxylapatite microspheres versus human-based collagen for the correction of nasolabial folds. Dermatol Surg 2007; 33: S112–S121. 14. Bass LS, Smith S, Busso M, McClaren M. Calcium hydroxylapatite for treatment of nasolabial folds: long-term safety and efficacy results. Aesthetic Surg J 2010; 30(2): 235–8. 15. Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multi-center, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg 2007; 33: S144–S151. 16. Moers-Carpi M, Tufet JO. Calcium hydroxylapatite versus nonanimal stabilized hyaluronic acid for the correction of nasolabial folds: a 12-month, multicenter, prospective, randomized, controlled, split-face trial. Dermatol Surg 2008; 43: 210–15. 17. Marmur ES, Taylor SC, Grimes PE, Boyd, CM, Porter JP. Six-month safety results of calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds in Fitzpatrick skin types of IV–VI. Dermatol Surg 2009; 35(s2): 1641–5. 18. Busso M, Voigts R. An investigation of changed in physical properties of injectable calcium hydroxylapatite in a carrier gel when mixed with lidocaine and with lidocaine epinephrine. Dermatol Surg 2008:34:S16-S24. 19. Busso M. Calcium hydroxylapatite (Radiesse®): safety, techniques and pain reduction. J Drugs Dermatol 2009; 8(10): 21–3. 20. Marmur ES, Green L, Busso M. Controlled, randomized study of pain levels in subjects treated with calcium hydroxylapatite premixed with lidocaine for correction of nasolabial folds. Dermatol Surg 2010; 36(3): 309–15. 21. Marmur ES, Al Quaran H, Earp A. A multi-patient, pilot study of calcium hydroxylapatite injection for treatment of the aging hand. Dermatol Surg 2009; 35(12): 1978–84. 22. Werschler, WP. Treating the aging hand with soft tissue filler: off-label application promises few visits and long-term results. MedEsthetics 2009; 5(5): 10–11.

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PLLA (Sculptra) Cheryl M. Burgess

PLLA OVERVIEW

Introduction Poly-L-lactic acid (PLLA; Sculptra® Aesthetic; Dermik, Bridgewater, New Jersey, USA) is an injectable medical device with approval by the U.S. Food and Drug Administration (FDA) for the treatment indicated to correct shallow to deep nasolabial fold (smile lines) contour deficiencies and other facial wrinkles which are treated with the appropriate injection technique in healthy people; it is also approved for the treatment of facial lipoatrophy in patients with human immunodeficiency virus (HIV). It is a biodegradable bioabsorbable synthetic polymer, which has been used for several decades in resorbable medical devices, such as sutures, surgical sealant meshes, screws, plates, and membranes for guided tissue regeneration (1,2). Facial lipoatrophy can develop due to (i) the natural course of aging in healthy adults, (ii) surgical procedures to cause extensive weight loss, (iii) specific disease states, either inherited or acquired, in which lipodystrophy syndrome causes metabolic disturbances that lead to abnormalities in adipose tissue, and (iv) treatment of HIV patients with certain antiviral cocktails (3). The etiology remains unclear, but studies suggest a strong link between lipodystrophy syndrome and treatment with protease inhibitors and nucleoside reverse transcriptase inhibitors. Researchers remain uncertain as to whether the effect results from individual or synergistic drug activity 3–6. Lipodystrophy syndrome has proven difficult to define, leading to widely varying estimates of prevalence among patients with HIV that range from 15% to greater than 80% (7). The highest estimate of lipodystrophy incidence was 83% and occurred in patients within 8 to 10 months of initiating protease inhibitor therapy (3). Several scales for grading lipoatrophy severity have been developed. However, the Facial Lipoatrophy Grading Scale ( Table 19.1) that was introduced in 2006 by the Facial Lipoatrophy Panel is the current standard for grading lipoatrophy severity in all patients. In soft tissue augmentation, PLLA is used exclusively to produce volume in areas of “sinking and sagging” skin. It is not intended for the focused treatment of specific wrinkles. Rather, PLLA is intended for the treatment of areas requiring contouring or sculpting. PLLA can be used with other soft tissue fillers for a variety of applications in soft tissue augmentation. It can be used to build up the maxillary fat pads, but should not be injected into the lips (2). PLLA is also appropriate for rejuvenation of hands, correction of foot problems, and the correction of localized lipoatrophy from medical conditions. The effects of volume restoration can persist for as long as 18 to 24 months, but are not permanent (2,8). After this period, only one booster treatment is needed to maintain the cosmetic effect (9). Mechanism of Action PLLA differs in mechanism from other fillers because in point of fact it is not a dermal filler. To the contrary, PLLA is a biocompatible, biodegradable synthetic polymer that serves as a catalyst that stimulates the process of neocollagenesis (10–14). PLLA causes an immediate effect by physically occupying space. However, this initial response is temporary, lasting only one week or less (8). Once the carrier solution is absorbed, a delayed but progressive volumizing effect begins. PLLA causes a foreign body giant cell reaction that leads to the gradual production of collagen. This occurs through a process of hydration, loss of cohesion and molecular weight, and

solubilization and phagocytosis of PLLA by the host’s macrophages. PLLA is slowly degraded into lactic acid microspheres and CO2 through non-enzymatic hydrolysis. Respiratory excretion eliminates CO2, leaving behind crystals, which stimulate collagen and a granulomatous reaction. This inflammatory reaction elicits (i) resorption, (ii) formation of fibrous connective tissue about the foreign body, and (iii) dermal fibroplasia that leads to the desired cosmetic effect (2). Over the course of several months, the process of dermal thickening is gradually achieved (10–14). Safety History Special training is required for the authorized use of PLLA. Without proper training, the potential for certain adverse events increases. However, PLLA use is especially safe. Since 1999, over 150,000 people in more than 30 countries have been treated with PLLA for a variety of facial volume and contour deficiencies (1,15). In our own clinic— the Center for Dermatology and Dermatologic Surgery (Washington, D.C., USA)—PLLA has been successfully used to treat lipoatrophy of the hands, feet, face, and buttocks in both immunocompetent and immunocompromised patients. In fact, of 61 HIV-infected patients treated with PLLA, excellent responses to treatment was observed in 100% of patients at 6 months follow-up. After treatment was complete, the patients were followed every 6 months from 2001 to 2005, with no reports of allergic reactions, infections, or severe adverse events (2). Several other studies have shown safety and efficacy in both immunocompetent and HIV-infected patients 16–18. For example, a study in 102 HIV-positive patients receiving highly active antiretroviral therapy (HAART) and 620 cosmetic (presumed immunocompetent) patients, treatment with PLLA resulted in optimal volume enhancement in all the patients, even at two years post-final injection. In addition, adverse events were minimal, and included five cases of palpable, non-visible papules, and one possible foreign body reaction found one-year post-injection, resulting in a mild visible nodule. No allergic reactions were observed (19). Clinicians have begun to identify other conditions for the use of PLLA. For example, a recent publication has reported that the use of PLLA to treat acne and varicella scars yielded excellent safety and efficacy results (20). Also in development, is the novel use of PLLA as an injectable craniofacial implant in a supraperiosteal location to address both soft tissue volume loss and loss of craniofacial support (21). In the United States, the safety record of PLLA has continued to be excellent—only a small number of adverse events have been reported in connection with PLLA treatment. In Europe, the earlier experience with PLLA was marked by a much greater propensity for adverse events. When adverse events have occurred with the use of PLLA, insufficient reconstitution and incorrect injection technique has typically been implicated. Physicians must remember that PLLA is not a filler, and requires a different approach to treatment and injecting. Thorough knowledge and training is absolutely required. Additionally, because of the gradual mechanism of dermal thickening, physicians must employ patience, as well as an artistic approach to restoring volume. Duration of Effect Soft tissue augmentation with PLLA is not permanent. Since the effect of augmentation is limited to approximately 24 to 30 months, there is less concern for errors in technique to become permanent. There is also less concern for problems that result as facial contours continue to

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change with age. For example, permanent fillers that initially provide satisfactory results may become more visible with age or create an unnatural appearance as patients grow older (22). INDICATION: TREATMENT OF LIPOATROPHY IN PATIENTS WITH HIV

Treatment of Lipoatrophy in Patients with HIV New advances in antiretroviral therapy have enabled patients with HIV and acquired immune deficiency syndrome (AIDS) to live longer, healthier lives (23). This therapy, however, is not without adverse effects. Patients receiving HAART often develop lipodystrophy syndrome, a condition characterized by insulin resistance, hyperlipidemia, and fat loss/redistribution. Lipodystrophy-associated fat redistribution consists of fat loss from the limbs, buttocks, and face; fat accumulation in the abdomen and the dorso-cervical fat pad (the so-called “buffalo hump”), and sometimes breast hypertrophy (4). The most visible component of fat redistribution—the component that causes the patient the most distress—is facial lipoatrophy (5). Facial lipoatrophy begins in the nasolabial region, progresses outward to the temples, and finally affects the eye sockets. As fat loss progresses, the facial skin comes to rest directly on the underlying muscles, resulting in a gaunt, anorexic appearance (3). For the patient, the psychosocial effects of facial lipoatrophy are significant. Collins surveyed HIV-infected patients regarding their feelings about their body fat changes (5). The study found that patients often felt their doctors expressed much less concern about the effects of lipoatrophy than the amount of concern felt by the patient (3,5). Poor body image, low self-esteem, and depression were frequently described. Patients reported being socially withdrawn and that sexual relationships were adversely affected. Some patients were forced by their appearance into disclosing their HIV status. Perhaps most significant, some patients stopped taking their antiretroviral regimen in order to avoid the adverse psychosocial affects of fat wasting (5). Patient Selection PLLA can be used to treat HIV patients with any level of severity (Table 19.1). Prior to beginning treatment, the physician should carefully discuss details of (i) patient satisfaction and expectations, (ii) potential discomfort during or after injection, (iii) risk for adverse events, (iv) the results that should be expected immediately after the initial treatment and throughout subsequent sessions, and (v) typical durability expected after all sessions have been completed. The patient’s medical history should be reviewed, with attention to the use of prescription and nonprescription medications, allergies, autoimmune disorders, history of cold sores, and prior facial operations or soft tissue augmentation, including facial implants. Patients should be counseled to avoid medications, herbs, or supplements that might increase bleeding. Informed consent should be obtained. Table 19.1 Facial Lipoatrophy Grading Scale to Assess the Degree of Lipoatrophy in all Patients Grade 0 Grade 1

Grade 2 Grade 3

Grade 4 Grade 5

No facial lipoatrophy. Mild flattening or shadowing of one or more facial regions. No prominent pony landmarks. No visibility of underlying musculature. Intermediate point between grade 1 and grade 3. Moderate concavity of one or more facial regions. Prominence of bony landmarks. May have visibility of underlying musculature. Intermediate point between grade 3 and grade 5. Severe indentation of one or more facial regions. Severe prominence of bony landmarks. Clear visibility of underlying musculature.

Source : Adapted from Ref. 29.

PLLA-Injection Preparation Unlike many other products for soft tissue augmentation, PLLA does not come ready to use. It must be reconstituted prior to use. Experts recommend reconstituting in a minimum of 5 ml of sterile water to allow for light-to-moderate plunger pressure, and to help distribute the product evenly (1). In highly mobile areas, such as around the eye and around the lip, it is recommended to reconstitute PLLA in 6 to 8 ml. However, it is not recommended to use large dilutions in large areas or in non-mobile areas (24). Treatment Plan Physicians must fully comprehend the differences in technique between this product and dermal fillers before attempting to use PLLA. Therefore, physicians must adjust their approach from treating a “specific line” to a strategy of “returning volume to a facial area” (1). PLLA is not injected in the typical place where fillers such as collagen or hyaluronic acid (HA) are injected. PLLA should be placed in the deep dermis or subcutaneously for creating supportive structure and foundation. Correct placement in the deep dermal and/or deep dermal subcutaneous plane is crucial; too shallow and visible nodules and/or blanching of the skin occurs (2). PLLA, due to the thickness of the hydrogel or insufficient reconstitution and preparation, tends to clump in the syringe and is somewhat difficult to inject. In addition, the gradual mechanism of dermal filling means that overcorrection is not required and must be avoided (1). Several treatments, administered 4 weeks apart or more, are required to achieve maximum benefit; the exact number depends on the severity of the lipoatrophy. Mild cases may require two to three treatment sessions; moderate cases, approximately three to four treatment sessions; and severe lipoatrophy could require four to six treatment sessions. In our treatment of HIV patients with lipoatrophy, we found that the required amount of PLLA varied from one to four vials, depending on the degree of lipoatrophy severity and areas of involvement. The number of treatment sessions also varied. Mild cases required two to three treatment sessions; moderate cases, approximately four treatment sessions; and severe lipoatrophy required four or more treatment sessions. The amount of PLLA was gradually decreased over subsequent sessions (2). Injection Technique Several treatments, administered four or more weeks apart, are required to achieve maximum benefit; the exact number depends on the severity of the lipoatrophy. Mild cases may require three treatment sessions; moderate cases, approximately four treatment sessions; and severe lipoatrophy could require five to seven treatment sessions (9). Injection Steps Obtain pre-operative photographs. Prior to injection, the areas of correction are prepped with isopropyl alcohol. The treatment areas are anesthetized with topical lidocaine, nerve blocks, or 1% lidocaine with or without with 1:100,000 epinephrine infused into the reconstituted vial of PLLA. Areas of concavity are outlined with a wax marking pencil or eyeliner pencil (Fig. 19.1A). Before and after results of contouring the outlined areas (Fig. 19.1B and C). For the enhancement of the under-eye area, prevent the development of subcutaneous nodules in the thin skin of the orbital rim, by injecting under the orbicularis oculi musculature. If at the time of injection, the PLLA suspension is not fully reconstituted, vigorously Shake the suspension and then warm it to a temperature of 92°C to 96°C (197.6–204.8°F) by submerging the suspension in hot water or by using a Bed Buddy (microwave for 2–3 minutes). These steps cause the covalent bonding to occur

• • • • • •

PLLA (SCULPTRA)

•

•

more rapidly. In more sophisticated laboratories, use a laboratory vortex mixer to shake vigorously prior to the procedure and during the procedure to prevent settling of the suspension. The PLLA suspension is injected into the dermal subcutaneous juncture with a 25-gauge 0.5-, 1-, or 1.5-inch needle. For bolus injections, use a 25-gauge 0.5- or 1-inch needle. Move the needle in a fan-like sweep through the horizontal plane, in approximately 15° increments from each other, while injecting the PLLA with a retrograde technique (Fig. 19.2A). Place the needle adjacent to the first location in the same horizontal plane and repeat the injection using a fanning motion so that the fans overlap and cross to create a lattice of PLLA deposits (Fig. 19.2B). For injections into the temples, give a bolus injection using 0.5-inch 25-gauge needle (no fanning) (Fig. 19.1B).

• •

153

Minimize bruising by using arnica montana, bromelain, or Bruise Relief ®. Vigorous massage and manual sculpting was performed by the physician and/or nurse on patients with and without HIV for 5 minutes to treatment areas to distribute the material evenly. To minimize bruising and swelling, patients were given instructions to apply ice packs to the injected areas for 15 minutes of every hour over the next 12 to 24 hours.

Operative Steps Because dermal thickening is a gradual process, the full effects of PLLA may take three months to six months to develop (15). This is a gradual process, which differs significantly from traditional methods of augmentation, and requires a radically different approach and

(B)

(A)

(C) Figure 19.1 (A–C) Areas of concavity are outlined with a wax marking pencil or eyeliner pencil.

(A)

(B)

Figure 19.2 (A) Place the PLLA using a fan-like technique and disperse during retrograde withdrawal of the needle. (B) Place the needle adjacent to the first location in the same horizontal plane and repeat the injection using a fanning motion so that the fans overlap and cross to create a lattice of PLLA.

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treatment plan. Rather than immediately looking for an optimal correction, physicians should treat, wait, assess, and only then, decide how much more correction is needed (24). Moreover, dermal thickening is not achieved in equal amounts with each injection. More

(A)

(C)

correction takes place after the final injection, compared with the initial injection (15). Results

(B)

(D) Figure 19.3 Facial lipoatrophy (three sessions at 6 months): (A,C) before; (B,D) after.

(A)

(B) Figure 19.4 Facial lipoatrophy (three sessions at 1 year): (A) before; (B) after.

PLLA (SCULPTRA)

(A)

155

(B) Figure 19.5 Facial lipoatrophy facial contouring: (three sessions at 6 months): (A) before; (B) after.

TREATMENT OF LIPOATROPHY CAUSED BY THE AGING PROCESS IN HEALTHY INDIVIDUALS

Safety and Efficacy History A recent study by Hanke and Redbord found PLLA to be safe and efficacious for the satisfactory treatment of lipoatrophy in HIV and lipoatrophy of aging. In their study, 65 patients (27 HIV positive; 38 HIV negative) were treated with PLLA for facial lipoatrophy from August 2004 to August 2006. Nearly all patients reported that they were very satisfied with the PLLA treatments (93% of HIV-positive patients; 89.5% HIV-negative patients). Patient Selection PLLA can be used to treat cosmetic patients with a lipoatrophy severity of grade 2 to grade 5 (severe) (Table 19.1). PLLA Injection Preparation Experts recommend reconstituting in a minimum of 5 ml of sterile water to allow for light-to-moderate plunger pressure, and to help distribute the product evenly (1). In highly mobile areas, such as around the eye and around the lip, it is recommended to reconstitute PLLA in 6 to 8 ml. However, it is not recommended to use large dilutions in large areas or in non-mobile areas (24). Treatment Strategy: The Atrophy/Hypertrophy Model for Aging The atrophy/hypertrophy model for aging represents a shift from focusing on wrinkles and gravitational sagging to a more comprehensive approach that treats the aging face from “the inside out.” To address the correct use of PLLA in soft tissue augmentation, it is vital that physicians understand the natural progression of changes in the aging face, the microstructural changes, and especially the macrostructural changes. In the young face, superficial and deep fat is distributed evenly, creating a homogenous topographical appearance with smooth primary arcs and convexities. With age, the distribution of fat becomes altered by fat atrophy and hypertrophy, producing hills and valleys with demarcations between the cosmetic units. Fat atrophy becomes clinically apparent in the temple and cheek and is followed by fat loss around the chin and mandibular areas. Features become concave, characterized by flat lips, sunken temple and cheek, scalloped mandible, and increased shadowing from hills and valleys. With aging, the most significant change in appearance is the sagging of excess skin, which develops as primary arcs become straight lines. Skin tends to drape inferiorly and diagonally from the temporal area toward the

perioral region, creating a central focus on the perioral and mandibular regions. Fat atrophy is observed in the periorbital, forehead, buccal, temporal, and perioral areas. Fat atrophy is the result of decreased fat cell size, diminished fat cell function, impaired fat cell differentiation, and redistribution of fat cells. Fat hypertrophy occurs submentally, in the jowl, lateral nasolabial fold, lateral labiomental crease, and lateral malar areas. The accumulation of fat pulls the encumbered skin downward under the force of gravity. The loss of fat leaves skin excessive in proportion to the diminished volume, causing the excess skin to sag (25,26). Volume must be restored in regions experiencing fat atrophy and excess fat must be removed from regions where fat has accumulated. Correcting the distribution of volume throughout the face can help restore homogenous topography, eliminate demarcations between cosmetic units, and restore the primary arcs (25). Injection Technique Several treatments, administered four or more weeks apart, are required to achieve maximum benefit; the exact number depends on the severity of the lipoatrophy. Mild cases may require two to three treatment sessions; moderate cases, approximately three to four treatment sessions; and severe lipoatrophy could require four to six treatment sessions. Injection Steps Obtain pre-operative photographs. Prior to injection, the areas of correction are prepped with isopropyl alcohol. The treatment areas are anesthetized with topical lidocaine, nerve blocks, or 1% lidocaine with or without with 1:100,000 epinephrine infused into the reconstituted vial of PLLA. Areas of concavity are outlined with a wax marking pencil or eyeliner pencil (Fig. 19.1A). For the enhancement of the under-eye area, prevent the development of subcutaneous nodules in the thin skin of the orbital rim, by injecting under the orbicularis oculi musculature. If at the time of injection, the PLLA suspension is not fully reconstituted, vigorously Shake the suspension and then warm it to a temperature of 92°C to 96°C (197.6–204.8°F) by submerging the suspension in hot water or by using a Bed Buddy (microwave for 2–3 minutes). These steps cause the covalent bonding to occur more rapidly. In more sophisticated laboratories, use a laboratory vortex mixer prior to the procedure and during the procedure to prevent settling of the suspension.

• • • • • •

156

•

COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT The PLLA suspension is injected into the dermal subcutaneous juncture with a 25-gauge 0.5-, 1-, or 1.5-inch needle. For bolus injections, use a 25-gauge 0.5- or 1-inch needle. Move the needle in a fan-like sweep through the horizontal plane, in approximately 15° increments from each other, while injecting the PLLA with a retrograde technique (Fig. 19.2A). Place the needle adjacent to the first location in the same horizontal plane and repeat the injection using a fanning motion so that the fans overlap and cross to create a lattice of PLLA deposits (Fig. 19.2B).

(A)

• •

Minimize bruising by using arnica montana, bromelain, or Bruise Relief®. Vigorous massage and manual sculpting was performed by the physician and/or nurse on patients with and without HIV for 5 minutes to treatment areas to distribute the material evenly. To minimize bruising and swelling, patients were given instructions to apply ice packs to the injected areas for 15 minutes of every hour over the next 12 to 24 hours.

Results

(B)

(C)

Figure 19.6 Cosmetic treatment of lipoatrophy (two sessions at 12 months). The patient is a 71-year-old black female patient with facial sinking and sagging; she is not a candidate for a face-lift. (A) Before; (B) after one session at 9 months; (C) after sessions at 1 year.

TREATMENT OF LOCALIZED FACIAL LIPOATROPHY FOR OTHERWISE HEALTHY YOUNG INDIVIDUALS

Patient Selection PLLA can be used to treat cosmetic patients with a lipoatrophy severity of grade 2 (mild–moderate) to grade 5 (severe) (Table 19.1). Treatment Strategy Physicians must fully comprehend the differences in technique between this product and dermal fillers before attempting to use PLLA. Therefore, physicians must adjust their approach from treating a “specific line” to a strategy of “returning volume to a facial area” (1). PLLA is not injected in the typical place where fillers such as collagen or HA are injected. PLLA should be placed in the deep dermis or subcutaneously for creating supportive structure and foundation. It can be used to build up the maxillary fat pads, but should not be injected into the lips (2). In addition, the gradual mechanism of dermal filling means that overcorrection is not required, as it is with some of the dermal fillers, and must be avoided (1). In our treatment of HIV patients with lipoatrophy, we found that the required amount of PLLA varied from one to four vials, depending on the degree of lipoatrophy severity and areas of involvement. The number of treatment sessions also varied. Mild cases required one to two treatment sessions; moderate cases, approximately three to four treatment sessions; and severe lipoatrophy required three to four or more treatment sessions. The amount of PLLA was gradually decreased over subsequent sessions(2).

Injection Technique Several treatments, administered four or more weeks apart, are required to achieve maximum benefit; the exact number depends on the severity of the lipoatrophy. Mild cases may require two to three treatment sessions; moderate cases, approximately three to four treatment sessions; and severe lipoatrophy could require four to six treatment sessions (9). Injection Steps Obtain pre-operative photographs. Prior to injection, the areas of correction are prepped with isopropyl alcohol. The treatment areas are anesthetized with topical lidocaine, nerve blocks, or 1% lidocaine with or without with 1:100,000 epinephrine infused into the reconstituted vial of PLLA. Areas of concavity are outlined with a wax marking pencil or eyeliner pencil. For the enhancement of the under-eye area, prevent the development of subcutaneous nodules in the thin skin of the orbital rim, by injecting under the orbicularis oculi musculature. If at the time of injection, the PLLA suspension is not fully reconstituted, vigorously Shake the suspension and then warm it to a temperature of 92°C to 96°C (197.6–204.8°F) by submerging the suspension in hot water or by using a Bed Buddy (microwave for 2–3 minutes). These steps cause the covalent bonding

• • • • • •

PLLA (SCULPTRA)

•

to occur more rapidly. In more sophisticated laboratories, use a laboratory vortex mixer prior to the procedure and during the procedure to prevent settling of the suspension. The PLLA suspension is injected into the dermal subcutaneous juncture with a 25-gauge 0.5-, 1-, or 1.5-inch needle. For bolus injections, use a 25-gauge 0.5- or 1-inch needle. Move the needle in a fan-like sweep through the horizontal plane, in approximately 15° increments from each other, while injecting the PLLA with a retrograde technique (Fig. 19.2A). Place the needle adjacent to the first location in the same horizontal plane and repeat the injection using a fanning motion so that the fans overlap and cross to create a lattice of PLLA deposits (Fig. 19.2B).

• •

157

Minimize bruising by using arnica montana, bromelain, or Bruise Relief ®. Vigorous massage and manual sculpting was performed by the physician and/or nurse on patients with and without HIV for 5 minutes to treatment areas to distribute the material evenly. To minimize bruising and swelling, patients were given instructions to apply ice packs to the injected areas for 15 minutes of every hour over the next 12 to 24 hours.

Results

(A)

(B)

(C)

(D)

Figure 19.7 Medical indication for localized lipoatrophy two sessions, two vials. The patient had two sessions that were 8 weeks apart with two vials of PLLA per session. (A,B) Before; (C,D) after.

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OFF-LABEL USE: REJUVENATION OF THE HANDS

Legal and Ethical Considerations for Using PLLA Off-Label The legal and ethical considerations for the off-label use of any drug or medical device can appear complex. However, FDA regulations allow physicians to use medications or devices in an off-label manner when doing so is recognized as a common practice of physicians. In fact, for many diseases, the best treatment or only treatment available may be the off-label use of a medication. In such cases, this is not only acceptable, it might be considered unethical to do otherwise. According to Goldberg, “there is no question as to the legality

(A)

of off-label use for dermal fillers.” The off-label use of an FDA-approved dermal filler is legal when “off-label” is defined as using the filler in a manner consistent with how it is used by other physicians—once dermal fillers are used in such a way, there is no basis for liability (27,28). Patient Selection Hands with a significantly “bony prominence” (Fig. 19.8A) respond better to soft tissue augmentation compared to hands with significantly visible veins.

(B)

(C) Figure 19.8 Off-label use of PLLA for rejuvenation of hands: (A) before; (B) example of pinching and lifting the skin of the dorsal aspect of the hand before; (C) after.

(A)

(B)

Figure 19.9 Off-label use of PLLA for lipoatrophy of the metatarsal foot pads. (A) before; (B) after (note fullness in the metatarsal head regions).

PLLA (SCULPTRA) Injection Technique Most filler substances can be injected in the subdermal plane of the skin of the dorsum of the hands.

• • • •

Collagen HA Calcium hydroxylapatite PLLA

Filler substances are injected into the interosseous spaces with a 0.5- to 1-inch 25- to 27-gauge needle depending on the filler substance. Entry is through the web spaces. Dilution is accomplished with 8 ml sterile water and 2 ml of lidocaine/with epinephrine. The augmentation requires multiple sessions to obtain the full enhancement. Injection Steps The dorsal skin of the hand is pinched and lifted (Fig. 19.8B) or tented for easy access to the subdermal plane. The needle is advanced avoiding prominent dorsal veins. Injection is in a retrograde manner as the needle is being pulled out of the skin. Massage is particularly important in the enhancement of the hands, due to the elevated risk of papule or nodule formation.

• • •

OFF-LABEL USE: CORRECTION OF FOOT PROBLEMS

Patient Selection Metatarsal fat pad lipoatrophy

•

Injection Technique Place plantar surface of the foot on an ice compress (ice anesthesia). Use one vial at 3 cm3 dilution with sterile water plus 1 cm3 lidocaine/with epinephrine and a 21-gauge needle with a 1 cm3 syringe. Patient may require two to three treatment sessions at one month apart (Fig. 19.9).

• • •

Injection Steps Inject 1 cm3 at each metatarsal fat pad area. PLLA is injected between the first, second, third, and fourth metatarsal heads. Massage for 2 to 3 minutes.

• • •

SUMMARY

Poly-L-lactic acid (PLLA) has been shown safe and effective for the treatment of facial lipoatrophy through numerous studies in both immunocompromised and immunocompetent patients. PLLA works by a mechanism of action that it is completely different from other products for soft tissue augmentation. Significant differences in mechanism, treatment strategy, injection preparation, and injection technique require an approach, completely different from other products for soft tissue augmentation. In addition, a successful treatment strategy depends on the full understanding that aging of the face develops from the collective effects of fat atrophy and hypertrophy. Although PLLA is FDA approved to treat facial lipoatrophy, it is also used for offlabel treatment of the foot and hands in the United States. There are no legal risks when using PLLA off-label, as long as the off-label use is consistent with the common practices of other dermatologists and plastic surgeons. The formation of granulomas and nodules is avoided by using correct techniques that include (i) complete reconstitution with adequate dilution of PLLA, (ii) proper injection technique, and (iii) a strategy of treating facial units and not wrinkles. Today, new clinical applications for PLLA are gaining interest and studies have demonstrated excellent safety and efficacy in these new

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uses. For the dermatologist and plastic surgeon, this represents an exciting, but challenging era. As the marketplace of soft tissue fillers continues to grow, clinicians must develop expertise in a variety of divergent techniques. Therefore, the necessity for appropriate medical education and continued training on specific products becomes increasingly crucial. REFERENCES

1. Vleggaar D, Bauer U. Facial enhancement and the European experience with Sculptra (poly-L-lactic acid). J Drugs Dermatol 2004; 3(5): 542–7. 2. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly- L-lactic acid for the treatment of HIV-associated facial lipoatrophy. J Am Acad Dermatol 2005; 52(2): 233–9. 3. James J, Carruthers A, Carruthers J. HIV-associated facial lipoatrophy. Dermatol Surg 2002; 28: 979–86. 4. Dieterich DT. Long-term complications of nucleoside reverse transcriptase inhibitor therapy. AIDS Read 2003; 13: 176–84, 87. 5. Collins E, Wagner C, Walmsley S. Psychosocial impact of the lipodystrophy syndrome in HIV infection. AIDS Read 2000; 10: 546–50. 6. Jones SP, Qazi N, Morelese J, et al. Assessment of adipokine expression and mitochondrial toxicity in HIV patients with lipoatrophy on stavudine- and zidovudine-containing regimens. J Acquir Immune Defic Syndr 2005 15; 40(5): 565–72. 7. Moyle G. Lipodystrophy: lack of agreement on definition and etiology presents a challenge to research and therapy. AIDS Read 2002; 12: 438, 440–2. 8. Mest D. Experience with injectable poly-L-lactic acid in clinical practice. Cosmetic Dermatol 2005; 18(2 S2): 5–8. 9. Resources DAAI. Legal and Regulatory Issues Regarding New-Fill. Resources DAAI, Inc., 2001. 10. Cutright DE, Hunsuck EE. Tissue reaction to the biodegradable polylactic acid suture. Oral Surg Oral Med Oral Pathol 1971; 31(1): 134–9. 11. Li S, Vert M. Aliphatic polyester. In: Scott G, Gilead D, eds. Degradable Polymers. London: Chapman and Hall; 1995. 12. Hartman M. Biopolymers from Renewable Resources. Berlin, Heidelberg: Springer-Verlag; 1998. 13. Gruber P, Hall E, Kolstad J, Iwen M, et al., inventors. US Patent 5142023, 1992. 14. Micard V, Guilbert S. Thermal behavior of native and hydrophobized wheat gluten, gliadin and glutenin-rich fractions by modulated DSC. Int J Biol Macromol 2000; 27: 216–29. 15. Werschler W, Bondar G, Esch P. Six simple steps to Sculptra success: expert advice for incorporating this new filler agent into your practice. Skin and Aging 2005; 13(1): 56–64. 16. Onesti MG, Renzi LF, Paoletti F, Scuderi N. Use of polylactic acid in face lipodystrophy in HIV positive patients undergoing treatment with antiretroviral drugs (HAART). Acta Chir Plast 2004; 46(1): 12–5. 17. Valantin MA, Aubron-Olivier C, Ghosn J, et al. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open-label study VEGA. Aids 2003; 17(17): 2471–7. 18. Moyle GJ, Lysakova L, Brown S, et al. A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection. HIV Med 2004; 5(2): 82–7. 19. Bauer U. Improvement of facial aesthetics at 40 months with injectable Poly-L-lactic acid (PLLA). Paper presented at: The Aesthetic Meeting 2005, 2005; New Orleans, LA. 20. Beer K. A single-center, open-label study on the use of injectable poly-L-lactic acid for the treatment of moderate to severe scarring

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from acne or varicella. Dermatol Surg 2007 Dec; 33(Suppl 2): S159–S167. 21. Vleggaar D, Fitzgerald R. Dermatological implications of skeletal aging: a focus on supraperiosteal volumization for perioral rejuvenation. J Drugs Dermatol 2008; 7(3): 209–20. 22. Saylan Z. Facial fillers and their complications. Aesthet Surg J 2003; 23: 221–4. 23. Isada CM. New developments in long-term treatment of HIV: the honeymoon is over. Cleve Clin J Med 2001; 68: 804–7. 24. Anonymous. Questions and answers: ASCDAS 3rd Annual Meeting. New options in the recognition and treatment of lipoatrophy with volume restoration. Cosmetic Dermatol 2005; 18(3): 235–9.

25. Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol Surg 2000; 26(12): 1107–12. 26. Alster T, Jorizzo J, Hanke W, et al. The aging face: more than skin deep CME. [Available from: http://www.medscape.com/viewprogram/340; 2004] 27. Goldberg DJ. Legal ramifications of off-label filler use. Clin Plast Surg 2006; 33(4): 597–601. 28. Goldberg DJ. Legal ramifications of off-label filler use. Dermatol Ther 2006; 19(3): 189–93. 29. Ascher B, Coleman S, Alster T, et al. Full scope of effect of facial lipoatrophy: a framework of disease understanding. Dermatol Surg 2006; 32(8): 1058–69.

20 Permanent fillers Derek Jones

Currently the only injectable permanent filler with specific U.S.– Food and Drug Administration (FDA) device approval is Artefill. Liquid injectable silicone is available legally for off-label use only. Other permanent fillers such as Aquamid are currently undergoing FDA study. Permanent fillers should be reserved for select indications where temporary fillers may not perform as well or have suitable longevity, such as in HIV lipoatrophy or certain cases of acne scarring. As errors or adverse events with permanent fillers may be unforgiving, they should be avoided in patients who are naïve to injectable soft tissue augmentation, or are unclear of their treatment goals. LIQUID SILICONE

Liquid silicone (LIS), an inert and biocompatible synthetic polymer, was first used as an injectable filler in the 1950s. Before collagen injectable fillers became available in the early 1980s, LIS was the injectable filler of choice. However, there was no standardized FDA-approved LIS and different products of varying purity were often injected in large bolus form, which led to frequent product migration. Many products were intended for industrial rather than in vivo use, and impurities lead to frequent foreign body reactions. Subsequently, in the early 1990s, all forms of silicone for cosmetic implantation were banned by the FDA, citing possible toxicity and systemic reactions related to LIS and silicone breast implants. After a lengthy review, the FDA resolved safety issues regarding implantable and LIS, and in the 1990s, two new forms of highly purified LIS were approved (Silikon-1000 in 1997 and Adatosil-5000 in 1994) for use as an injectable intraocular implant to treat retinal detachment. While this is the only FDA-approved indication for LIS, the FDA Modernization Act of 1997 makes off-label uses legal, provided that the physician or drug manufacturer does not advertise for such use. Therefore, LIS may now legally be used off-label for softtissue augmentation (see “Indications” below). Compared to Adatosil, Silikon-1000 has a lower viscosity and is the most suitable for injectable soft tissue augmentation, as it is easier to inject through smaller gauge needles. Current opinion on liquid injectable silicone is polarized between opponents and advocates. Opponents argue that despite use of proper technique and products, serious adverse events are common and that LIS is inherently unpredictable. Proponents rely on a wealth of anecdotal data to argue that liquid injectable silicone is safe and effective as long as three rules are employed: (i) Use highly purified FDA-approved LIS; (ii) employ microdroplet serial puncture technique (defined as 0.01 cc per injection site injected into the subdermal plane), and (iii) use small volumes (0.5 ml for smaller defects and up to 2 ml for larger areas of atrophy) at each session with multiple sessions staged at monthly intervals or longer. Mechanism of Action After LIS is injected, a capsule of new collagen develops to encircle each microdroplet of silicone. This process continues for about 3 months, during which time the collagen capsule adds volume around the LIS microdroplet. The collagen also holds the droplets in place to prevent migration (1). Indications Although LIS is used off-label for many indications, it is the author’s opinion that LIS should not be routinely employed for the average

cosmetic patient until longer term studies with current products resolve some of the controversy regarding longer term safety and efficacy. However, for the unique and disfiguring defects associated with HIV facial lipoatrophy (FLA) and serious acne scarring, LIS produces cosmetically superior and more durable results than currently available less permanent options (see “Efficacy and Safety” below). Efficacy and Safety LIS has been demonstrated to be an excellent choice for HIV-associated FLA. In one trial, highly purified 1000-cSt silicone oil was studied among 77 patients with HIV-FLA who received 2 ml of Silikon 1000 at monthly intervals with microdroplet technique until optimal correction was achieved. The researchers reported that the number of treatments, amount of silicone, and time required to reach optimal correction were directly related to the initial severity of lipoatrophy and that highly purified 1000-cSt silicone oil is a safe and effective treatment option for HIV-associated lipoatrophy (Fig. 20.1) (2). Fiveyear data are now available on this cohort and no serious adverse events have been found (D Jones, data on file). Using the microdroplet, multiple-injection technique, Barnett and Barnett also have had success with injections of LIS for acne scars lasting over a 10-, 15-, and 30-year follow-up period (3). Technique Clinicians should inject only highly purified FDA-approved LIS, such as Silikon-1000, using the microdroplet serial puncture technique (0.01 ml or less injected through a 27-gauge needle into the immediate subdermal plane at 2–4 mm intervals). Intradermal injections should be avoided, as these may create intradermal papules (4). However, intradermal injections may be used for atrophic dermal acne scars, using 0.001 ml microdroplets. Very small amounts of LIS should be injected at monthly intervals, or longer. The immediate goal is undercorrection. Optimal correction occurs slowly as fibroplasia develops around the microdroplets, creating further tissue augmentation and anchoring each microdroplet into place. POLYMETHYLMETHACRYLATE

Injectable polymethylmethacrylate (PMMA, Artefill, Artes Medical, San Diego, California, USA) is a suspension of 20% PMMA smooth microspheres and 80% bovine collagen. Artefill is the product of third-generation PMMA microsphere technology. Previous generations include Arteplast (used in Germany from 1989 to 1994) and Artecoll (used worldwide, except in the United States and Japan, from 1994 to 2006). Artefill represents a third-generation product containing fewer nanoparticles (less than 20 µm), which were thought to be associated with granulomatous reactions observed with previous generations. Artefill was approved by the FDA in 2006 for the correction of nasolabial folds. Artes filed for Chapter 7 bankruptcy in December 2008, and was subsequently acquired by Suneva, Inc. (San Diego, California, USA) who now distributes the product in the United States. Mechanism of Action After PMMA is injected, the collagen vehicle is absorbed within 1 to 3 months. Afterward, foreign body neocollagenesis ensues which engulfs and encapsulates the remaining estimated six million PMMA

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Figure 20.1 (A,B) Pretreatment and post-treatment liquid injectable silicone for HIV-associated facial lipoatrophy. Source : Courtesy of Derek Jones, MD.

Before treatment

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After 6 months

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After 1 year

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After 5 years

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Figure 20.2 (A–D) Results of Artefill for the treatment of nasolabial folds at pretreatment, one year post treatment, and beyond one year post treatment. Source : From Ref. 5.

particles in 1 ml of Artefill. This process of fibroplasia also contributes to tissue augmentation. Although the collagen is absorbed, the PMMA is permanent and not re-absorbed (5). Indications Injectable PMMA is indicated for nasolabial folds. It is also been used off-label for glabellar frown lines, radial lip lines, and mouth corners. Injectable PMMA is contraindicated for use in patients with a positive result to the required Artefill skin test, patients with severe allergies (as indicated by a history of anaphylaxis or multiple severe allergies), patients with known lidocaine hypersensitivity, patients with a history of allergies to bovine collagen products, and patients with known susceptibility to keloid or hypertrophic scarring.

The product should not be used for lip augmentation. Efficacy and Safety The U.S. pivotal clinical trial for Artefill was a controlled, randomized, prospective, double-masked trial of 251 patients at eight centers across the United States. Patients received either Artefill or bovine collagen dermal filler (control). Efficacy was rated by masked observers using a photographic Facial Fold Assessment Scale. The study demonstrated a significant improvement with Artefill compared with the control group at 6 months ( p < 0.001) in nasolabial folds. A subset of patients was observed at 12 months and all showed persistent wrinkle correction (Fig. 20.2) (5). A subgroup of 69 patients returned for follow-up 4 to 5 years later. Investigator Facial Fold Assessment ratings at 4 or 5 years were improved from baseline by 1.67 points (p < 0.001). Nearly all subjects

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(C) Figure 20.3 Bio-Alcamid abscess pre- (A) and post- (B) incision and drainage; gram stain of drained material reveals streptococcal bacteria (C). Source : From Ref. 9.

(95.5%) reported that they were at least somewhat satisfied and 81.8% reported that they were either satisfied or very satisfied (6). Five patients reported six late adverse events that occurred from 2 to 5 years after the initial injection. Of these, four were mild cases of lumpiness, and two were severe. The total number of late, adverse events was 6 (2.2%) of 272 of wrinkles injected (6). Granulomatous reactions (manifested by inflamed red nodules), which were more common with previous generations of Artefill, may be treated with intralesional cortisone combined with antibiotic therapy. Technique Injectable PMMA is placed into the dermal–subcutaneous junction using the tunneling or linear threading technique with a 26-gauge, 5/8inch needle. Overcorrection is not recommended. It is preferable to inject more deeply as superficial injection can cause permanent skin surface texture or color impairment. Patients should be evaluated 4 to 6 weeks after the injection to assess the need for further treatments. Optimal correction usually requires two to three treatments, and touch-up implantations should be at intervals of at least 2 weeks or longer depending upon the amount of implant used, the site of placement, and the dynamics of the corrected sites. INVESTIGATIONAL PERMANENT AGENTS: HYDROGEL POLYMERS

Hydrogel polymers are a novel class of fillers, comprised mostly of water with a small amount of synthetic polymer. The so-called injectable “endoprosthesis” agents include Bio-Alcamid (Polymekon, Milan, Italy) and Aquamid (Aquamid, Ferrosan, Copenhagen, Denmark), both of which are used in Europe but are not yet FDA approved. These

nonbiodegradable fillers are composed of 96% water and 4% synthetic polymer: polyalkylimide, in the case of Bio-Alcamid, and polyacrylamide for Aquamid. Both agents are used for large-volume augmentation such as hemi-FLA (Romberg’s disease) or HIV-associated lipoatrophy. Mechanism of Action Once injected, the gel particles become covered by a thin collagen capsule (0.02 mm) which completely surrounds the particles and isolates them from the host tissues, creating an injectable prosthesis. According to the manufacturer, Bio-Alcamid has much stability, integration among living tissues, and more simple removal, if required, than other dermal fillers. The results are considered permanent, but removal can potentially be performed through incision and drainage. Indications While both agents are used for replacement of facial volume due to lipoatrophy, they also used for the treatment of nasolabial folds, lip augmentation, depressed scars, and enhancement of cheekbones and jawline. They are not indicated for the treatment of fine wrinkles. Efficacy and Safety Recent reports in the literature document the success of Bio-Alcamid for the treatment of HIV-associated FLA (7,8). According to the manufacturer, risk of infection or allergy is very low (0.6%) and only 0.2% of patients have had an immune response to the implant, which created localized swelling that required drainage over a 1- to 6-month period. Late-appearing bacterial abscesses are common with Bio-Alcamid. A paper by the author and colleagues reports five patients who received

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Bio-Alcamid for HIV-associated lipoatrophy and developed lateappearing streptococcal bacterial abscesses (Fig. 20.3) (9). In each case, an acute abscess developed several months and up to years after the initial injection of Bio-Alcamid. All five cases responded quickly to incision and drainage combined with antibiotic therapy, although in two cases the abscesses became recurrent. In one case, the patient also developed methicillin-resistant Staphylococcus aureus infection and required extensive intravenous antibiotic therapy. Based on the cases, it appears that local oral streptococcal bacteria may be capable of directly invading the interior of the implant material, which may evade host defenses. It also seems possible that the bacteria may reach the implant through a needle puncture during a dental or surgical procedure, possibly warranting prophylactic antibiotic therapy before dental and surgical procedures in patients who have received Bio-Alcamid. A recent study by Narins studied 315 subjects using Aquamid with a linear threading technique in the nasolabial folds against a parallel group who received Restylane. The correction achieved with Aquamid was considered non-inferior to Restylane at 6 months and continued to be effective at 12 months. One serious adverse event (infection) occurred in the Aquamid group and resolved. A 12-month extension study is currently underway to determine the longer term safety and efficacy of Aquamid (10). Bio-Alcamid and other hydrogel polymers carry the risk of foreign body reaction, infection, migration, or granuloma formation. Technique These agents are injected subcutaneously, usually under local anesthesia, and massaged smooth by the clinician. A thin layer of collagen gradually forms around the injected gel over a period of 4 to 8 weeks when the gel becomes completely surrounded and isolated from host tissues—in effect making it an endogenous prosthesis.

REFERENCES

1. Alam M, Gladstone H, Kramer E, et al. ASDS guidelines of care: injectable fillers. Dermatol Surg 2008; 34: S115–S148. 2. Jones D, Carruthers A, Orentreich D, et al. Highly Purified 1000-cST silicone oil for treatment of human immunodeficiency virus-associated facial lipoatrophy: an open pilot trial. Dermatol Surg 2004; 30: 1279–86. 3. Barnett JG, Barnett GR. Treatment of acne scars with liquid silicone injections: 30-year perspective. Dermatol Sug 2005; 31: 1542–9. 4. Jones D. HIV facial lipoatrophy: causes and treatment options. Dermatol Surg 2005; 31: 1519–29. 5. Cohen SR, Holmes RE. Artecoll: a long-lasting injectable wrinkle filler material: report of a controlled, randomized, multicenter clinical trial of 251 subjects. Plast Reconstr Surg 2004; 114: 964–76. 6. Cohen SR, Berner CF, Busso M, et al. Artefill: a long-lasting injectable wrinkle filler material—summary of the U.S. Food and Drug Administration trials and a progress report on 4- to 5-year outcomes. Plast Reconstr Surg 2006; 118(35): 64S–76S. 7. Protopapa C, Giuseppe S, Caporale D, et al. Bio-Alcamid in druginduced lipodystrophy. J Cosmet Laser Ther 2003; 5: 226–30. 8. Treacy P, Goldberg D. Use of a biopolymer polyalkylimide filler for facial lipodystrophy in HIV-positive patients undergoing treatment with antiretroviral drugs. J Dermatol Surg 2006; 32: 804–8. 9. Jones DH, Carruthers A, Fitzgerald R, et al. Late-appearing abscesses after injections of nonabsorbable hydrogel polymer for HIVassociated facial lipoatrophy. Dermatol Surg 2007; 33: S193–8. 10. Narins R. A 12-month controlled study in the United States of the safety and efficacy of hydrogel, a permanent soft-tissue filler. Abstract Presentation, American Society of Dermatologic Surgery Annual Meeting, Phoenix Arizona, October 2009.

21

Liposuction my way Patricia Wexler

The past 20 plus years of tumescent liposuction performed in my practice have seen remarkably few dramatic changes. Despite the introduction of power technology and the addition of various laser and light sources to assist liposuction, the basic premise of tumescent liposuction has remained constant. This has afforded my patients a high degrees of safety and satisfaction with the outcomes I achieve. Before discussing the technique of liposuction, we need to discuss the art of liposuction. Some of my best cases were performed in my first two years of practice when I had no power technology at all, and all of my cases were done using a 60 cc syringe and luer-lock cannulas. This procedure required huge amounts of time, effort and perspiration and performing a two or three liter case using tumescent anesthesia could take hours. However, my patients were awake and I had the opportunity to bond with them and explain the procedure as we proceeded. Performing the procedure slowly also enabled me to learn a great deal about contouring the body. I learned patience in sculpting the waist and lower back. I learned to proceed slowly and cautiously in shaping inner thighs and knees. I also learned to use the cannula in my right hand and to use my left as a tactile aid to guide the procedure. The addition of vacuum assisted aspiration, followed by powerassisted liposuction, and now laser-assisted liposuction, has done more to add longevity to the joints of the surgeon than to the contour of the patient. Laser-assisted liposuction has a role in my practice in a limited number of cases which I will go on to explain; and I am anxious to see what role external ultrasound and radiofrequency will have in the future. But in general, tumescent liposuction is the same today as it was when I started over 20 years ago. Liposuction remains as much an art form as a medical technique and its evolution in my practice has followed that form. Part of liposuction can be taught from physician to physician but some of it (the art portion) needs to be learned as an individual artist. Each procedure begins with a thorough patient evaluation. The most successful liposuction starts not with the actual insertion of the cannula but with choosing your patient carefully. Liposuction is not a method of weight reduction, it is not a quick diet, and it is not a solution to an unhappy marriage. It is however, a perfect procedure for someone with a body disproportion whose weight is virtually stable, and who is highly motivated to maintain their weight with good eating habits and exercise. Each of these points needs to be explained to the patient and should be included in the consent form. THE CONSULTATION

When a patient comes for a liposuction consultation they are first seen in my consultation room where we discuss their goals and expectations. A history is taken of their prior cosmetic procedures, any weight fluctuations within the past several years, and any history of bariatric surgery, along with any intentions of pregnancy in the near future. This is all done to ascertain whether they are initially good candidates and whether they will be able to maintain good results. I conclude with a general medical history to see if they are medically capable to undergo the procedure or require further evaluation. Then we proceed to the exam room where they are provided a gown and examined undressed and photographs of the appropriate areas are taken. I evaluate at that point for proportion, volume, skin tone, skin laxity, and prior surgical defects which could make success less than perfect.

The patient is weighed, and if I deem the patient a good candidate for the procedure I then review the photographs that were taken, along with before and after photographs I feel are relevant to their case so we can discuss expectations. I point out both the positive and negative outcomes they should expect. We then discuss which type of liposuction I plan to use. Further along we will discuss when I veer from my tumescent liposuction with power assistance and use laser-assisted liposuction. At this point I will say if the patient is a good candidate we would do pre-operative testing. Patients under the age of 50 are screened as medically indicated, i.e. autoimmune disease, history of cancer, history of radiation, etc. Over the age of 50, patients require medical clearance consisting of blood work including CBC with different platelets; Chemistry 18, PT, PTT, EKG, and a letter of medical clearance from the primary care physician or internist; additional medical clearance is requested if the history requires it. All testing is done within one month of the procedure. If the procedure is delayed the patient is reevaluated and the screening and testing are repeated. These are our specific guidelines due to our Joint Commission certification. At the time of the consultation, both my surgical coordinator and I review with the patient the pre- and post-operative instructions thoroughly which includes what to expect in preparation of the procedure, the morning of surgery, the procedure, and post-operative care. They are then given literature to take home, along with any prescriptions they made need to take before and after the procedure. In my office, this would include a broad spectrum antibiotic, such as a cephalosporin and a pain medication. My surgical coordinator will give a date for the surgery which will be confirmed two weeks prior to the procedure. PRE-OPERATIVE PHASE

One week prior to surgery I ask all patients to refrain from alcohol, aspirin, any anti-inflammatory medication (Advil), multi-vitamins, vitamin E, and fish oils (omega-3), as these can all contribute to increased bleeding and bruising. During the patients’ evaluation of their medical history, we have identified medications the patients need to stop prior to the procedure, which will require medical clearance from their primary care physicians. An example would be certain medications that work on the central nervous system, as proteases inhibitors may increase the toxicity of lidocaine. Certain drugs such as the SSRI antidepressant Zoloft, or the antibiotics Erythromycin, Ketoconazole, and Fluconazole may impair the cytochrome P450 3A4 that is required to metabolize lidocaine. These drugs should be discontinued at least 10 days prior to surgery. In addition, there is a very comprehensive list that needs to be reviewed with patients to ensure no contraindication with lidocaine or parenteral anesthesia. THE DAY OF SURGERY

When the patient returns to the office the day of their surgery they are brought into the presurgical room. This is where they are put into a gown, undergarment, and robe. All jewelry is removed. File verification is completed. Vital signs are taken, and review of all clearance and paperwork is done. The contact person is provided for patient pick up. This then has to be verified because surgery cannot be performed if there is no one to pick them up. The patient is never left alone at any point. I then meet with the patient and verify that anatomic and aesthetic expectations are the same, and reasonable. Once that is agreed

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upon, markings are done. I tend to tell the patient exactly what I can and cannot accomplish while marking. All prior defects are identified so the patient is fully aware of their physical state. I am very clear about what will be done and what won’t be done. Then pictures are taken along with measurements and weight. Then the patient has to sign the consent form while I am in the room with the surgical assistant as a witness. The patient is then medicated with Valium, usually starting with 5 mg and in the OR additional Valium is given if needed. The patient is walked to the OR, disrobed and given a scrub top and asked to lie down on the table. At this point in the process, we have identified whether the patient will have tumescent liposuction with or without laser assistance. In my practice less than 20% of the procedures performed are laser assisted. There are several reasons for this. The first is that I believe that laser-assisted liposuction is best reserved for patients who are having repeat liposuction where there is significant scar tissue where they need the laser to break the fibrous bands without mechanical trauma. This is also indicated when there are significant striae, indicating loss of elastic tissue usually indicating a poor candidate for traditional liposuction. In addition tissue contraction and areas of genetically fibrotic fat are difficult to remove with a traditional tumescent technique; an example would be male love handles, a dowager hump, and a thick male neck. Sun damaged skin, traditionally less rich in elastic tissue and less likely to get good contraction, would also benefit from a laser technique. Although I know it has become a very successful marketing tool, it is misunderstood by the public and people believe that laser liposuction does not require removal of fat making them believe it is a procedure it is not. In some cases I believe it adds an element of heat and swelling that can actually increase the time of recuperation compared to traditional tumescent power-assisted liposuction with compression postoperatively, which you will see in my pre-and post-operative photography. For example, a 65-year-old male patient with an extremely lax neck who would not consider that a rhydidectomy was treated in my office with Botulinum A to his platysmal bands two weeks prior to tumescent liposuction to his neck and had exceptional

(A)

results that were following yearly for five years. Because the platysmal bands were treated prior to his liposuction, I was able to have better access to the nuchal fat and subplatysmal fat and his results continue to maintain. No further Botox treatments were done until year 5. Other patients have had Botulinum A, as part of their continued maintenance. I cannot image that laser assistance would have made the results any better or more comfortable for these patients. CASE STUDY A

In case study A (Fig. 21.1), BotoxTM was given two weeks prior to procedure. Sixty units of a 1 cc dilution were given in eight individual superficial injections in a horizontal band approximately 2 cm beneath the mandible. The Procedure The day of the procedure, the patient has markings drawn along the jaw line, and inferior aspect of the heaviest part of the neck ending above the thyroid anteriorly, and tapering toward the ear lobe attachments. I make additional markings for any additional jowls lateral and superior to the DOA. I then take close-up photography of the areas to be treated. The patient is then laid down with head in extension with neck roll and given a white colored blind fold. A Carly Simon CD is then played and we continually speak with the patient during the entire procedure so they know that they are not being left alone. The skin is then prepped with hibiclens; I use local anesthesia 2% XylocaineTM with EpinephrineTM. I make four small incisions of two millimeter each, two midline under the chin and one behind each ear for a multiple approach strategy. I inject standard Klein Tumescent anesthesia using the McGhan injector gun and a butterfly needle into the entire area with slow but steady infiltration through the area that is already injected making it comfortable and giving me accessibility to very small spaces. As the patient is awake and cooperative, I have them do manipulations to make sure that nerve function remains intact of the lip and if any motor changes occur I can assure the patient this is due to the anesthesia alone and not due to any traumatic injury from the liposuction cannulae. Also by certain

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(E) Before and After

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Figure 21.1 (A) Consultation photo. (B) Profile at consultation. (C,D) Two weeks post-platysmal Botox; pre-op. (E,F) Five days post-liposuction.

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LIPOSUCTION MY WAY manipulations of the tongue, I have better access to subplatysmal fat giving me even better correction of the neck with a higher safety profile. Using a 15 cm, 2 mm triport blunt-tip cannula, and using a fanning technique I remove the fat starting from the midline of the chin fanning toward the earlobe laterally. It is the only place on the body where I will actually try to attain a windshield technique allowing the cannula to flow evenly from one end to another, virtually removing the majority of fat present. Then to assure there is no rippling or unevenness, I go from the ear incision back toward the chin and do the same fanning technique with windshielding. During this time I ask the patient to stick their tongue out, which gives me better access to subplatysmal fat. And after initial volume reduction I have the patient sit for final sculpting to chisel a sharp jawline and sub-mental area, prior to completing the procedure. I suture before I use compression garments, and do not require drainage of the suture site. This allows fibrosis of the skin to underlying structures and minimizes visibility of the suture sites. I ensure that the patient can swallow liquids with a straw and I mark the dressing with a permanent marker to show the patient where the dressing belongs in case they move it accidentally. They are instructed to sleep elevated in an arm chair with a neck support for the first evening and to eat soft foods for the first evening. Most critical is the post-operative check up the morning after surgery to ensure that the compression garment is not too tight which can cause discomfort to the patient and respiratory distress. Patients are

given very specific instructions and provided both my cell phone number and my surgical assistant’s number. They are told to call if they experience any unusual symptoms. At day 5, the compression garment is removed and only used at bedtime for two additional weeks. Any significant bruising may be treated with the Vbeam; any significant swelling can be treated with external ultrasound once or twice weekly. The patient is given post-operative broad spectrum antibiotics for 1 week, and pain medication to be taken as needed. Most patients do not find this painful, just annoying, or mildly uncomfortable. There is remarkably scant bruising at day 5 upon compression garment removal. Patients may elect continuing Botox treatment of the platysmal bands periodically for optimal results. CASE STUDY B

A 50-year-old female complaining of increased fat deposition in the upper and lower abdomen, hips, waist, and lower back (Fig. 21.2). The method I chose with this patient given the fact that she had no prior procedures and had good skin tone was power assisted tumescent liposuction. As with case A the patient evaluation, pre-operative evaluation, and day of surgery, and patient preparation are done in the same manner. The patient is evaluated for laxity of the skin, striae, areas of fibrosis or scar tissue, and previous areas of surgical intervention. If none of these are present, laser-assisted liposuction is not used in addition to my usual technique.

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Before

After

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Figure 21.2 (A,B) Pre-op hips, waist, upper, and lower abdomen of a 50-year-old female. (C,D) One month post-liposuction hips, waist, upper and lower abdomen.

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It is essential when evaluating for liposuction to evaluate the upper as well as the lower abdomen, as liposuction of the lower abdomen only will usually result in any weight gain going to the upper abdomen which will result in contouring that is more disturbing than the original shape. With this case, it was important to point out utilizing the before photographs that were taken, that because her hips and waist are full, liposuction of the abdomen alone would not give the change in contour that she desires. In addition, though she did not like the increased fat of her lower back, this would not be correct with liposuction of the area. In fact it will redistribute upon liposuction of her hips and waist. In this case I elected to do power-assisted liposuction using the Microaire Pal-600ETM hand piece and console, in conjunction with PSI Tec III AspiratorTM. This machine has decreased the incidence of carpel– tunnel syndrome to the surgeon, and increased the speed of the procedure and the uniformity of dispersion of the anesthesia. It also provides easier accessibility to fibrotic areas such as hips, waist, and back. I used a 15 cm, 2 mm blunt triport cannula. My liposuction technique itself is the same regardless of laser or power assistance. I place the cannula in the adipose layer of the skin with my dominant hand, and with my non-dominant hand I feel the surface of the area being suctioned at all times, feeling for the depth of the tip of the cannula. It is critical that you see no dimpling of the skin, or retraction of the skin which can leave permanent depressions, or in the case of laser liposuction the creation of burns or skin necrosis. I am continuously moving the cannula in a fanning technique through the tumescent-treated fat, and at no time do I leave the cannula in the on position at rest or in one position. It must be in constant movement,

which I describe as a fanning movement to allow for even removal of adipose tissue without ridging, hill, or valleys. When I feel that at least 50% or more of the volume desired to be removed has been accomplished I stand the patient and continue to aspirate the fat using the same technique using multiple sites of access from both sides of the area being treated. At the completion of liposuction, incision sites are sutured with a 5-0 ethibond mattress suture, at each site. One should not be concerned with the number of suture sites because the more direct the accesses to the fat, the more perfect the contour. Trying to have less incisions and trying to achieve a perfect contour with a longer cannula, or making impossible anatomic turns will never achieve smooth symmetric results. I have frequently made games with myself where I try to do 100% of the case in a supine position before standing the patient and I have yet to find a patient that I have not been able to do more and achieve better results when standing the patient. It’s espeically true in the case when a patient has poor elasticity so the patient must stand so I can feel and look at how the skin will drape to achieve what I feel is the perfect end point. In my practice if my patient could not stand I would not continue to do liposuction. As you can see in the before and after pictures of study B, liposuction of the hips and waist only caused the excessive back fat to redistribute, resulting in a smooth silhouette not requiring liposuction of the lower back. CASE STUDY C

We see a 65-year-old female with a very large upper and lower abdomen, as well as hips and waist (Fig. 21.3). This patient would have been

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Before

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Figure 21.3 (A,B) Pre-op hips, waist, upper, and lower abdomen of a 65-year-old female. (C,D) One month post-liposuction.

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LIPOSUCTION MY WAY an ideal candidate for laser-assisted liposuction due to the laxity of her skin and the presence of striae which would indicate additional improvement with the use of laser-assisted technology. Since this was not available, the patient was informed that liposuction could be done with the risk that her skin would show laxity afterward, but she would look better dressed without the associated risk of abdominalplasty with general anesthesia. Although laser technology was not used, we used tumescent liposuction with power assistance with the addition of French Tape and a compression garment for seven days post-operatively. The compression closes the dead space created by the liposuction between the skin and the deeper tissues, and encourages the redraping and adherence of the skin to the underlying structures. It also encourages return of the tumescent fluid to the lymphatic system to be cleared by the body. Preparation, marking, fat removal, and suturing technique remain consistent with prior procedure. I apply the tape in a criss-cross pattern like a basket weave, from the bottom of the area to the most superior aspect, overlapping and draping the tape. It is removed at one week, in one midline posterior cut and removal. The compression garment is worn for two additional weeks. Aerobic activity is discouraged at this time to avoid swelling. If patients feel excessively swollen or bruised, external ultrasound may be performed in the office twice weekly five minutes per area to speed recover and aid in patient comfort. CASE STUDY D

A 42-year-old male who has had liposuction twice in the past with recurrent weight gain resulting in significant fibrosis and scar tissue (Fig. 21.4). This would be his third liposuction of his upper and lower abdomen, hips, and love handles. On physical exam all previously treated areas are fibrotic and bound down to underlying structures causing his skin to look uneven and feel marbleized. I discussed the case in detail with the patient explaining that liposuction is not a diet, and that if I agreed to do the procedure it was his last possibility of having liposuction without severe complications such as perforation or necrosis of skin or muscle. The case would have only been possible using laser-assisted liposuction technology. This is a classic example of laser-assisted liposuction being used to break up scar tissue, and create more even contours in a patient with already compromised skin prior to removing the fat with powerassisted liposuction. In this patient’s case I used the Cool Lipo technology with 1320 nm wave length, at treatment levels eight watts, 20 Hz.

(A)

Before

The Cool Lipo works by liquefying fat using photoacoustic disruption, not thermal energy. Energy of 50 Hz is also associated with tightening of subdermal collagen. As you are using the fiber tip technology you can see the oily fraction of the fat escaping the incision site. When the resistance is no longer palpable, the laser assistance is discontinued and the liposuction is switched to power assisted and traditional liposuction is performed to remove the remaining liquefied and unliquified fat. At the completion of contouring incision sites are sutured, the patient is wrapped with French tape and post-operative compression garment as usual. Antibiotics are given. As you can see from the before and after pictures done one week post-operatively, there is an even contour, especially posterially. One can see the lack of swelling and the minimal bruising present all due to the addition of laser technology to the extremely difficult corrective case. CASE STUDY E

This patient presented with large defects in the hip area which occurred after liposuction was performed under general anesthesia by a plastic surgeon leaving large defects over the trochanteric regions of both hips (Fig. 21.5). After reviewing her case it was decided that it could be corrected doing syringe-assisted liposuction saving large volumes of adipose tissue from her hips and saddlebags, and re-injecting both immediately and on post-surgical visits to the areas of deficit at one month intervals. The patient was prepared in our usual fashion, but in lieu of powerassisted liposuction the fat was removed using 60 cc luer-lock syringes, with my usual triport blunt-tip cannulas and a clicker lock device. After removal of 900 cc of fat bilaterally from hips and saddle bags, each 60 cc syringe was attached to a female-to-female luer-lock transfer adapter and washed with sterile saline, discarding the oily layer and blood cells, leaving pure fat to be transferred via this closed technique to 5 cc syringes. During the first liposuction session, the fresh fat was injected using the triport cannula through the incision site into the area of defect until cosmetically satisfactory. This used approximately 600 cc of the 900 cc’s harvested. The incision sites were sutured with one single 5-0 Ethibond suture each and the area wrapped with elastiplast tape before putting the patient into a surgical garment. The sutures and tape are removed at one week. The patient returns at one month intervals for up to one year for follow-up injections if necessary using the frozen fat which is identified using the patients name, date of birth, and SS number, by two

(B)

After

Figure 21.4 (A) Pre-op laser-assisted liposuction repair of upper and lower abdomen, love handles, and hips. (B) One month post-liposuction.

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT Before and After

(A)

(B)

(C)

Figure 21.5 (A) Pre-op repair of irregularities post-liposuction saddle bags. (B) One month post-liposuction his, saddles and transplantation of 600 cc of fat into defects. (C) Post-op one year.

staff members. One hour before the patient arrives the fat was placed into a sterile container and defrosted at room temperature. The fat was then centrifuged for 42 seconds and then put into 3 cc syringes. The fat was then brought into the room, patient identification was reconfirmed, and the areas are injected using a 16-gauge, 1.25-inch BD needle, after topical anesthesia. The procedure remains a closed technique at all times. No further antibiotics are needed after the initial liposuction. The key to permanent correction is progressive re-injection of surgical defects to allow fat to graft to surrounding blood supply. If too large an amount is injected in any one session, the central area of injection will not graft leaving a small area of peripheral grafting only. It is a tragedy that so many corrective surgeries are denied because surgeons have frequently said that patients that are unhappy with their work and will never be happy with corrective procedures, and for that reason they are refused the opportunity to be given a chance at a normal aesthetic contour. An aesthetic surgeon’s greatest challenge should be taking something of misfortune and making into something of beauty. Misconception 1. If you have liposuction you are going to die. Liposuction under local anesthesia with tumescence with patients awake has the highest safety profile of any liposuction performed. Deaths have only been associated with patients under general anesthesia and usually associated with patients undergoing multiple procedures at one time. Dermatologists have the highest safety profile of any specialty doing liposuction. Misconception 2. Laser-assisted liposuction is a lunch time procedure. Laser-assisted liposuction is used in addition to the removal of fat with tumescent liposuction. It is to aid in the tightening of skin that is loose, or less than optimum for traditional liposuction. It is used for areas of fibrosis or scar tissue. It should only be used in association with traditional liposuction. Misconception 3. Liposuction is a method of weight reduction. Liposuction should not be done on a person who is constantly going up and down in weight. It should be done on a person who has had a stable weight for at least six months to a year and within 10% to 15% of a goal weight. It is used to correct body disproportion, i.e., a person with a large abdomen and stick arms and legs. Not to reduce entire body mass. Misconception 4. If you have liposuction and gain weight it will grow back in the same place. Unfortunately when you remove the bulk of fat cells in one location, when you gain weight it usually goes to a less desirable location. So if you have liposuction of your neck and you gain weight you may find

you gain it in your back or breast. So if you consider having liposuction be prepared to remain stable in weight 5 to 7 lbs. You can’t gain weight where you don’t have fat cells. They have been removed. Laser-assisted liposuction is an evolving technology and there will be some techniques and procedures that are kept and others will become outdated. As Thoreau once said, “everything that is better was once new, but not everything new is better.” CONCLUSION

Despite the technical advances in liposuction over the past 25 years the technology for the most part has benefited the surgeon in terms of speed, and diminishing stress on joints, thus resulting in less injury to the wrists, elbows, and shoulders. The patient is benefiting from enjoying liposuction that would not have been available previously in the presence of poor skin tone, stretch marks, and previous scar tissue. What we look forward to in the future are new modalities of external fat reduction and skin tightening using external ultrasonic methods and radio frequency waves. The challenge we have will be the administration of adequate heat in a uniform manner to the deep tissue without damage to the superficial epidermis in a way that will be tolerated without excessive pain to the patient. Studies with numerous devices are underway and we look forward to exciting results. BIBLIOGRAPHY

Asken S. Autologous fat transplantation: micro and macro techniques. Am J Cosmetic Surg 1987; 4: 111. Bernstein G, Hanke W. Safety of liposuction: a review of 9,478 cases performed by dermatologist. J Dermatol Surg Oncol 1988; 14: 1112–14. Bisaccia E, Scarborough DA. Breast enlargement after liposuction. Am J Cosmetic Surg 1992; 7: 97. Butterwick KJ, Bevin AA, Iyer S. Fat transplantation using fresh versus frozen fat: a Sid-by-Sid two-hand comparison pilot study. Dermatol Surg 2006; 32(5): 640–4. Chang KN. Surgical correction of post liposuction contour irregularities. Plast Reconstr Surg 1994; 94: 126. Coldiron BM, Healy C, Bene NI. Dermatologic surgery: office surgery incidents: what seven year of Florida data show us. 2008; 34: 285–91. Coldiron B, Fisher AH, Adelman E, et al. Dermatologic surgery: adverse event reporting: lessons learned from 4 years of Florida office data. 2005; 31: 1079–2. Coldiron B, Shreve E, Balkrishnan R. Dermatologic surgery: patient injuries from surgical procedures performed in medical offices: three years of Florida data. 2004; 30: 1435–43.

LIPOSUCTION MY WAY Coleman VP. Autologous fat transplantation. Plast Reconstr Surg 1991; 88: 736. Dolsky RL. Adipocyte survival. Presented at the Third Annual Scientific Meeting of the American Academy of Cosmetic Surgery and the American Society of Liposuction Surgery, Los Angeles, CA, February 1987. Fournier PF. Liposculpture: The Syringe Technique. Paris: Arnette, 1991. Glagau RG. MIcrolipoinjection. Arch Dermatol 1988; 124: 1340–43. Guideline from the American Academy of Dermatology, 2006. Hanke CW, Berstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients. J Dermatol Surg Oncol 1995; 21: 459–62. Hudson DA, Lambert EV, Bloch CE. Site selection for autotransplantation: some observations. Aesthetic Plast Surg 1990; 14: 195.

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JeffreyKleinliposuction.com: The Klein Technique; Pharmacology. Klein AW. Dermal fat augmentation: a reality. J Dermatol Surg Oncol 1993; 19: 1030. Klein JA. The tumescent technique for liposuction. J Am Acad Cosmetic Surg 1987; 4: 263–7. Pinski KS. Micro lipo injection adn autologous collagen. Dermatol Clin 1995; 13: 339–51. Platt MS, Kohler LJ, Ruiz R, et al. Forensic science: deaths associated with liposuction: case reports and review of the literature. 2002; 47: 205–7. The Original French TapeTM 10 cm × 100 inch www.Mentorcorp.com

22

Chemical peeling Sue Ellen Cox

Chemical peeling is the application of one or more exfoliating agents to the skin, to produce a controlled partial-thickness injury. The agent usually, an acid solution, removes varying amounts of epidermis, and depending on the strength, affects dermal collagen (1). Partialthickness wounds heal by secondary intention. Wound repair consists of epidermal regeneration by migration from adenexal structures or epithelium derived from adjacent uninjured skin (2). Replacement of new dermal connective tissue results in skin rejuvenation including improvement in skin color and texture and removal of actinically related growths. HISTORY

Aesthetic improvement of the skin dates back to ancient Egypt. Papyruses contain descriptions of the use of acids, balms, and oils for chemical peeling. Greek and later Roman physicians used sour milk, grape juice, and lemon extracts for rejuvenation. The active ingredients in these substances were the alpha hydroxy acids (AHA): lactic acid, tartaric acid, and citric acid (3). In the early 1980s, Stegman’s comparison of different wounding agents based on histology set the stage for a more academic approach to chemical peeling (4). Simultaneously, VanScott and Yu published extensively on the effects of AHA on the stratum corneum (5). This led to the widespread use of superficial AHA peels by dermatologists in the 1990s. Brody and Hailey introduced the concept of using two superficial peeling agents to produce a medium depth peel in 1986. They combined solid CO2 followed by trichloroacetic acid (TCA) to produce injury of the skin at the upper reticular dermis (6). In 1989, Monheit described the use of Jessner solution followed by the application of 35% TCA. This medium depth peel is extremely popular and reproducible (7). Coleman published on the combination of glycolic acid plus TCA to produce medium depth injury to the skin (8). PRE-OPERATIVE PREPARATION FOR CHEMICAL PEELING

The level of injury and the depth of penetration into the skin quantify superficial, medium, and deep peels. It is important to match the skin pathology to the chemical agent. For instance, a patient with extensive actinic keratoses would be better served by a medium depth peel; whereas a patient with acne would do better with repetitive more superficial agents such as glycolic acid or salicylic acid peels. Preparation of the skin prior to chemical peeling is extremely important. The simplest skin care program consists of patient education regarding sun avoidance, the use of effective sunscreen on a daily basis and pretreatment with tretinoin, and/or AHA. PRE-TREATMENT WITH TRETINOIN FOR CHEMICAL PEELS

Numerous benefits may be seen with the use of topical tretinoin on photo damaged skin. Tretinoin improves skin texture, reduces fine wrinkling, and mottled hyperpigmentation (9–12). Histologically, tretinoin increases epidermal and granular layer thickness, decreases melanin content, and causes stratum corneum compaction (11,13). Tretinoin also increases dermal collagen production and stimulates angiogenesis (14,15). These effects may account for the improved wound healing in patients that are pretreated prior to resurfacing procedures. Topical tretinoin pre-treatment accelerates wound healing after medium depth chemical peels. In a double-blind, placebo

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controlled, prospective, randomized study, 16 males with actinically damaged skin were treated daily with tretinoin 0.1% verse placebo cream in a split face, forearms, and hands 14 days before a 35% TCA peel (16). Post-peel healing was evaluated on days 3, 5, 7, 9, 11, and 14. The appearance of intact, pink skin after the brown desiccated skin had sloughed off was an indication of re-epithelialization. In 94% of the patients, the sloughing occurred earlier and was more uniform, regardless of body location, in skin pre-treated with tretinoin than with placebo treated skin. Maximal area of healing on the tretinoin treated facial skin was evident after 5 days (68% vs. 52%; p < 0.005). Hands and forearms took longer at 9 and 11 days, respectively (16,17). Tretinoin should be started in advance of the chemical peel. Six weeks or more is preferable. Once re-epithelialization has occurred, tretinoin should be re-started initially using a low concentration emolliant or cream preparation such as 0.02% Renova™ or 0.025% tretinoin cream. Newer retinoic acid receptor creams such as tazarotene can be used pre- and post-peels and may be more effective than tretinoin. ALPHAHYDROXY ACIDS

AHAs have been used both prior to peels and as a superficial chemical peeling agent. AHAs exert their epidermal effect at the level of the stratum corneum and granulosum junction. A thinner stratum corneum with a normal-appearing basket weave pattern is achieved by reducing the corneocyte cohesion. This produces a smoother, more supple skin surface (18). AHAs have also been used as an adjunct to tretinoin therapy without increasing adverse sequelae (19–21). SUNSCREENS

Sunscreens work by absorbing, reflecting, and scattering UV light. The effectiveness of the sunscreen is indicated by a sun protection factor (SPF), which represents the ratio of the amount of radiation needed to produce erythema with sunscreen to the amount of radiation needed to produce redness without the sunscreen (22). A sunscreen should be chosen that blocks both UVA and UVB radiation. The mechanism of action is to decrease pigmentation and lessen the potential for development of hyperpigmentation. The decrease in UV damage allows the skin to rest prior to the peel. This should be started at least three months prior to the peel and continued indefinitely after the peel. HYDROQUINONE

Many surgeons advocate the use of pre-treatment with hydroquinones to reduce the risk of post-inflammatory hyperpigmentation postresurfacing procedures. Hydroquinone is cytotoxic to melanocytes; it decreases melanosome formation by inhibiting tyrosinase. Alster and West provide us with a randomized study of 100 patients that were pretreated with topical skin lightening agents versus placebo two weeks prior to laser resurfacing. There was no significant difference in the incidence of hyperpigmentation post-resurfacing in the pre-treated groups or the placebo group (23). The use of hydroquinones postoperatively for post-inflammatory hyperpigmentation is effective (24). ANTIVIRAL PROPHYLAXIS

All resurfacing procedures have the potential to induce reactivation of herpes simplex. Active herpes infection is a contraindication to proceeding with a chemical peel. Because many patients are unaware of their

CHEMICAL PEELING exposure to the herpes virus, it is prudent to prophylax all patients prior to a medium depth peel. Antiviral agents have been shown to be effective in reducing reactivation. A recent study looked at infection rates following laser resurfacing after using prophylactic valcyclovir 500 mg twice per day, beginning the day prior to the procedure and continuing for 10 days or 14 days following the procedure. Out of 120 patients, no patients developed an HSV infection or recurrence (25). PHOTOGRAPHY

All patients should have pre-operative photographs taken to document the degree of actinic damage and facial dyschromia. Additionally, patients tend to forget their pre-operative appearance and it is helpful for them to appreciate the degree of improvement by looking at their photographs. In our office we use the Mirror Image Suite version 7.2 by Canfield Imaging Systems (Fairfield, New Jersey, USA). CONSENT

Patient’s sign consent for superficial, medium, and deep chemical peels. The consent specifies the most common risks associated with peels. These stated risks include stinging, burning sensation of the skin, visible peeling, scaling, pigmentary changes, infections, and rarely scarring.

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(Table 22.1). Relevant history would include knowledge of the patient’s history of herpes simplex virus. Active viral, bacterial or fungal infection, preclude chemical peeling until there is complete resolution. Medications and past medical and surgical history should be carefully reviewed. Patients who have been on isotretinoin within the past 6 to 12 months should not be resurfaced. Isotretinoin produces atrophy of the pilosebaceous unit. Re-epithelialization originates from these adenexal structures so alteration of them can impair wound healing and increase the risk of scarring. Similarly, patients who have had exposure to previous facial radiation therapy have diminished adenexal structures and are at a higher risk for scarring after dermal injury. Previous recent facial surgery in which the blood supply to the skin has been compromised by surgical undermining is a contraindication to peels that affect the dermis. Facial rhytidectomy or larger flap repairs for skin cancers should delay resurfacing for six months or more. Smokers have impaired microcirculation to the skin and increased rates of infection. Additionally, smoking damages the elastic fibers and collagen producing an increase in wrinkling and actinic damage. Smokers can benefit from chemical peeling; however, they need to be educated regarding realistic expectations and complications. SUPERFICIAL CHEMICAL PEELS

CONSULTATION

At the consultation it is important to identify the patients’ motivation for chemical peeling and to direct the patient to the most effective treatment based on the individuals’ problems. The physician needs to explain the limitations of each type of peel and make sure that the patient has realistic expectations. An explanation of the post-operative course especially with medium and deep resurfacing is essential. Patients need to see post-peel photographs so that they can visualize the healing process. Verbal descriptions are not adequate. It is also important to stress the post-operative care needed to ensure a good result. The patient’s life style with regard to recreational activities and sun exposure is important to ascertain. It is necessary for the physician to stress to the patient that it is their responsibility to protect their skin from sun exposure both during the healing phase and thereafter to ensure that post-inflammatory hyperpigmentation does not occur. A questionnaire filled out by the patient prior to the consultation is helpful so that the physician is aware of pertinent medical history

Table 22.1 Patient Evaluation

• Physician–patient relationship • Patient’s realistic expectations • Fitzpatrick skin type • Skin thickness and sebaceous activity • History of herpes virus • History of keloid formation • History of previous radiation exposure • History of immunosuppression Table 22.2 Superficial Peeling Agents

• Trichloroacetic acid (TCA)10–25% • 35% (one coat) • Jessner’s solution: resorcinol/salicylic acid/lactic acid • Modified Unna’s resorcinol paste • Solid CO Slush • Salicylic acid • Alphahydroxy acids (AHA) • Tretinoin solution 2

Superficial chemical peeling is the application of wounding agents designed to injure part or all of the epidermis which may in turn lead to mild stimulation of collagen in the superficial papillary dermis. There are many agents of varying strengths that can accomplish this injury (Table 22.2). The indications for superficial peeling include melasma, post-inflammatory hyperpigmentation, ephelides, acne vulgaris, solar lentigines, photoaging, and fine rhytides. Pre-operative Considerations The popularity of superficial peels underscores the many advantages of light peels (Table 22.3). The appeal of rapid healing, relatively low cost, and minimal risk even in darker skin types offsets the limitations of the procedure for most patients (Table 22.4). Superficial peels are helpful in the treatment of acne and may improve melasma. They provide smoothness and luster to photo damaged skin but will not usually eliminate fine lines or actinic keratoses (26). Solar lentigines lighten but may not resolve. The combination of a series of three to six peels is likely to produce the best results in conjunction with a topical regimen at home. A common misconception among patients is that multiple superficial peels will produce the same result, as one deeper peel (27).

Table 22.3 Advantages of Superficial Peels

• • • • • • • • •

High safety record May be used on all Fitzpatrick skin types Rapid healing Repeated peels can give cumulative effects Amplifies effects of topical agent Can be combined with laser modalities May be performed by trained aestheticians Affordable No anesthesia needed

Table 22.4 Limitations of Superficial Peels

• • • • •

Little effect with one peel Multiple superficial peels do not equate with one deep peel Marketing has created unrealistic patient expectations Minimal effect on medium to deep rhytides Skin biopsies indicate a return to pre-peel conditions within two years without the use of topical agents

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A Wood’s lamp can be utilized to detect epidermal melasma (28), but in one study, the response to a superficial peel was difficult to predict on the basis of this test (29). Technical aspects of superficial peeling varies from producing a very superficial slough of only a few layers of the stratum corneum to producing a slough of the entire epidermis and papillary dermis. The depth of the peel is determined not only by the particular agent and the concentration but also by the area treated, skin preparation, methods of application, and the sebaceous quality of the patient’s skin (Table 22.5). These variables may change during the course of successive peeling in the same patient and need to be evaluated prior to each peel. The technique of application is a significant determinant of the depth of the peel. The type of applicator and the degree of saturation of the applicator determines the amount of peel solution applied. Commonly used applicators include 4 × 4 gauze, 2 × 2 gauze, cotton tipped applicators, and sable brushes. Of these, the sable brush was found to deliver the greatest quantity of solution in one study (2). The degree of rubbing, pressure, and also the number of coats applied further determine the response to the peel. The condition of the skin and the skin preparation technique similarly influence the depth of the peeling. If the patient’s epidermal barrier is disrupted for any reason, such as retinoid dermatitis, seborrheic dermatitis, or active acne with erosions, the peeling solution may penetrate more deeply and result in a medium depth peel when a superficial peel was intended (29). The depth of the peel is also altered by the choice of the skin preparation technique. In general, the thicker and more sebaceous the skin, the less susceptible it is to the peeling agent. Non-facial areas such as the neck, forearms, and dorsum of the hands have significantly fewer sebaceous glands and adenexal structures from which to regenerate new skin. Due to delayed healing and a tendency to scar, these areas must be peeled conservatively and only with superficial peeling agents repeated over time. With successive peeling, the concentration of the agent applied may be titrated up depending on the reaction to the peel. The author preferred applicator for superficial peeling is wrung out 4 × 4 gauze for TCA or Jessner peels. Saturated cotton balls are used for glycolic peeling because they are less abrasive. The infraorbital region is always treated with saturated cotton tipped applicators regardless of the agent and care is taken to minimize drip or splash exposure to the eyes. The level of discomfort is generally quite tolerable. A hand-held fan is placed six inches from the face to minimize discomfort. Occasionally with 50% to 70% glycolic acid, the patient experiences more than mild discomfort. With this agent, significant pain is an important sign that the peel is penetrating more deeply and the peel should be neutralized sooner than anticipated. Post-operative Care Immediate post-operative care is minimal with superficial peeling. The newly peeled skin appears mildly to moderately erythematous for a few hours to a few days. Superficial desquamation will then occur over the following few days to a variable degree depending on the peel. The

Table 22.5 Variables of Peeling

• • • • • • • • •

Agent selected Concentration of agent Technique of application Skin preparation technique Prior use of tretinoin Sebaceous gland density Integrity of epidermal barrier Frequency of peeling Area treated

patient is instructed to cleanse twice daily and to resume his or her regular skin regimen as soon as the skin seems back to normal. Patients are instructed to avoid sun exposure and to wear sun-blocking agents as soon as the skin will tolerate them. Superficial Peeling Agents Trichloroacetic Acid 10% to 25% TCA is one of the most commonly used and time-honored agents for superficial peeling. It has no known systemic toxicity. The depth of cutaneous penetration varies with the concentration of this agent. TCA 10% to 25% will produce necrosis of superficial layers by precipitation of proteins, clinically causing a mild epidermal slough. Many classify one coat TCA 35% in the superficial category (30). However, the depth of penetration of this concentration will vary with patient factors and technique and an intermediate to medium depth peel can be produced (31). Light peels can be performed weekly at concentrations of 10% to 15% for acne vulgaris with minimal downtime. Applications of 25% to 35% TCA may take five to seven days to heal with darkening of the face for two to three days and fine desquamation days 3 to 6. These are predictable peels that can be adjusted to the patient’s pathology and available downtime by the concentration utilized. For pigmentary problems such as post-inflammatory hyperpigmentation or melasma, the results may be variable with TCA and the problem may even worsen. Starting with lower concentrations and/or performing test patches have been recommended (32). Jessner’s Solution Jessner’s solution (also known as Combes formula) consists of 14 grams each of resorcinol, salicylic acid, and lactic acid in ethanol (Table 22.6). The result is a good keratolytic caused by breakage of intracellular bridges with minimal side effects. Jessner’s solution is applied to prepped skin and rubbed in or painted on. It is not necessary to neutralize this peel. The first peel usually consists of just one coat, with subsequent peels of two to three coats as dictated by the patient’s pathology and available down time. There is usually no frosting, just erythema, and white speckling. A Jessner’s peel will usually result in two to three days of light white desquamation, which often serves as a pleasing demonstration to the patient that the peel is effective. For the treatment of melasma, Jessner’s peels were found in one study to be comparable to 70% glycolic peels in efficacy and had fewer side effects (29). Alphahydroxy Acids AHAs are naturally occurring organic acids extracted from fruit, sugar cane, and other foods (33). Of the AHA’s, glycolic acid is the smallest compound and the most commonly used in superficial peeling. The choice of available formulations ranges from 20% to 70%. AHA are keratolytic at low concentrations and cause epidermolysis with increasing concentrations and duration of contact time. In some studies, serial glycolic peels have been found to have a long-term effect on both the epidermis and dermis with an increase in dermal and epidermal glycosaminoglycans, an increase in dermal collagen, and an increase in epidermal thickening (33). These beneficial effects on the papillary dermis occur without tissue necrosis at that level (34). This may account for more clinical improvement than one would predict with

Table 22.6 Jessner’s Solution Formula

• • • •

Resorcinol 14 gm Salicylic acid 14 gm Lactic acid 14 gm Ethanol 95% qs ad 100 cm3

CHEMICAL PEELING the level of injury sustained. They are reported to be of particular benefit in treating post-inflammatory hyperpigmentation, solar lentigines, and melasma, even in Fitzpatrick IV-VI skin types (35,36). Many other properties of glycolic solutions also affect penetration, rendering this agent somewhat less predictable in a given patient (Table 22.7) (37). Low pH solutions (pH < 2 ) appear to create more necrosis without improving efficacy (38). Most physicians use 70% glycolic acid unbuffered and unneutralized (39). It is important for the practitioner to gain experience with one formula and technique and to be consistent with peeling methods in order to gain predictability with these peels. In addition, the depth of penetration of glycolic peels appears to be more dependent on the condition of the epidermis at the time of peeling. An irritated or inflamed epidermis will have minimal resistance to penetration and it is often best to delay treatment another week until the barrier is intact. Time dependence is a unique aspect of glycolic peeling. The agent is left on anywhere from 15 seconds to 3 minutes maximum for the first peel. With subsequent peels, the solutions may be left on 15 to 30 seconds longer, up to 7 minutes maximum. The nurse assistant monitors the time and announces each 15- to 30-second time interval. The peel is neutralized with water or a 5% to 10% solution of sodium bicarbonate with multiple rinses. Pinpoint frosting, edema, or microvesiculation is sometimes seen selectively around acne lesions. Indicators to neutralize the solution include an unusual degree of patient discomfort, mild erythema, or adequate time interval. Salicylic Acid Salicyclic acid (ortho-hydroxybenzoic acid) is a beta hydroxyl acid employed by dermatologists as a topical agent for acne, skin disorders, and anti-aging in low concentrations for decades. Utilized for years as a component of Jessner’s solution at 14%, it has been used more recently as a solo agent in 20% to 30% solutions for superficial peeling. There are few reports in the literature regarding salicylic acid peels. Kligman developed the 30% salicylic acid peel and noted several advantages over glycolic acid peels (40). Salicyclic acid offers the advantage of uniform application because the peel causes an immediate white precipitation and skip areas are readily visible. The peel is self-limited and there is no need for timing or neutralization. Due to the anesthetic property of salicylic acid, there is very little discomfort immediately following the procedure. Theoretically, this peel may benefit acne more than other peels, because besides being keratolytic, it is comedolytic. The peel has been used successfully in Fitzpatrick V and VI skin types although it is advised to start with the 20% peel and to resume hydroquinone topically 48 hours after the peel (41). Optimizing Outcomes of Superficial Peels It is important that the goal of the peel does not exceed the capability of the superficial peel series. As stated previously, multiple superficial peels, rather than one or two, need to be performed to achieve optimal improvement. Indeed, maintenance peeling should be discussed with all patients in advance since the effects of superficial peels are not permanent. Studies have shown a return to the pre-peel state within 60 days to 6 months (42,43).

Topical regimens are essential to successful long-term results. For patients with sensitive skin or dark skin types, the peels will be optimized by avoiding a problem at the outset. It is essential to assess the integrity of the epidermis and avoid peeling inflamed skin in these patients to avoid “hot spots” of deeper penetration. Start with light peeling and build with successive peels, peels appear to be effective in Fitzpatrick types IV-VI with few side effects, particularly if combined with a topical bleaching agent (37,44,45). TECHNIQUE MEDIUM DEPTH PEELS

Medium depth peeling is defined as injury to the skin at or through the level of the papillary dermis. The injury is associated with coagulation necrosis of the epidermis and part of the papillary dermis with inflammation to the reticular dermis. Indications for this type of peel include epidermal growths such as actinic keratoses, superficial seborrheic keratoses, lentigines, and other pigmentary dyschromia (46). TCA has been the gold standard wounding agent to achieve a medium depth injury to the skin. Medium depth peeling concentrations range from 35% to 50%. However, 45% to 50% TCA may produce an unpredictable response. In an attempt to reduce morbidity of higher concentrations of TCA, combinations of chemical peeling agents should be used. These combination peels produce a more even and deeper penetration of wounding agents than does a higher concentration of TCA (Table 22.8). The most common combination peels include Jessner’s solution with 35% TCA, and glycolic acid 70% with 35% TCA. Whichever technique is chosen it is important to be consistent so that one can be confident of obtaining good results. Table 22.9 shows indications for proceeding with medium depth peeling. Benefits are seen in patients with moderate actinic damage and sallow discoloration of the skin without significant wrinkling. Drs. Lawrence and Cox showed a 75% reduction in the number of actinic keratoses after a medium depth peel with Jessner’s solution and 35% TCA. This was equal to the results one could achieve with 5% fluorouricil topical therapy (47) (Fig. 22.1A–C). Other indications include atrophic acne scars (48), pigmentary dyschromia such as lentigenes, and melasma. Blending of facial areas in conjunction with other deeper resurfacing methods can optimize the outcome of a medium depth peel. Other acids such as bichloacetic acid can be carefully used as spot treatments for conditions such as trichodiscomas, sebaceous hyperplasia, syringomas, and trichoepitheliomas. TCA in higher concentrations such as 50% or greater can be used to spot treat thick actinic keratoses. The technique of medium depth peeling with Jessner’s solution and 35% TCA includes pre-treatment conditioning of the skin as described previously in this chapter.

Table 22.8 Medium Depth Chemical Peeling Agents

• • • • • •

50% TCA Solid CO2 + 35% TCA Jessner’s solution + 35% TCA 70% Glycolic acid + 35% TCA 88% phenol Pyruvic acid

Table 22.7 Factors Affecting the Penetration of AHA’s

• • • • • •

Acid concentration pH bioavailability Degree of buffering Volume of agent applied Duration of time acid remains on skin Condition of the epidermal barrier

175

Table 22.9 Medium Depth Peel Indications

• • • • •

Actinic damage Epidermal growths Pigmentary Dyschromias Superficial scarring Blending photo aging skin with deep resurfacing modalities

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(A)

(B)

(C) Figure 22.1 TCA medium-depth peel for actinic keratosis: (A) before, (B) eight days after, (C) six months after.

The patient comes in without makeup and cleanses the skin with a gentle cleanser. With the patient in the upright-seated position, the inferior edge of the mandible is marked so that when the patient is supine one can feather the 35% TCA below this point. The neck can be treated with Jessner’s solution at the same time as a medium depth facial peel. The author uses 4 × 4 gauze with acetone and a moderate pressure scrub to degrease the skin. This is repeated until no residual oils are apparent on the skin. After cleansing is complete, Jessner’s solution is applied with large cotton tip applicators or 2 × 2 gauze. The cotton applicators are not as easily saturated and deliver less acid to the skin. One to two coats of Jessner’s solution is applied in order to achieve a light, white even frost. Patients usually experience a mild stinging and burning sensation. The skin appears slightly erythematous with speckled areas of whitening. One can identify the uniformity of the peel solution by using a Wood’s lamp. The salicylic acid in the Jessner’s solution fluoresces under the Wood’s light, giving the physician another method for ensuring even coverage of the solution (49). The use of Jessner’s solution disrupts the barrier function of the skin allowing for a uniform penetration of TCA. Thirty-five percent TCA is applied starting from the mid-face, where there is the highest concentration of sebaceous glands. Several large cotton tip applicators are used to apply the acid. The applicator is more saturated initially; this is the rationale for starting in the central face where there is less risk of scarring. The entire face should be treated and feathering into the hairline and below the jawline should be done to ensure that no lines of demarcation occur between treated and untreated areas. The reaction of precipitated protein coagulation of the skin is manifested as a “frost” or whitening and it takes one to two minutes to be complete. The time it takes for the skin to frost is directly related to how well the skin has been pretreated and degreased. An additional factor is the amount and concentration of the TCA used and the degree of

actinic damage. The coarser, more sun-damaged skin will react more slowly and require more heavily applied acid. Areas where frosting is patchy may be retreated with a minimally saturated cotton tip applicator. The more heavily saturated the applicator the deeper the penetration of the acid. For this reason when treating the lower eyelid skin it is important to use a minimally damp “Q-tip” type applicator. Additionally, an assistant should hold two small dry cotton tip applicators at the medial and lateral canthus of the eye to catch any tears that may develop and prevent “wicking” of the acid into the eye. Artificial tear solution, for rapid flushing of the eyes should be available if necessary. Having a dry 4 × 4 gauze so that acid does not drip onto an untreated areas is useful. If the patient has deep vertical upper lip lines and one is not using a deeper peeling agent or laser resurfacing, an assistant should stretch out the lip lines while the peel solution is applied with a small cotton tip applicator. This allows for even coating and prevents pooling of acid into rhytides. Hyperkeratotic growths such as thick seborrhic keratoses and actinic keratoses can be curetted or frozen with liquid nitrogen prior to the peel. Thinner lesions can be treated simply by applying extra peel solution and rubbing it directly into the lesions (50). Within seconds of applying the TCA there is a burning sensation on the skin. Whitening appears and the intensity of the burning decreases quickly. There is no neutralization of TCA peels. Once the solution has been applied, there is about 30 s in which it can be diluted prior to keratocoagulation and the frosted appearance. Ice-soaked gauze is applied directly on the skin to relieve the burning sensation and cool packs are placed over this gauze to decrease the hot sensation. Once the patient feels comfortable, vaseline petrolatum based ointment (Chesebrough-Ponds Inc., Greenwich, Connecticut, USA) or Aquaphor ointment (Beiersdorf Inc., Kolkata, India) is applied. The patient may be given an injection of steroid or an oral steroid taper to help decrease post-procedure edema.

CHEMICAL PEELING

(A)

177

(B)

(C) Figure 22.2 TCA medium-depth chemical peel and glabellar botox: (A) before, (B) two days after, (C) twelve days after.

of pigmentary dyschromia and freckling appear darker. Desquamation begins around the mouth and in the central portion of the face. The last areas to peel are usually along the hairline. Peeling often starts on day 3 and is complete within one week. Once peeling has occurred the skin will have a subtle erythema. If peeling has occurred too quickly the skin will appear blotchy and redder than expected. It is important to counsel patients not to facilitate the peeling process by scrubbing or picking at the skin. It is also important to warn them against coming in contact with harsh chemicals or cleaners that may be aerosolized and irritate the newly epithelialized skin (Fig. 22.3). Patients can wear makeup within 7 to 10 days post-peel and the erythema fades between two and four weeks post-peel (Fig. 22.4). Sun avoidance and the use of sunscreen are required once re-epithelialization is complete. Post-operative visits may vary among physicians. The author (SEC) sees the patients on day 3 and day 7, to reassure them and review post-operative care. AHA may be re-started at week 3 post-peel and tretinoin four to six weeks after the peel if the skin is not too sensitive. Figure 22.3 Seven days after TCA medium-depth chemical peel. Contact dermatitis as a result of Tilex cleaning solution exposure. Note the patchy erythema on chin and area superior to the nasolabial folds.

Post-operative Care Within approximately 30 min after the peel, the skin appears erythematous and there is a “sun burn” like sensation. Edema occurs within the first 24 h. The patient is instructed to keep the skin greasy with the above ointments at all times until desquamation is complete generally within 5 to 7 days. Acetic acid 0.25% and cool water soaks can be done three to five times for the first few days. Alternatively, patients can splash cool water on their face or shower several times during the day. By 24 hours after the peel the skin has a light brown appearance (Fig. 22.2A–C). Areas

Optimizing Outcomes The use of botulinum toxin injections (BOTOX, Allergan Inc., Irvine, California, USA) 7 to 10 days pre-peel will enhance one’s results. Botox denervates the underlying muscles of facial expression that produces dynamic wrinkling. The onset of action occurs within 24 to 72 hours after injection and lasts three to six months (51). New collagen formation can then be laid down over a stationary area allowing the fabric of the skin to heal without reinforcing the creation of the wrinkles. Other ancillary procedures such as injectable fillers will enhance the results. Laser resurfacing to the deeper perioral rhytides complements medium depth peeling. It allows the practitioner to individualize the peel and optimize patient’s results.

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Figure 22.4 TCA medium-depth peel for actinic keratosis: (top row) before, (bottom row) 12 weeks after.

Table 22.10 Baker/Gordon Phenol Formulation

• • • •

Phenol USP 88% 3 ml Distilled water 2 ml Septisol liquid soap (8 drops) Croton oil (3 drops)

DEEP CHEMICAL PEELING

Proper patient selection is the most important aspect of obtaining satisfactory results. The ideal patient is a thin-skinned woman with fair complexion and fine generalized wrinkling. These individuals are less likely to have lines of demarcation between peeled and unpeeled skin. The following conditions are most successfully treated. 1. 2. 3. 4.

Fine facial wrinkles, periocular and periorbital regions Pigmentary dyschromia Actinic keratoses Superficial, shallow acne scars (52)

Pre-operative Preparation Adequate cleansing of the face and removal of deep facial oils is imperative especially if an open technique is used instead of taping the skin post-operatively. For a discussion of the virtues of taped versus open technique, Dr. Beeson has an excellent chapter in Skin Resurfacing (52). The use of Septisol is advocated as the astringent of choice as it has keratolytic properties. Following facial cleansing, acetone is used to further remove facial oils. Intravenous sedation is standard when full-face phenol chemexfoliation is being performed. Adequate hydration is necessary to avoid renal toxicity. The recommended hydration consists of 500 ml of Ringer’s

lactate before applying the solution followed by an additional 1000 ml of fluid during the operative and immediate post-operative period (52). Phenol is known to be cardiotoxic. To avoid cardiac arrhythmias, a full-face peel should extend over a 60- to 90-minute period. No more than 50% of the face should be treated during a 30-minute period (49). Cardiac monitoring is necessary during and after the procedure. Baker’s formula is the most widely used deep peeling agent (Table 22.10). This solution consists of: 3 ml Phenol USP (88%), 2 ml distilled water, three drops Croton oil, eight drops 0.25% Septisol (liquid hexachlorophene soap in alcohol-Septisol-Calgon Vestal Laboratories, St Louis, Missouri, USA). The solution should be freshly prepared and stirred constantly both before and during the application to ensure a more even peel. NON-FACIAL PEELS

Peeling techniques have traditionally been limited to the face, because standard techniques have resulted in inconsistent results. Non-facial skin has a decreased number of hair follicles, sebaceous glands, and dermal vessels. This decrease in adenexal structures impairs wound healing. Non-facial areas have a narrower margin for error than the face. Traditionally peeling of these areas requires lower concentration of acids and serial treatments. A controlled chemical peel technique for non-facial skin using 70% glycolic acid gel combined with 35% or 40% TCA has given consistently good results on the arms, hands, chest, neck, back, and legs. This peel is easy to implement and produces a peel in which the depth can be controlled more precisely, ranging from light to medium. The technique has been called the “Cook Total Body Peel” (45). The skin is degreased with acetone, 70% glycolic acid gel is applied to the skin using 4 × 4 gauze, this is followed immediately by 40% TCA on 4 × 4

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Figure 22.5 Frosting from Cook body peel.

gauze. The skin is carefully monitored so the physician can neutralize the peel at the desired depth with copious amounts of 10% sodium bicarbonate solution. The typical endpoint desired is characterized by erythema with scattered white speckles (Fig. 22.5). If the endpoint is not achieved additional TCA can be layered on top of the glycolic acid gel. It is important to use glycolic acid gel rather than liquid, because the gel acts as a partial barrier to the TCA penetration. Liquid glycolic acid could result in increased penetration of the TCA and resultant scarring. After this body peel, the skin will flake for two to four weeks depending on the area (Fig. 22.6). Hydrating the skin with an emollient helps during the healing phase. Clinical results produce smoother skin texture, decreased wrinkling, fading of lentigines (Fig. 22.7A,B). The author (SEC) has also used this peel to achieve reduction of actinic keratoses and disseminated superficial actinic keratoses (Fig. 22.8A,B). Other peeling options for non-facial skin include low concentrations of TCA varying from 20% to 25% and performing serial treatments over time. Dr. Brody has advocated the use of 35% TCA for acne scarring of the back with the placement of 50% TCA to the elevated peripheral scar edges (53). Serial Jessner peels and 50% salicylic acid ointment under occlusion described by Swinehart (54) may also be used. COMPLICATIONS (TABLE

22.11)

Complications from peels increase proportionately with the depth of the wound. Superficial peels carry the lowest risk of adverse reactions and if they occur are usually pigmentary in nature. Medium depth peels can cause pigmentary changes and rarely scarring. Deep peels are associated with the above risks and systemic reactions can occur.

Figure 22.6 In the process of peeling five days after Cook body peel.

(A)

Pigmentation (Hypopigmentation/Hyperpigmentation) The most common complication of chemical peeling is abnormal pigmentation. Lighter peels are more likely to be associated with hyperpigmentation and deeper peels with hypopigmentation. Hyperpigmentation is usually transient and is best treated with hydroquinone bleaching agents, retinoic acid or tazarotene cream and a physical barrier sunscreen such as titanium dioxide. Exogenous estrogens, photosensitizing medications, and direct sun exposure during the first six weeks after peels increase the risk of hyperpigmentation (Fig. 22.9). Hypopigmentation is a normal sequela of phenol peels and deeper resurfacing procedures. It is essential to educate the patients pursuing

(B) Figure 22.7 Cook body peel: (A) before, (B) 21 days after.

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(A)

(B) Figure 22.8 Cook body peel for disseminated superficial actinic porokeratosis: (A) before, (B) after two treatments.

Table 22.11 Complications of Chemical Peeling

• • • • • • • • • • a

Pigmentation alteration Scarring Infection Milia Persistent erythema Atrophy Textural changes Cardiac, renal, hepatic toxicitya Laryngeal shocka Toxic shock syndromea

Limited to phenol peels.

Figure 22.9 Post-inflammatory hyperpigmentation.

deeper peels that hypopigmentation or a line of demarcation between peeled and non-peeled areas is a tradeoff for smoother, more youthful skin. Accentuation of nevi may also occur after chemical peeling. Milia Milia result from occlusion of the pilosebaceous unit. They usually occur within the first one to three months after peels. They may be due to the use of petrolatum-based ointments that are applied to the skin during the early healing process. They are easily treated with an 18-gauge needle and comedone extractor.

Prolonged Erythema Persistent erythema is more closely associated with deeper resurfacing procedures but it may be seen after medium depth peels and rarely after superficial peels. When erythema is localized and persistent one needs to consider both contact dermatitis and early impending scarring. Long-pulsed dye laser treatment can be initiated if the erythema persists beyond six weeks to –eight weeks or if textural changes occur (Fig. 22.10A,B). Rarely does one need to administer intralesional steroids. Infection Infection is rare following chemical peels. Both TCA and phenol are bactericidal (55), although this is generally not a factor since infection occurs often days after the peel. Poor wound care is what most frequently contributes to post-peel bacterial infection. Occlusive ointments may promote folliculitis that may be secondarily infected with Staphylococcus or Stretococcus (Fig. 22.11). Pseudomonas is another pathogen that can be identified with poor wound hygiene. When infection is suspected, cultures should be taken and immediately broad-spectrum antibiotics and frequent acetic acid soaks should be instituted. Toxic shock syndrome has been reported in association with phenolbased peels (56). Chemical peeling may activate Herpes simplex virus (HSV) (Fig. 22.12). It is important to note that the development of postoperative HSV infection cannot be predicted based on a prior history of a “cold sore.” This supports the policy of prescribing anti-viral prophylaxis for all patients regardless of past HSV history (57). Cutaneous candida infection may also be seen after chemical peeling or resurfacing (Fig. 22.13). Perioral pustules develop and rapidly spread to adjacent areas. Patients complain of itching or burning sensation. Topical or oral anti-fungal agents can be used to treat this superficial infection. Perleche, concomitant vaginal candidiasis, and recent oral antibiotics may be predisposing risk factors. Scarring Scarring is one of the most dreaded complications of chemical peeling. The risk of scarring increases with the depth of the peel. TCA at high concentrations, greater than 50% is unpredictable and can lead to scarring. Factors that may increase the risk of scarring include a history of isotretinoin within a six-month period. Surgery that involves large areas of undermining may increase the risk of sloughing if done at the same time as a peel. Previous medium or deep peels, dermabrasion, or laser resurfacing

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(A)

(B) Figure 22.10 (A) Persistent erythema one month after 70% glycolic acid peel. (B) After two treatments with pulse dye laser.

Figure 22.12 Perioral Herpes simplex virus (HSV) infection after resurfacing.

Figure 22.11 Bacterial infection after peel.

Figure 22.13 Cutaneous candida infection after peel.

without waiting 6 to 12 months also can increase the risk for scarring. Hereditary predisposition or connective tissue disease such as the mitis form of Ehlers–Danlos syndrome can affect the rate of healing (58). Early scarring manifested as indurated, patchy erythema should be treated aggressively as discussed above with pulsed dye laser, topical, intralesional, or oral steroids.

Systemic Complications Systemic complications may be seen with phenol peeling. Phenol applied quickly can produce cardiotoxicity, hepatotoxicity, and nephrotoxicity. It is suggested that peeling the skin in segments and intervals allows the metabolism of the absorbed phenol and thus decreases the chance of arrhythmias (49). For that reason, cardiac monitoring is

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extremely important. Intravenous hydration assists in clearing the phenol from the circulation and decreases the likelihood of toxicity. REFERENCES

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CHEMICAL PEELING 48. Waiz M, Ali A-S. Medium-depth chemical peels in the treatment of acne scars in dark skinned individuals. Dermatol Surg 2002; 28(5): 383–7. 49. Matarasso SC, Glogan RG. Chemical face peels. Dermatol Clin 1991; 9: 131–50. 50. Monheit GD. The Jessner-trichloroacetic acid peel an enhanced medium-depth chemical peel. Cosmetic Dermatol 1995; 13: 277–83. 51. Carruthers J, Carruthers A. Combining botulinum toxin injection and laser resurfacing for facial rhytides. In: Skin Resurfacing. Baton Rouge, LA: Williams and Watkins, 1998: 235–43. 52. Beeson W. Facial rejuvenation: phenol-based chemexfoliation. In: Skin Resurfacing. Baltimore, Maryland: Williams and Wilkins, 1998: 71–86.

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53. Brody HJ. American Society for Dermatologic Surgery Meeting New Orleans Oct 2003. 54. Swinehart J. Salicylic acid ointment peeling of the hands and forearms. J Dermatol Surg Oncol 1992; 18: 495–8. 55. Brody H. Complications of Chemical Peeling. J Dermatol Surg 1989; 15: 1010–24. 56. Resnik SS. Complications of chemical peeling . Cosmetic Dermatol 1995; 13(2): 309. 57. Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing. Dermatol Surg 1998; 24: 315–20. 58. Moloney BP, Millman B, Monheit G, et al. The etiology of prolonged erythema after chemical peel. J Dermatol Surg 1998; 24: 337–41.

23

Aesthetic considerations in facial enhancement: A plastic surgery perspective Julius Few

With growing demand, education, and technologic advancement come exciting opportunities in facial enhancement surgical and nonsurgical interventions. This chapter is written from a plastic surgery perspective and it covers various advances in facial aesthetic enhancement. Focus is directed at maximal effect and safety. Special consideration will be given to people with darker skin and less well-known concerns. A FEW FACIAL CONSIDERATIONS

The process of facial aging has several components that can often be predicted with careful observation. The realization of these changes is integral to a natural enhancement result. The changes can be categorized as skin, soft tissue, bone, or a combination of structural changes. The variety of dermatologic conditions, including fine rhytid formation, will be reviewed elsewhere in this text. I will focus my attention on rejuvenation of the deeper tissue, incorporating skin only when clinically relevant to the approach for the subcutaneous tissue. The evaluation process often begins at the anterior and temporal hairline. It is often useful to view photos of the given patient in their youth, to better understand the “baseline” anatomy. The forehead, temple, and brow are the primary scaffolds of support for any aesthetic facial surgical enhancement, in order to prevent further downward movement of the upper one-third facial anatomy. Lifting and re-supporting the forehead and brow through brow lifting, either open or with limited excisions described by authors such as McCord, Few, Knize, and others (1–4). This support creates a platform for successful periorbital and midfacial rejuvenation, while avoiding the potential for unnatural transitions between the upper and middle one-third of the face. It has been shown in the literature that patients of color tend to show lesser and later aging changes in the upper one-third of the face, making less invasive techniques particularly attractive, such as filler injection to the forehead and/or brow to internal browpexy done through the upper eyelid alone. The term rhytidectomy (facelift), taken literally, means removal of wrinkles or skin with wrinkling. While a small percentage of patients may benefit from the removal of skin alone, using a facelift incision, the vast majority require repositioning of the deeper soft tissue. Therefore, the simple removal of skin, alone, around the ear can lead to significant complications. Please note the patient in Figure 23.1, after a “Style” facelift procedure (performed at a different clinic), done in about an hour. The patient was not aware of the more involved indication or significant need for deeper tissue repositioning. In addition, given the patient’s darker skin, heavy load skin tightening alone likely leads to her keloid formation. In Figure 23.1, please note the patient’s appearance after revision facelift, with SMAS plication facelift. SMAS plication, popularized by Dr. Baker (5), has been shown to have results very comparable to more extensive face lifting procedures, such as deep plane and extended SMAS elevation procedures. In addition, the longevity of the result is extremely significant, making the procedural choice extremely desirable to the patient. While the procedure is less invasive, it does share the same requirement for appropriate training and skill to execute it appropriately (6). Rejuvenation of the face has seen many advances recently. In particular, the advent of harmonic technology has been a major achievement. Firmin (7) describes a technical approach for face lifting using the harmonic device. The harmonic scalpel is a device that oscillates at

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55 MHz, creating a zone of coagulation while separating the desired tissue plane. The use of this technology results in less potential ecchymosis and edema, leading to a faster recovery. I have found that the addition of local anesthesia to the field leads to facilitated dissection and a recovery that is very favorable, with patients often returning to normal life activity after a week or less. In addition, the use of local anesthesia provides a comfortable option for facial rejuvenation under sedation or in some cases local anesthesia with an oral sedative. The use of autologous fat injection during or around the time of face lifting further enhances the overall result and the result relies less on aggressive over tightening of the skin (8). The continuum of aesthetic care is focused on restoration and preservation. Many patients can avoid more invasive surgery by combining minimally invasive and nonsurgical modalities, as demonstrated in Figure 23.2. In the example shown, the patient treated was approached by extensive evaluation of the skin and underlying soft tissue. She desired to avoid periorbital surgery and undergo filler and botulinum toxin A injection in combination with her in-office facelift procedure. The procedure can be done in an office due to the limited and strategic nature of the undermining. In addition, the timing of anesthetic injection with the beginning of surgery is carefully orchestrated so that the patient is not allowed to experience any significant discomfort. The submental area remains a challenge for most plastic surgeons and often requires a variety of approaches. I prefer to leave the submental area alone if there is minimal central neck banding and agerelated changes. For more involved cervical changes, a direct submental approach can be utilized for either a formal platysmaplasty and/or platysmal band excision. PERIORBITAL CONSIDERATIONS

Once a plan has been made regarding the upper face, attention is turned to the upper and lower eyelids, with consideration for the midface. There are a variety of considerations for the eyelids that are both functional and aesthetic in nature when rejuvenation of the eyelids is planned. It is essential to do a comprehensive ophthalmic history and physical exam prior to rejuvenation. If the history is suggestive, I favor referring the patient for ophthalmic exam to determine if visual acuity impairment of unknown etiology exists. The aging of the periorbital area is predictable and follows a composite process. In particular, we know that the brow deflates and flattens with aging. The upper eyelid also loses volume over time and the skin becomes redundant at the level of the supratarsal crease. As the process progresses, the lateral canthal complex begins to drop, leading to loosening of the lower eyelid sling. The loosening of the lower eyelid then often leads to the relative elongated appearance of the lower eyelid and the beginning of the tear trough. As the midface begins to move inferiorly, the formation of midface ptosis and prominent submalar and nasolabial folds. Finally, in end stage aging we see that the midface begins to merge into the jowls. Understanding this transition is vital in successful rejuvenation. Many of these known changes can be treated with fillers and toxins in their early stages. In more advanced change, surgery is often the most efficient and effective way to yield an improved appearance. Figure 23.3 demonstrates the aging changes seen around the eye, by showing a morphed image of the same woman at different stages of life. As stated previously, it is my preference to use the brow as

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Figure 23.1 (A–E) The patient is a 57-year-old African-American woman who presents one year after a “Style” facelift procedure performed at a different clinic. She developed a symptomatic keloid 4 weeks after her surgery and it progressed to the level of presentation shown in A and B. This case shows the danger of a tight, skin pull, facelift in a person of color. In C and D, we see the patient more than 6 months after excision of keloid, revision facelift using an SMASectomy approach. The patient has no symptoms of keloid recurrence and has an acceptable correction of aging changes.

a scaffold, and then rejuvenate the upper eyelids and lateral canthus next. The upper eyelids are treated specific to ethnic guidelines, taking into account the differences in supratarsal height between Asian and Caucasians for example. In addition, remembering that the upper eyelid and brow lose volume over time and traditional excisional approaches, removing a major swath of orbicularis and/or septal fat, ill advised. It is important to remember that the lateral canthal area ages as well, descending with the periorbital aging process, especially in Asians and African-Americans (9,10). It is vital to rejuvenate the lateral canthus when rejuvenating the eyelids surgically, as described by the author in past publications. When approaching the lower eyelids, I prefer to utilize a transconjunctival point of access to resect or reposition septal fat. This allows for additional access to the tear trough. While the approach is direct, experience with eyelid plastic surgery is essential to avoid potential

complications such as injury to the globe, skin perforations, and lower eyelid malposition (11). The midface can be rejuvenated by direct transconjunctival deep plane midface lift with or without a traditional facelift. The advantage of the transconjunctival midface lift is the low rate of complication, in trained hands, and the significant natural correction of periorbital and midfacial aging. While a more detailed description has been published in the literature (11), the technique offers significantly reduced recovery time as compared to traditional midfacial rejuvenation approaches. The only significant limitation to this approach is the inconsistent correction of heavy malar bags or festoons. In this challenging group, a more traditional midface lift, with the elevation of skin muscle flaps is warranted. The more traditional approach will result in a 2 to 3 week recovery period, but does represent the gold standard for midfacial rejuvenation and should only be performed by well trained, experienced surgeons (Figs. 23.3 and 23.4).

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Figure 23.2 (A–F) The patient is a woman in her late fifties wanting to look refreshed for the work force. A–C are pre operative and D–F are post operative (1 week). The procedure included open submental neck dissection with the removal of prominent platysmal bands. The tear trough and nasolabial folds were injected with hyaluronic acid filler to further enhance the result and minimize the recovery time and donor site associated with fat transfer.

SPECIAL CONSIDERATIONS

FILLERS IN DARKER SKIN PATIENTS

In the era of “wanting more for less,” patients continue to challenge the specialist to deliver more dramatic results for less financial investment and less recovery time. Some patients can be effectively temporized with nonsurgical modalities but there are limits to this ; in particular, the patient who “does not want surgery” but has severe skin laxity and/ or atrophic changes. This type of patient has been treated in “the Spa” and is unhappy with their results. In these instances, it is far better to decline extensive surgical treatment and consider less invasive surgical modalities. The use of fillers can be a great, off-label, adjunct for the post-surgical patient with an irregularity. For instance, fillers can be placed into residual tear trough deformities, post-rhinoplasty irregularities, and residual rhytids post-facelift. Corrective “tweaking” in these locations can produce dramatic results. This technique is extremely useful because of the significant longevity of product in limited mobility locations.

We know that patients with darker skin tend to resist the effects of ultraviolet light exposure. As a result the thicker skin, inherent sebaceous content, and resistance to fine wrinkles make this subgroup ideal for filler injection. While the aging process seems to hit at a later phase, we find that the soft tissue atrophic changes do occur in a similar fashion. I have found that filler use in darker skin extremely rewarding. The effects seem to last at least as long as in fairer skinned individuals. There are several points that are vital to avoid unwanted effects. In particular, it is ideal to minimize the number of needle perforations to the skin in order to avoid the potential for post-traumatic hyperpigmentation. In addition, deeper placement, either in the deep dermis or subcutaneous layer is clearly preferred in this specific group (8,12). Hyaluronic acid is my preferred non-autogenous injection material for the soft tissue replacement. Hydoxyappetite is my preferred substance for deep augmentation to the hypoplastic malar eminence. The use of

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(E) Figure 23.3 (A–E) The split image shown, in figure A, outline the changes that have occurred and will be used to reference the appropriate location for her lateral canthus relative to the medial canthus. In addition, it is important to visualize her asymmetry prior to the procedure (B). In particular, her right brow is lower and flatter than the contralateral side, creating a more hooded appearance to the right upper eyelid. She has forehead rhytids, but they are largely reactive, dynamic in nature to involuntarily address brow and eyelid ptosis. Upon simulated correction, the forehead assumes a more aesthetic position, making direct forehead rhytidectomy unnecessary. In D and E, the patient is seen more than 2 years after combined browpexy, upper blepharoplasty, transconjunctival deep plane midface lift with direct fat transfer to the nasojugal fold. On the split face image the left is pre operative and the right side is more than 15 years prior.

hyaluronic acid injection is particularly effective in patients with darker skin due to the skin’s ability to cover the injected product so effectively. SPECIAL CONSIDERATIONS FOR SURGERY IN THE PATIENT OF COLOR

Aesthetic surgery in patients with darker skin requires special attention to certain details. In particular, it is very important to limit or avoid the use of absorbable sutures on the epidermis, as this will lead to increase

inflammatory response and enhance the risk of keloid/hypertrophic scar formation. It is vital to limit direct tension on skin closures, either by being more conservative with the skin tightening procedure and/or using progressive skin tension sutures in the closure technique. Be prepared to use steroid injections and topical silicone therapy in the early post-operative period for patients at risk for hypertrophic/keloid scar formation. I will typically see patients at 6 to 8 weeks post-surgery to evaluate for early signs of scar irregularity. Triamcinolone acetonide

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Figure 23.4 (A,B) The patient shown illustrates the importance of having a well-laid plan and understanding what the patient really desires. This is a woman who had a four-lid blepharoplasty at another clinic, more than a year prior, and was never happy with her end result. The patient feels the result makes her look “tired” and “unhappy.” She has objective signs of uncorrected canthal ptosis and lower lateral eyelid retraction, creating a gapping at the lateral aspect of the eye and increased scleral show. Had the previous surgeon looked at her more youthful photos, he or she would have appreciated the significance of her canthal ptosis and subsequent loosening of the lower eyelid mechanism. The inferior lateral cant of the eye makes her look angry. Given these findings, we felt that revision of upper and lower blepharoplasty would be appropriate with transconjunctival deep plane midface lift. Images A and B shows the patient before and after the procedure, respectively.

(20 mg/ml) is my preferred medication for injection. It is imperative to be certain that the injection is completely intralesional rather than subcutaneous. Injections of steroids into the subcutaneous tissues will cause lipoatrophy and depigmentation. In patients with hyperpigmentation, perioperatively treatment is warranted to avoid post-surgical hyperpigmentation. Treatment with 4% hydroquinone, azeleic acid, or kojic acid may be helpful in patients with darker (type IV–VI) skin. Treatment should begin 2 to 6 weeks prior to surgery and resume 2 weeks afterwards. Patients of color are significantly concerned about the risk of losing their ethnic identity and these concerns need to be addressed and respected during any procedure. To help understand their youthful images, photos of the patient when they were younger should be reviewed. Several key points need to be respected when treating patients of color. The first is that this population tends to have a “fuller” upper eyelid, similar in morphology to persons of Asian background. In ethnic populations wider cheeks tend to offset broader noses and provide facial balance. Facial aging with its concurrent loss of facial volume can produce the appearance of a relatively larger nose in this patient population. In this patient population, rhinoplasty would be inappropriate without a trial of volume restoration and/or repositioning of the aged midface tissue. Finally, it is important to address the goals and expectations, particularly in the person of color without preconceived notions. The field of ethnic plastic surgery continues to grow and evolve and it is vital to realize many “norms” do not apply to persons of color. CONCLUSION

As a plastic surgeon, specializing in aesthetics, enhancement of aging changes in the face is a combination of several expertises. The primary goal is using the tools that have the least insult and/or downtime to achieve the patient’s goals. In diverse patient populations the field is in a particular state of evolution and requires further inquiry prior to initiating treatment. Following these general principles will typically lead to significant patient and physician satisfaction.

REFERENCES

1. Knize MD, David M. Limited incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 2001; 108(2): 564-7. 2. McCord CD. Browpexy and browplasty. Plast Reconstr Surg 1991; 87(3): 582. 3. Friedland JA. Transpalpebral browpexy. Plast Reconstr Surg 2004; 113(7): 2181. 4. Few J. Rejuvenation of the African American periorbital area: dynamic considerations. Semin Plast Surg 2009; 23(3): 198–206. 5. Alpert BS, Baker DC, Hamra ST, et al.. Identical twin face lifts with differing techniques: a 10 year follow up. Plast Reconstr Surg 2009; 123(3): 1025–33. 6. Baker DC. Lateral SMASectomy, plication, and short scar facelift: indications and techniques. Clin Plast Surg 2008; 35(4): 533–50, vi. 7. Firmin FO, Marchac AC, Lotz NC. Use of the harmonic blad in face liftng: a report based on 420 operations. Plast Reconstr Surg 2009; 124(1): 245–55. 8. Grimes PE, Few JW. Injectable fillers in skin of color. In: Carruthers J, Carruthers A, eds. Procedures in Cosmetic Dermatology: Soft Tissue Augmentation, 2nd edn. Philadelphia, PA: Saunders Elsevier, 2008: 143–51. 9. Odunze M, Reid RR, Yu M, Few J. Periorbital rejuvenation and American-American patient: a survey approach. Plast Reconstr Surg 2006; 118(4): 1011–18. 10. Odunze M, M.D., M.P.H.; Rosenberg DS, M.D.; Few JW, M.D. Periorbital aging and ethnic considerations: a focus on the lateral canthal complex. Plast Reconstr Surg 2008; 121(3):1002–8. 11. Few JW, Lorente O. Transconjunctival deep plane midface rejuvenation. In: Codner MA, ed. Midface Surgery: de Castro and Boehm, Techniques in Aesthetic Plastic Surgery. Philadelphia, PA: Saunders/Elsevier, 2009: 161–72. 12. Odunze M, Cohn A, Few JW. Restylane and people of color. Plast Reconstr Surg. 2007; 720: 2011–16.

24 Periorbital rejuvenation utilizing blepharoplasty and adjunctive surgical techniques Craig N. Czyz, Brian S. Biesman, and Jill A. Foster

The periorbital region is often the first facial area to show signs of aging, and patient requests for periorbital rejuvenation are common in a facial aesthetic surgery practice. To plan appropriate surgical rejuvenation, one must have a thorough understanding of periorbital anatomy and the tissue changes that lead to the perception of aging. Blepharoplasty surgery is indicated when the eyelids require recontouring. Blepharoplasty techniques may be used to excise redundant skin, alter and recontour, redistribute, or remove orbital fat. The majority of perceived facial cosmetic deficiencies are multifactorial in etiology; thus rarely will a single surgical procedure provide complete improvement. Therefore, adjunctive procedures to blepharoplasty are incorporated concurrently to provide the most suitable appearing results. Adjunctive surgical procedures include plication or partial excision of orbicularis oculi muscle, repositioning and/or horizontal tightening of the lax eyelid, plication of the lacrimal gland, and volume replacement with autoplastic or alloplastic grafts or implants. Adjunctive nonsurgical techniques include carbon dioxide laser resurfacing, chemical peels, botulinum toxin injection, dermal filler injection, plasma skin resurfacing, fractional laser resurfacing, and monopolar radiofrequency skin tightening. These various techniques are reviewed in detail elsewhere in this book. This chapter will detail surgical approaches to periorbital rejuvenation. The text is written to give the reader a complete evaluative and procedural overview, but not to distract the reader with complex anatomical and procedural descriptions. The reader should explore the numerous references provided throughout the text if they wish to familiarize themselves further with these topics. SURGICAL ANATOMY

Skin Aging changes of the skin are characterized by development of rhytids, textural and pigmentary changes, and loss of elasticity (1). In contrast to the other areas of the face, the eyelid skin is thinner and lacks a subcutaneous fat layer (Fig. 24.1). The constant motion this skin undergoes with blinking leads to laxity, furthered with advancing age. While blepharoplasty can address skin laxity, it does not alter skin quality. Adjunctive modalities such as dermabrasion, chemical peeling, and/or laser skin resurfacing may need to be incorporated into rejuvenation strategies to address issues other than laxity. These adjunctive modalities are addressed elsewhere in this text. Eyelids Anatomically, the upper eyelid consists of seven distinct layers (Fig. 24.1). These layers from anterior to posterior are (i) skin and subcutaneous tissue, (ii) orbicularis oculi muscle, (iii) orbital septum, (iv) orbital fat, (v) levator and Müller’s muscles (eyelid retractors), (vi) tarsus, and (vii) conjunctiva. The anatomy of the lower eyelid is similar to that of the upper eyelid with two distinct differences. In the lower eyelid, the capsulopalpebral fascia and inferior tarsal muscle are analogous to the upper eyelid’s levator and Müller’s muscles, respectively. These structures are less well developed and defined than their upper lid counterparts. Directly beneath the thin eyelid skin lays the circular orbicularis oculi muscle, the main protractor of the eyelid. The concentrically arranged muscle fibers function in eyelid closure and the lacrimal pump mechanism. The orbicularis muscle is divided into pretarsal,

preseptal, and orbital regions (Fig. 24.2). The pretarsal fibers arise from the posterior lacrimal crest (deep) and the anterior limb of the medical canthal tendon (superficial). The upper and lower eyelid portions of the pretarsal orbicularis fuse in the lateral canthal area to contribute to the lateral canthal tendon. The preseptal orbicularis fibers originate from the upper and lower borders of the medial canthal tendon and arc laterally, eventually forming the lateral palpebral raphe. The orbital orbicularis muscle is formed from fibers emanating from the anterior limb of the orbital portion of the frontal bone, the frontal process of the maxillary bone anterior to the lacrimal crest, and the anterior limb of the medial canthal tendon. The fibers insert just below the point of origin forming a continuous ellipse. The orbital septum is a thin, firm, multilayered fibrous tissue that originates from the arcus marginalis, the thickened periosteum of the superior and inferior orbital rim. In the Occidental upper eyelid, the septum extends toward the tarsal plate where it fuses with the levator aponeurosis 2 to 5 mm above the superior tarsal border (2). The site of fusion and/or the position of the orbital fat varies between Occidental and Asian eyelids. In the Occidental lower eyelid, the orbital septum fuses with the capsulopalpebral fascia at, or slightly below, the inferior tarsal border. The fused complex inserts on the anterior and posterior tarsal surfaces at the inferior border of the tarsus. Laterally, the septum is contiguous with the lateral horn of the levator aponeurosis and the lateral canthal tendon. The septum functions as an anatomic barrier between intraorbital and extraorbital structures, specifically the orbital fat. As a result of aging, the septum may become attenuated contributing to anterior herniation of the orbital fat in the upper and lower eyelids. Surgically, the septum should be distinguished from the levator aponeurosis in the upper eyelid. The septum should not be sutured to avoid eyelid retraction, restriction of eyelid movement, or incarceration in the surgical wound (2). In the upper eyelid, the orbital fat is located posterior to the septum and anterior to the levator aponeurosis. The fat is separated into two distinct “pockets,” nasal and central. The central fat pocket is an important landmark in upper eyelid surgery as it lies anterior to the levator aponeurosis. The potential space between the orbital septum and the levator aponeurosis is greatest immediately inferior to the superior orbital rim; thus for the novice eyelid surgeon, this is an ideal location for the septum to be incised to minimize the risk of injuring deeper structures. A central incision also aids in avoiding the lacrimal gland laterally and the trochlea of the superior oblique muscle medially. The central and nasal fat pockets are anatomically separated by a vertical septum and can be differentiated by color. The central fat is yellow in color, whereas the nasal fat is white to pale yellow. The preaponeurotic fat pockets should be distinguished from descended retro-orbicularis oculi fat (ROOF) and the submuscular fat located anterior to the septum in Asian eyelids. The orbital fat in the lower eyelid has classically been described as being divided into three compartments: nasal, central, and temporal (3–6). While clinically distinct, certain studies indicate that there is no actual anatomic division, rather there exists a single, large lower orbital fat compartment (7). Other recent studies suggest that the fat pads are anatomically distinct in horizontal as well as anterior to posterior planes (8). The fat pockets are encased by wispy fibroconnective tissue septae that are anterior projections of the orbital septal system (9). It has been proposed that the temporal fat pocket is further subdivided

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Skin Frontalis muscle

Subcutaneous fat Orbital fat

Sub-brow fat pad Preorbital orbicularis muscle

Superior transverse ligament (whitnall’s ligament) Krause glands Levator muscle Superior rectus muscle

Orbital septum Preseptal orbicularis muscle

Superior oblique muscle

Superior tarsal muscle (Müller’s muscle)

Conjunctiva

Levator aponeurosis Wolfring glands

Peripheral arterial arcade Eyelid crease

Tarsus

Pretarsal orbicularis muscle

Conjunctiva

Marginal arcade vessel Meibomian gland orifices

Inferior oblique muscle

Orbicularis muscle

Inferior rectus muscle

Lower lid retractors Orbital Septum

Capsulopalpebral head

Orbital fat Suborbicularis oculi fat

Figure 24.1 Upper and lower eyelid and selected periorbital anatomy. Source : From Ref. 73.

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Figure 24.2 (A) Orbicularis muscle and related tissues: A, frontalis muscle; B, corrugator supercilii muscle; C, procerus muscle; D, orbicularis muscle (orbital portion); E, orbicularis muscle (preseptal portion); F, orbicularis muscle (pretarsal portion); G, medial canthal tendon; H, lateral canthal tendon. Source : Adapted from Beard C. Ptosis, 3rd edn. St. Louis: Mosby, 1981. Modified by Cyndie Wooley. (B) Retro-orbicularis oculi fat (ROOF). The forceps nearest the eyelid margin are grasping the preaponeurotic fat and the forceps nearest the brow are grasping the ROOF. Note the white color of the underlying orbital septum.

into two pads, one adjacent to the central pocket and the second more posterior and lateral (10). Dye injection studies have failed to demonstrate these divisions, leading some to suggest there exists only one fat compartment in the lower eyelids (4).The inferior oblique muscle

originates from along the anterior medial orbital floor, posterior to the lacrimal sac fossa, and inserts onto the inferolateral globe (Fig. 24.1). The inferior oblique muscle may be located clinically by gently separating the medial and central fat pockets and following that plane

PERIORBITAL REJUVENATION UTILIZING BLEPHAROPLASTY AND ADJUNCTIVE SURGICAL TECHNIQUES posteriorly into the orbital fat. The central and lateral fat pockets are separated by the arcuate expansion of the inferior oblique muscle fibers, a fascial band extending to the inferolateral orbital rim. This fascial band may be divided during transconjunctival lower blepharoplasty to enhance exposure of the lateral fat compartments. The retractors of the upper eyelid are the levator muscle, with its aponeurosis, and Müller’s muscle. The levator, via its tendinous aponeurosis, is the primary retractor of the upper eyelid. The levator muscle originates in the apex of the orbit, arising from the periorbita of the lesser wing of the sphenoid above the annulus of Zinn. The levator and its aponeurosis are 54 to 60 mm in length from origin to insertion, with the most anterior 14 to 20 mm being comprised of the aponeurosis (11). Whitnall’s ligament (superior transverse ligament) is a sheath of white elastic tissue surrounding the levator muscle at the zone of transition from muscle to aponeurosis. Medially, Whitnall’s ligament attaches to connective tissue surrounding the trochlea and superior oblique tendon. Laterally, it passes through the stroma of the lacrimal gland and attaches to the inner aspect of the lateral orbital wall approximately 10 mm above the orbital tubercle (12). The primary functions of Whitnall’s ligament are to act as a fulcrum for the levator and as a suspensory support for the upper eyelid and superior orbital tissues. The levator aponeurosis divides into anterior and posterior portions prior to its insertion. The anterior portion is composed of fine leaflets of aponeurosis that insert into the septa between the pretarsal orbicularis muscle and the skin of 8 to 10 mm above the eyelid margin. These attachments result in close apposition of the pretarsal skin and orbicularis to the tarsal plate. The most superior of these attachments, aided by contraction of the levator aponeurosis, forms the upper eyelid crease. This insertion of the anterior portion of the levator aponeurosis (eyelid crease) is commonly marked as the inferior border of the upper blepharoplasty incision. The posterior portion of the levator aponeurosis is a broad band that inserts into the anterior–superior portion of the tarsal plate. Surgical or mechanical disruption of the levator complex may result in upper eyelid ptosis. Müller’s muscle is a sympathetically innervated smooth muscle that originates from the underside of the levator aponeurosis, approximately at the level of Whitnall’s ligament, and inserts along the superior tarsal margin. Posteriorly, Müller’s muscle is firmly attached to the palpebral conjunctiva. This secondary elevator of the upper eyelid provides approximately 2 mm of lid elevation (9). The disruption of Müller’s muscle results in mild ptosis, as evidenced in patients with Horner’s syndrome. Intraoperatively, Müller’s muscle can be identified by the landmark of the eyelid vascular arcade that passes anterior to Müller’s muscle and underneath the levator aponeurosis. The retractors of the lower eyelid are comprised of the capsulopalpebral fascia and the inferior tarsal muscle. The capsulopalpebral fascia is analogous to the levator aponeurosis in the upper eyelid. The fascia emanates as the capsulopalbebral head from the terminal fibers of the inferior rectus muscle and divides as it envelops the inferior oblique muscle fusing with the sheath of the inferior oblique muscle. Anterior to the inferior oblique muscle the two heads rejoin to form Lockwood’s suspensory ligament, extending anteriorly to the inferior conjunctival fornix as the capsulopalbebral fascia. The capsulopalpebral fascia inserts onto the inferior tarsal border and fuses with the orbital septum 3 to 5 mm inferior to the tarsus. Lockwood’s ligament is attached medially and laterally to the orbital walls, and laterally is incorporated into the lateral retinaculum. The lateral retinaculum is comprised of the lateral horn of the levator aponeurosis, lateral canthal tendon, Lockwood’s ligament, and the check ligament of the lateral rectus muscle. The inferior tarsal muscle is analogous to Müller’s muscle of the upper eyelid. It is located between the capsulopalpebral fascia and palpebral conjunctiva. The smooth muscle fibers that comprise the inferior tarsal muscle are most abundant in the area of the inferior fornix (9).

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The tarsi are firm, dense plates of specialized connective tissue, neither purely fibrous nor cartilaginous, that serve as the mechanical support of the eyelids (13). At its center, the upper eyelid tarsal plate has a greater vertical dimension (10–12 mm) than the lower eyelid tarsal plate (4 mm) (14). Both upper and lower tarsal plates measure approximately 1 mm in thickness and taper toward their attachments (9). The upper and lower eyelid tarsal plates have solid attachments to the periosteum via the canthal tendons medially and laterally. Laxity, involutional changes, or mechanical disruption of either supporting tendon can result in displacement of the tarsi. The meibomian glands, holocrine sebaceous glands that secret the oil component of the tear film, are located within the tarsus. The posterior surface of the upper and lower eyelids is lined by the palpebral conjunctiva. The conjunctiva that surrounds the globe is the bulbar conjunctiva. The fornices are the areas of transition between bulbar and palpebral conjunctiva. Conjunctiva is composed of nonkeratinizing squamous epithelium. The conjunctiva contains the accessory lacrimal glands of Wolfring and Krause and the mucin-secreting goblet cells. The accessory lacrimal glands are located primarily in the palpebral conjunctiva (9). The function of the conjunctiva is to lubricate, support, and protect the ocular surfaces (14). ADDITIONAL SURGICAL ANATOMICAL CONSIDERATIONS

Asian Eyelids The anatomic differences between Occidental and Asian eyelids are reflected in the upper eyelid crease appearance and arrangement of the preaponeurotic fat. In the Asian upper eyelid, the orbital septum and levator aponeurosis fuse below the superior tarsal border and anterior to the tarsus. This gives the appearance of a “low” or “absent” eyelid crease (15). It also causes the Asian lid to appear “fuller,” as the preaponeurotic fat pad encroaches closer to the eyelid margin (16). The Asian eyelid contains a sub-orbicularis fat pad not found in Occidental eyelids (17). It lies superior to the tarsal boarder spanning its length. These anatomical differences can be confusing to the novice Asian eyelid surgeon, and are not addressed within the surgical section of this chapter. Texts dedicated to this subject should be consulted prior to undertaking Asian upper blepharoplasty. Retro-Orbicularis Oculi Fat (ROOF) The retro-orbicularis oculi fat (ROOF) originates deep to the brow and continues into the upper eyelid as the posterior orbicularis fasica (18). The ROOF consists of fibrofatty tissue located deep to the orbicularis oculi muscle and superficial to the orbital septum and periosteum (Fig. 24.2B) (19). The ROOF may descend and overlap the preaponeurotic fat accentuating the eyelid skin fold. This can cause the ROOF to be mistaken for orbital fat and excised. While resection of the ROOF may improve the contour of the lateral eyelid (20), further descent from involutional changes is likely. Plication of the ROOF is a viable alternative that restores the native brow contour, improves the eyelid contour, and retards further descent. Suborbicularis Oculi Fat (SOOF) Analogous to the upper eyelid ROOF, the lower eyelid suborbicularis oculi fat (SOOF) lies deep to the orbital portion of the orbicularis oculi muscle immediately inferior to the inferior orbital rim (Fig. 24.1) and is continuous with the superficial musculoaponeurotic system (SMAS). It varies in thickness from medial to lateral, with central and lateral regions being the most robust. The infraorbital nerve marks the division between the thick central area and the thin medial area of the SOOF. The SOOF encompasses the zygomaticus, levator labi superioris alaeque nasi, and levator labi superioris muscles. In the region of the nasolabial fold, the zygomaticus and levator labi superioris muscles transverse the SOOF and insert into the dermis. With involutional

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changes, the SOOF descends downward, thinning the lower eyelid and accentuating the tear trough along the inferior orbital rim. Superficial Musculoaponeurotic System (SMAS) The SMAS is a discrete fibromuscular layer that is an extension of the superficial cervical fascia in the neck. Its region-specific anatomy consists of a three-dimensional scaffold of collagen fibers, elastic fibers, and fat cells (21). The SMAS envelops the facial mimetic muscles and transmits their contractions, thus facilitating facial expressions. The numerous ligamentous attachments between the SMAS and dermis enable the muscular contractions to animate the overlying skin. The SMAS is anchored to the underlying facial bones via ligaments and fibrous septa. The SMAS is attached superiorly to the inferior orbital rim and laterally to the body of the zygoma and the zygomatic arch (22). Inferiorly, the SMAS is continuous with the platysma muscle (23). Medially the thin nature of the SMAS makes its site of attachment difficult to identify. The osteocutaneous ligaments and ligaments formed by a condensation of the superficial and deep facial fasciae are the main sources of attachment. The aging changes of the midface can be attributed to attenuation of these ligamentous attachments, involution of the SMAS and SOOF, and dermal elastosis. Malar and Nasojugal Folds The underlying anatomy of the malar and nasojugal folds is likely multifactorial with variances between individuals. The surface anatomy is influenced by the osteocutaneous ligaments (orbitomalar ligaments) that have been described as fascial extensions from the inferior orbital rim through the orbicularis oculi muscle to the skin (24). The visible anatomy has been attributed to superficial subcutaneous features and atrophy of the fat and skin (25). The orbitomalar ligament is composed of collagen and elastin fibers originating from the inferior orbital rim periosteum and transversing the submuscular fat and the orbicularis oculi muscle before inserting into the skin (26,27). The orbitomalar ligament may become lax with advancing age contributing to the sagging appearance of the malar folds commonly referred to as festoons (28).

Descent of the of SMAS and SOOF, along with the stretching of the orbicularis oculi muscle fibers, results in a deficiency of tissue above the inferior orbital rim. The tissue descent and underlying bony anatomy result in formation of the nasojugal fold, also referred to as the tear trough deformity. When this deformity is present along with bulging of the orbital fat superior to the inferior orbital rim, a double convexity deformity is present. Traditional lower blepharoplasty addresses the superior aspect of the double convexity deformity only. Fat transposition or grafting, implants, or dermal fillers can be used to address the tear trough deformity (29,30). The malar folds require midface tissue elevation techniques such as SMAS, SOOF, and orbicularis plication. Canthal Tendons The structure of the palpebral fissure is maintained by the tarsal plates in combination with the medial and lateral canthal tendons (Fig. 24.3). The medial canthal tendon is formed by the merging of two tendinous limbs originating from the anterior and posterior lacrimal crests. The limbs fuse temporal to the lacrimal sac and then re-merge into two limbs that attach to the upper and lower eyelid tarsal plates. The tendinous attachment at the anterior lacrimal crest is robust, whereas that of the posterior lacrimal crest is delicate but crucial in maintaining apposition of the eyelids to the globe (9). The lateral canthal tendon inserts on a tubercle (Whitnall’s) located 2 mm posterior on the inner aspect of the lateral orbital rim (31). It branches into superior and inferior limbs that attach to the tarsal plates. The lateral canthal tendon inserts approximately 2 mm higher than the medial canthal tendon (9). This results in an upward slope of the palpebral fissure from medial to lateral. Aging or surgical disruption of medial or lateral tendons results in cosmetic and/or functional issues such as horizontal eyelid laxity. Correction of horizontal lower eyelid laxity can be undertaken concurrently with blepharoplasty surgery by a variety of canthoplasty techniques (32). Eyelid Margin The eyelid margin is a confluence of structures (Fig. 24.4). It is composed of cutaneous epithelium, the edge of the orbicularis, and the mucosal surface of the conjunctiva. The gray line is a visible structure on the eyelid margin. It consists of the superficial portion of the orbicularis oculi muscle anterior to the tarsus, known as the muscle of Riolan (33). The gray line is often confused with the mucocutaneous junction of the eyelid margin, which is actually located posterior to the meibomian gland orifices along the eyelid margin. The gray line is a

Gray line

Meibomian gland orifices Mucocutaneous junction Meibomian gland Conjunctiva

Figure 24.3 Deeper eyelid and anterior orbital structures—coronal perspective: A, lacrimal gland; B, superior transverse ligament (Whitnall’s ligament); C, superior oblique tendon sheath; D, levator aponeurosis; E, lateral horn; F, medial horn; G, lateral canthal tendon; H, medial canthal tendon; I, lacrimal sac; J, lower eyelid retractors; K, inferior oblique muscle. Source : Adapted from Beard C. Ptosis, 3rd edn. St. Louis: Mosby, 1981. Modified by Cyndie Wooley.

Glands of Moll

Lash follicle Glands of Zeiss

Orbicularis oculi muscle

Figure 24.4 Eyelid margin anatomy. Source : From Ref. 73.

PERIORBITAL REJUVENATION UTILIZING BLEPHAROPLASTY AND ADJUNCTIVE SURGICAL TECHNIQUES surgically important landmark in canthoplasty and other surgical procedures involving the eyelids. CLINICAL ANATOMY

The average distance between the upper and lower eyelids, the vertical palpebral fissure (VPF), is 8 to 10 mm in primary (straight) gaze (34). The upper eyelid margin rests approximately 2 mm below the superior corneal limbus. The lower eyelid margin should be at or 1 mm above the inferior corneal limbus so that no sclera is visible between the limbus and eyelid. The position of the upper and lower eyelids relative to the globe is measured from the central pupil to the eyelid margin, and referred to as margin-to-reflex distance (MRD). In MRD1, “1” denotes

Figure 24.5 Vertical palpebral fissure (VPF) and margin-to-reflex distances (MRD). The red line denotes MRD1 and the blue line MRD2. The sum of MRD1 and MRD2 equals VPF.

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that this measurement is to the upper eyelid margin, whereas MRD2 signifies the distance from the central pupil to the lower eyelid margin (Fig. 24.5). Thus, MRD1 plus MRD2 equals VPF. Abnormalities in the upper eyelid position should be recognized prior to surgery since underlying etiologies may require further evaluation and correction. Individuals with eyelid retraction have a lid margin that rests higher than normal (increased MRD1), and may have a “staring” or “surprised” appearance (Fig. 24.6A). Those individuals with ptosis have a decreased MRD1, and may appear “sleepy” due to the drooping of the lids (Fig. 24.6B). The horizontal width of the palpebral fissure (HPF) from medial to lateral canthus is approximately 28 to 30 mm (35). The lateral canthal angle is positioned approximately 2 mm higher than the horizontal meridian of the medial canthal angle. Involutional lowering of the lateral canthal angle can produce a “sad” midfacial expression (Fig. 24.7). Upper Eyelid The upper eyelid crease is created by the anterior insertion of the levator aponeurosis into the orbicularis and dermis. The crease is usually 9 to 12 mm above the central lid margin in adult occidental females, and 8 to 10 mm above the lid margin in adult occidental males (36). The upper lid crease in Asian individuals is lower, usually in the range of 2 to 5 mm from the eyelid margin. There are additional anatomic differences between Asian and Occidental eyelids, which are imperative for the surgeon to understand when performing eyelid surgery on Asian patients (37,38). While reference may be made to anatomical and clinical differences between the Occidental and Asian periorbita, the surgical technique will not be discussed. The lid fold represents the skin and orbicularis muscle that together drape over and obscure the lid crease when the eye is in primary position. Excessive folding or hooding may result from dermatochalasis, brow ptosis, or both (Fig. 24.8). Affected individuals may perceive a sensation of lid “heaviness,” early fatigue with reading or watching television, and even loss of superior and/or peripheral vision. The visual field defect is demonstrated with automated (Humphrey) or manual (Goldmann) visual field testing, and is required documentation if insurance coverage is sought to cover the expenses associated with upper blepharoplasty.

(B)

Figure 24.6 (A) Eyelid retraction. The patient has retraction of both upper and lower eyelids of the right eye and lower eyelid of the left eye. Lower eyelid retraction is also referred to as inferior scleral show. (B) Ptosis left eye. The MRD1 of the left eye is decreased versus the right eye due to upper eyelid ptosis.

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The superior sulcus is the region between the superior orbital rim and the globe. In young or thin individuals, the sulcus is typically flat. Sulcus fullness (convex) may be due to orbital fat herniation, generalized lid edema, expansion of the orbital soft tissues, or a mass lesion. Fullness localized to the lateral third of the sulcus may be attributed to lacrimal gland prolapse or extension of the preaponeurotic fat. Lacrimal gland prolapse is considered an involutional process, yet an estimated 10% to 15% of young individuals undergoing blepharoplasty

have symmetrically or asymmetrically displaced lacrimal glands (39). A physiological extension of the preaponeurotic fat can anteriorly protrude under the inferior border of the lacrimal gland toward the orbital septum clinically resulting in a bulge or fullness in the upper eyelid (40). Individuals with full sulci can undergo fat excision as part of the blepharoplasty procedure. However, excessive fat removal can cause a “skeletonized” facial appearance. In individuals who have a deep (concave) sulcus with a “skeletonized” appearance, various techniques can be used to replace the volume deficiency (Fig. 24.9) (41). In patients with both concave and convex sulcus areas, liposculpting, fat redistribution, or fat grafting (42–44) can be performed to smooth the sulcus contour and avoid exacerbating a deep or full appearance. Lower Eyelid With increasing age, there is a tendency for the lower eyelid to become horizontally lax and bow downward, sometimes resulting in scleral show (45). During youth, the lower lid contour is generally flat. Over time, adipose tissue may protrude anteriorly, resulting in prominence of the orbital fat pads, a condition known as steatoblepharon. This creates the impression of “bags under the eyes” and can give the individual a “tired” appearance. The adipose tissue appears clinically to protrude in three zones, conceptualized as medial, central, and temporal compartments.

Figure 24.7 Horizontal laxity of the lower eyelids resulting in lowering of the lateral canthal angle and inferior scleral show.

Figure 24.8 Dermatochalasis and brow ptosis resulting in “hooding” of the upper eyelid skin. Note how the skin overhangs the eyelid margin causing the appearance of a ptotic upper eyelid.

Periorbital Regions Periorbital hyperpigmentation, or dark circles, in the nasojugal area of the lower lids and medial canthus are an extremely common aesthetic concern. The etiology of dark circles is varied and can represent epidermal or dermal melanin deposition, post-inflammatory hyperpigmentation, periorbital edema, superficial location of vasculature, dermal thinning with visible underlying orbicularis, or can be created by a “shadowing” effect produced by tear trough depression, skin laxity, and pseudoherniation of orbital fat (46,47). Most frequently, the etiology is multifactoral and requires multiple treatment modalities which include bleaching compounds, chemical peels, topical retinoic acid, carbon dioxide laser, nitrogen plasma skin regeneration, soft tissue fillers, and surgery (48–56). It is important to identify the underlying etiology(ies) and select the most appropriate treatment(s), as it varies among individuals. Improvement is possible, but complete eradication proves difficult. The majority of the nonsurgical treatment modalities can be

Figure 24.9 Deep (concave) superior sulci resulting in a “skeletonized” appearance. This patient also has bilateral upper eyelid ptosis.

PERIORBITAL REJUVENATION UTILIZING BLEPHAROPLASTY AND ADJUNCTIVE SURGICAL TECHNIQUES undertaken concurrently with lower blepharoplasty, and are described elsewhere in this text. Periorbital rhytids, or crow’s feet, are fine wrinkles caused by a combination of skin laxity and orbicularis oculi function. Treatments include botulinum toxin, monopolar radiofrequency, carbon dioxide or fractional resurfacing, and surgical subcision, myectomy, or modification of the orbicularis (57–61). These adjunctive techniques can be used concurrently with blepharoplasty or as isolated treatments. Techniques for orbicularis modification are described in the surgical producers section. The nonsurgical adjunctive modalities are described elsewhere in this text. SURGICAL MANAGEMENT

Pre-operative Considerations Prior to any surgical intervention, especially an aesthetic surgical procedure, pre-operative counseling and setting of realistic expectations are of paramount importance. A general medical history should be taken with particular attention paid to symptoms of Graves disease or other thyroid conditions, environmental allergies, or episodic eyelid swelling that may suggest blepharochalasis syndrome, a variant of hereditary angioedema (62,63). Chronic blepharochalasis may result in stretching and wrinkling of the eyelid skin, ultimately leading to dermatochalasis. Patients should be asked about hypertrophic scar or keloid formation, especially patients younger than 30 years of age or with darker pigmented skin (64). A history of rheumatoid arthritis, autoimmune disease, or laser vision correction may be associated with coexisting dry eye syndrome, which can be compounded by post-operative lagophthalmos. A basal tear secretion test (Schirmer’s) and evaluation of the ocular surface is of value to predict the increased post-operative risks of exacerbated dry eye. Every patient should be questioned about hematologic disorders, use of aspirin, non-steroidal anti-inflammatory agents, anticoagulants, chronic oral steroids, vitamin E, St. John’s Wart, garlic, fish oils, and a variety of supplements in order to assess the relative risk for excessive intraoperative or post-operative bleeding. The decision to discontinue non-prescription anticoagulative agents at least 10 to 14 days preoperatively and through the early post-operative period should be made in conjunction with the physician in charge of the patient’s systemic management. Prescription of anticoagulation is managed in concert with the prescribing physician. Patient Evaluation Prior to performing any periorbital surgical procedure, patient evaluation begins with measurement of visual acuity using a standard eye chart or near card. The structural assessment begins by noting eyebrow position with the patient seated upright, chin level, and the eyes in primary gaze. The surgeon should inspect brow height in relation to the orbital rim, brow contour, sulcus contour, including fullness from decent of the ROOF pad or lacrimal gland prolapse, and texture of the skin. The position of the globe is noted relative to the orbital rim. In the setting of a flattened malar eminence, a shallow orbit, or axial myopia (near sighted patient with increased anterior to posterior globe length), the eye will appear to protrude forward (proptosis) causing the upper and lower eyelids to appear retracted. In cases such as these, removal of tissue from the eyelids must be performed with great care as the proptotic appearance of the globe may be accentuated, creating an aesthetically unacceptable “startled” or “staring” appearance (Fig. 24.6A), and possibly limiting the ability of the eyelids to fully close (lagophthalmos). The presence of actual proptosis is evaluated by exophthalmometry measurements and requires a medical work-up to determine etiology and appropriate management.

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Upper Lid Attention is then turned to the upper eyelid. The eyelid contour and position is observed. The presence of retraction or ptosis is noted (Fig. 24.6A,B). In order to standardize measurement, the brow should be in a neutral position when evaluating lid position. If the patient is elevating their brow the examiner should ask them to “relax” the brow. If the patient is unable to comply, the examiner should then place his/ her thumbs on the patient’s brow to secure it in a neutral position. The skin is inspected for evidence of medial canthal webbing, epicanthal folds, wrinkling, previous surgical scars, pigmentation, and lesions or other defects. Gentle pressure on the globe through a closed eyelid will demonstrate the size and position of the central and nasal fat pads of the upper lids. Fullness of the lateral third of the upper lid can be caused by lacrimal gland or fat prolapse and differentiation should be made prior to surgical planning. If the superior sulcus is relatively concave pre-operatively, the excision of orbital fat is contraindicated, as it will produce further “skeletonization” of the superior fornix (Fig. 24.9). In this setting, fat transposition or grafting may be required to achieve a cosmetically appealing sulcus contour. The position and definition of the upper eyelid crease is then observed. If the crease is poorly defined, or if there is asymmetry in crease height between the eyelids, the patient should be made aware of this prior to surgery. Elevation or blunting of the lid crease may be associated with ptosis and levator aponeurosis dehiscence. Patients are more likely to notice a difference in eyelid symmetry after surgery than beforehand, due to the careful attention typically given to the lids during the post-operative recovery period. As previously described, the “normal” position of the upper eyelid crease is higher in females, but varies from patient to patient regardless of gender. There are significant anatomical differences between Asian and Occidental eyelids (38), which are reflected in eyelid crease position, prominence, and contour. There can be great psychosocial significance placed on this feature by many Asian societies, therefore, these differences must be recognized and respected. Finally, a comprehensive ophthalmic examination should be completed to identify any pre-exisiting pathology that could be attributed to a surgical procedure if not identified and documented pre-operatively. Lower Lid Evaluation of the lower eyelid includes assessment of the lid margin position, horizontal laxity, integrity of the canthal tendons, orbicularis function, and the volume and position of the orbital fat. It is particularly important in lower blepharoplasty to identify and modify preexisting lower lid laxity to help prevent lower eyelid retraction. Lower lid position is assessed by measuring inferior scleral show, which is the distance between inferior limbus and lower lid margin. The normal measurement for inferior scleral show is 0 to –2 mm, meaning that the lower lid covers the inferior limbus (65). Laxity is evaluated by performing a snap-back test or assessing margin distraction. In the normal lower eyelid, when the lower lid is pulled downward away from the globe, upon release, it will quickly return to its natural position. When the snap back test is abnormal, the lower lid remains distracted until the patient blinks or until the lid is mechanically pushed back into position (Fig. 24.10A). The lid margin distraction test is performed by using the index finger to pull the medial lid laterally against the globe while assessing the lateral displacement of the punctum (Fig. 24.10B). If the punctum moves beyond the medial limbus, the eyelid is inappropriately lax. These tests help to determine those patients who will benefit from canthoplasty to improve lower lid tone at the time of blepharoplasty. The shape and volume of the lower eyelid fat are evaluated prior to surgery. Pre-operatively the surgeon creates a plan that might include removal of excess fat, transposition of fat for reshaping, or repositioning

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(A)

(B) Figure 24.10 Clinical tests to assess lower eyelid laxity: (A) snap-back test; (B) lid margin distraction test.

of fat posteriorly with orbicularis tightening. Transposition of the fat may be used to improve contour problems such as tear trough concavity. In some patients, laser resurfacing, alloplastic implants, and/or lid or cheek resuspension may make fat removal unnecessary. Soft tissue filler techniques also diminish the need for fat alteration to improve lower eyelid contour. The lower eyelid should be evaluated in motion as wall as at rest. Hypertrophy of the orbicularis oculi muscle will cause a bunching effect that is particularly prominent when an individual smiles. Therefore, the lower lid should be evaluated in both the relaxed state and with a forced smile in order to determine the relative contributions of skin, muscle, and fat to the eyelid’s overall appearance. This maneuver also helps determine if excess periorbital skin is present and provides valuable information about the skin’s elasticity. Just as the brow plays an essential role in the configuration of the upper eyelid, the cheek structures influence the lower eyelid contour. Pre-operative assessment includes evaluation of the adequacy of malar support and may indicate the need for alteration of the midface to improve cheek projection and lower eyelid support. Assessment of the SOOF position and the degree of descent may suggest that additional intervention with midface elevation is required to improve the contour of the lower eyelid. It is valuable to identify these concerns prior to surgery in order to provide the patient with the option of undergoing these procedures concurrently with the blepharoplasty, as well as to appropriately set patient expectations regarding surgical outcomes. Surgical Planning Upper Lids There are a myriad ways to design and mark an upper blepharoplasty incision; however, serious complications can be avoided if some basic guidelines are followed. Makeup should be removed and the lids cleansed with an alcohol pad so oil on the skin’s surface does not disrupt the marking ink. Care should be taken not to introduce alcohol onto the ocular surface. A fine-tipped surgical marking pen is used to mark the incision and areas of fat excision, addition, or transposition (Fig. 24.11A). The inferior border of the incision is typically placed on the eyelid crease, assuming it has not been distorted by previous surgery or raised by dehiscence of the levator aponeurosis. In occidental patients, the central portion of the crease is highest while the temporal and nasal ends are lower. In the Asian lid, the crease is relatively straight (37,38). If the creases are asymmetric, this should be discussed with the patient prior to the day of surgery. If surgical correction of the asymmetry is desired, the lid crease that is closest to the “natural” position is used as the guide. Therefore, the crease marking of the opposite lid may be above or below the current crease location. The incision should

extend no closer than 5 mm vertically from the superior punctum and, in general, should not extend medial to a line drawn vertically through this structure (Fig. 24.11A). Carrying the incision too far medially can result in cicatricial band formation also known as “webbing.” The temporal extent of the incision should not extend lateral to a line drawn vertically through the tail of the eyebrow. The superior border of the incision should pass no closer than 10 mm from the inferior border of the eyebrow (Fig. 24.11B). This represents the approximate point of transition between the thicker skin of the eyebrow and the thinner skin of the eyelid. Incorporating brow skin in the blepharoplasty closure can cause brow ptosis, as well as an unappealing cosmetic result due to differences in skin texture and thickness. There are varying techniques for estimating the amount of eyelid skin to be removed. While the more advanced blepharoplasty surgeon may simply “eye” the proper amount, the “skin pinch” method, with caliper confirmation, is recommended for the novice surgeon (Fig. 24.11C). The patient, in a supine position, is asked to gently close their eyes. One arm of a smooth forceps is then placed in the eyelid crease while the other arm pinches the redundant skin until the eyelashes just begin to rotate superiorly. This delineates the maximum amount of skin that may be safely removed as to not cause lagophthalmos. Once the eyelid skin is marked, a caliper or ruler should be used to measure the distance from the eyelid margin to the lid crease (Fig. 24.11D) and then from the superior incision line to the inferior brow (Fig. 24.11B). A minimum total of 20 mm of skin should remain between the eyelid margin and the inferior brow cilia (66). If this guideline is observed, lagophthalmos, and the associated secondary surgery for its correction, can usually be avoided. Once the eyelids have been marked with the patient in a supine position, the patient may be placed in a sitting position to account for gravitational influences on the eyelids and eyebrow and the markings carefully compared for symmetry. Initial eyelid markings are performed prior to administration of sedative agents or local anesthetic. Lower Lids Selecting the proper approach to lower lid blepharoplasty requires more sophisticated surgical experience. Pre-operative decision-making includes assessment of the amount of prolapsed fat and its location, the contributions of the tear trough and malar decent to the aesthetic periorbital appearance, the degree of laxity of the lower eyelid and canthal tendons, and whether redundant skin is present. The degree of horizontal lid laxity and amount of skin redundancy factor prominently into surgical approach and incision design. The surgeon determines whether soft tissues require resuspension, whether the eyelid needs to be shortened, and whether or not the lateral canthus

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(B)

(C)

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Figure 24.11 (A) Marked upper blepharoplasty incision. (B) Caliper measurement showing acceptable amount of skin remaining (10 mm) between the upper blepharoplasty incision and the inferior most brow cilia. (C) Skin pinch method of determining appropriate amount of skin excision in upper blepharoplasty. (D) Caliper measurement showing distance from lid crease incision to lid margin, which was 9 mm in this female patient.

requires repositioning. When the surgeon’s assessment of the lid identifies adequate horizontal tension in association with protruding fat, an isolated transconjunctival approach may be used. If the lid has mild horizontal laxity, an orbicularis plication/suspension or lateral canthopexy may be adequate. A transecting lateral canthoplasty is used if the lid requires shortening or lateral canthal repositioning. When possible, avoiding a transecting lateral canthoplasty minimizes disruption of orbicularis function and decreases the chance of creating an overriding upper eyelid in the lateral canthal region. Mild skin excess may be addressed with a transconjunctival approach and a subciliary (skin pinch) excision at the end of the case. More significant anterior lamellar excess is addressed with a skin muscle flap incision. Lower eyelid blepharoplasty commonly is combined with canthoplasty for increased operative exposure, in addition to correction of lid position. This is especially the case if volume augmenting implants are to be used in the nasojugal or malar regions. The use of such implants is beyond the scope of this text and implantation procedures will not be described. The markings for a subciliary incision or canthoplasty are less complex than those required in the upper eyelid. The subciliary incision should be placed 1.5 mm directly below the lash line. It should begin medially at the puncta and extend laterally to the lateral canthus. The canthoplasty incision begins at the lateral canthal angle and extends about 5 to 7 mm.

Skin excision markings should be done with exacting precision. Using forceps or an index finger and thumb, gently pinch the lower lid to determine the maximum amount of skin that can be resected from the subciliary area without inducing displacement of the lower lid margin. These markings will remind the surgeon of the upper limit of vertical shortening, thus helping to avoid post-operative complications. Once the decision for the location and type of surgical incision has been made, the surgeon plans soft tissue modifications. Protrusion of fat without contribution of tear trough hollowing may be addressed with fat sculpting and removal alone. If infraorbital hollowing is also a contributing factor, that may be modified with fat transposition. Areas of prominent fat protrusion should be marked with the patient sitting upright as the fat retracts posteriorly into the orbit when supine masking the contour. This can cause an underestimation of the location or the proper volume of fat to remove or transpose. Similarly, if volume augmentation is desired and fat is to be transposed or grafted, depressed areas should be marked with the patient in a seated position. PROCEDURES

Upper Blepharoplasty Upper blepharoplasty may be performed in an office setting, surgery center, or hospital operating room. It can be accomplished with local anesthesia alone or in conjunction with oral or intravenous sedation.

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Figure 24.12 (A) The orbital septum is grasped by forceps and the fat pad is exposed medially with the Wescott scissors pointing towards it. (B) The nasal fat is white in color opposed to other areas of orbital fat that are a yellow color.

Excessively nervous patients or those with certain medical conditions (lower back or cervical disorders, etc.) may require or request general anesthesia. Local anesthesia, usually 1% or 2% lidocaine with or without epinephrine 1:100,000 and 10 units hyaluronidase per 10 milliliters (mL) of local, is injected subcutaneously in the central upper lid using a 30-gauge (G) needle. Marcaine 0.75% may be added to the above in a 50:50 mixture for longer effect of anesthesia. A “bleb” containing approximately 2.0 cm3 of anesthetic is placed between the skin and orbicularis muscle in the central region of the upper lid. Injection trauma to the orbicularis muscle is avoided when possible to minimize pre-operative hematoma formation from the location injection. Digital massage is used to facilitate distribution medially and laterally throughout the upper eyelid. Hyaluronidase allows for a single injection site to be used due to increased diffusion of anesthetic throughout the tissues. This technique of administering local anesthetic avoids multiple punctures in the eyelid skin, thus reducing localized tissue trauma and the likelihood of ecchymosis or hematoma formation. The patient is then prepped and draped in the usual sterile fashion. If a carbon dioxide (CO2) laser is to be used, all laser-safe precautions are observed. The pre-operative markings may be faded or partially removed during skin prep. If so, the patient should be remarked at this time. Even if the markings do not need to be replaced, it is good practice to check the accuracy of the pre-operative measurements at this time using calipers or a ruler. The procedure is begun with the placement of corneoscleral eye protection (OculoPlasik, Montreal, Canada), first making certain that topical anesthetic eye drops were previously installed in the patient’s eyes. If a laser is to be used to make the incision, the ocular protection must be laser safe (plastic vs. metallic). The incision is made with either a #15 Bard-Parker blade or a CO2 laser. The laser base should be positioned so there is no tension on the handpiece as the surgeon holds it. It is difficult to execute the fine maneuvers required to perform blepharoplasty surgery when fighting against an ergonomically unfavorable device. The laser used for any incisional periorbital surgery should produce the smallest possible beam diameter, ideally no more than 0.2 mm. The laser may be operated in continuous wave or high frequency pulse mode. Regardless of instrument utilized, the temporal portion of the incision should extend only through skin so as to avoid dividing the terminal branch of the lacrimal artery, which passes between skin and orbicularis muscle at the level of the lateral orbital rim. Once the lateral orbital rim has been crossed, the incision is deepened to include orbicularis muscle. After the incision is complete, a toothed forceps, usually 0.5 mm or 0.3 mm Castroviejo forcep, is used to elevate the temporal end of the skin ellipse. The skin flap may be dissected with a laser,

radiofrequency device, monopolar cautery, or Wescott scissors. According to the surgeon’s preference, a skin only flap or a skin-muscle flap may be removed. The removal of orbicularis in upper blepharoplasty is based upon surgeon’s preference (67), but sulcus contour should be taken into consideration as in fat excision. For a skin only flap, traction is kept on the skin to help separate it from the underlying orbicularis muscle. Either dissection method should stay anterior to the orbital septum. If no fat removal is necessary, closure is performed at this point. If fat removal is desired, the procedure continues with opening of the orbital septum. Once the flap has been excised, the orbital septum will be visible. When fat removal is desired, or anterior ptosis repair to be done with the blepharoplasty, the septum is divided to expose the preaponeurotic fat pad (Fig. 24.12A). For the novice surgeon, it is recommended that the septum be initially incised in the region of the medial fat pad as the anterior–posterior separation of the septum and levator is greatest in this region. This reduces the risk of trauma to the levator aponeurosis. Once the proper tissue plane has been identified, the incision can then be extended laterally using Wescott scissors or laser. Next, the fat pad is grasped with a forceps and carefully elevated from the underlying levator aponeurosis to which it is loosely adherent. While superior anterior traction is placed on the septum and preaponeurotic fat, a cotton tip applicator can be used to aid in separating the fat from the underlying levator aponeurosis. If excessive fat is present, a small amount may be conservatively resected. This should be performed with caution, as over-resection of fat produces a “hollow” or “skeletonized” look in the eyelid/sulcus region. It should be noted that the injection of local anesthetic in the lid or fat pads directly will cause an “inflation” of the fat. Therefore, pre-operative marking of areas to be contoured is essential. The inferior cut margin of the orbital septum may be reflected inferiorly and transected just above its fusion with the levator aponeurosis to provide increased exposure. The nasal (medial) fat pad is explored and may be conservatively contoured. The nasal fat is identified by its white color in contrast to the yellow color of the central fat (Fig. 24.12B). Gentle pressure may be applied to the globe through the eyelid to help prolapse orbital fat into the surgical field. Forceps are then used to grasp the fat to be removed and to apply gentle anterior traction. This adipose tissue is quite vascular and, if not using a laser or cutting cautery tip for excision, it is recommended that the fat be clamped and cauterized before or after excision. This will reduce the chance of developing a post-operative hemorrhage. Although it is less frequently needed, the central fat pad is debulked in a similar fashion. Attention is then turned to the lateral brow where fullness and contour irregularity must be addressed. A pronounced appearance to the

PERIORBITAL REJUVENATION UTILIZING BLEPHAROPLASTY AND ADJUNCTIVE SURGICAL TECHNIQUES lateral brow may be caused by prominence of the underlying frontal bone or by relative enlargement or descent of the brow fat pad. This fat pad, usually referred to as the ROOF, tends to migrate inferiorly due to loss of support and natural attenuation (Fig. 24.2B). While many patients are reluctant to undergo reduction of the bony orbital rim, contouring of the ROOF complex may be readily performed with scissors, cautery, or laser to achieve an optimal aesthetic result. The ROOF fat is debulked by using any of the previously mentioned instruments to trim the fat just above the orbital rim and posterior to the orbicularis. As there are some relatively large vessels in this area, hemostasis is vital. A thin layer of fat is left intact on the surface of the superior orbital rim periosteum to preserve the brow glide plane. Hemostasis must be maintained in a meticulous fashion throughout the entire procedure to avoid orbital hemorrhage and the possibility of blindness. Hemostasis may be achieved with defocused laser, bipolar cautery, or monopolar cautery. If using monopolar cautery, a microdissection needle point (Colorado MicroDissection Needle, Stryker, Kalamazoo, Michigan, USA) is recommended to decrease the amount of adjacent thermal tissue injury Wound closure may be performed a multitude of ways. In cases where the lid crease is not to be reformed, interrupted or running 6-0 or 7-0 permanent monofilament suture, such as nylon or polypropylene, may be used. Some surgeons prefer 6-0 plain gut suture as removal is not necessary. A small cutting needle (P-1 or PC-1, Ethicon, Somerville, New Jersey, USA ) is sufficient, although some surgeons prefer a tapercut needle that may reduce trauma to the tissues. These needles may have the disadvantage of becoming dull more quickly than the cutting needles. In a simple closure, sutures should be passed from skin edge to skin edge without engaging the underlying orbicularis muscle as this can predispose to ecchymosis and hematoma formation or increased scar formation. Care should be taken to ensure the wound is properly aligned across its entire extent. Due to the curvilinear shape of the incision, the vectors of force vary across the width of the wound. If interrupted sutures are used, the wound should be aligned by initially placing cardinal sutures centrally, nasally, and temporally. Care should be taken to ensure wound edge eversion regardless of the method employed. In cases where the lid crease is to be changed from its original location, or if the surgeon desires a more distinct lid crease, or if the levator muscle is moved in the course of the surgery, additional steps to create a lid crease may be taken at the time of closure. If a lid crease is to be created, an interrupted 6-0 undyed polyglactin suture (Vicryl, Ethicon, Sommersville, New Jersey, USA) is placed through subcutaneous tissue on the inferior margin of the wound. The needle pass should then engage the levator aponeurosis at the desired location of the crease and then be passed through orbicularis muscle on the superior margin of the wound. Three such sutures are placed; one in the nasal portion of the lid, one in the central portion, and one in the temporal portion. One might also choose to place the Vicryl crease formation sutures through skin and orbicularis instead of placing them subcutaneously. The wound between these sutures is closed skin edge to skin edge with permanent or absorbable suture material depending on surgeon preference. Alternatively, the surgeon may chose to incorporate the levator aponeurosis into the sutures that close the skin at predetermined areas of the incision. This suture would pass through skin and orbicularis, then take a superficial bite of the levator aponeurosis along the superior border of the tarsus, and then a full thickness bite through the skin and orbicularis of the opposite side of the wound. These lid crease reformation sutures can be placed with either a running or interrupted closure using the skin suture. Typically the suture pass that catches the deeper tissue is spaced out at three to four locations in the closure. At the conclusion of the procedure, an ophthalmic antibiotic ointment or antibiotic-steroid ointment is placed on the eyelid incisions and may also be placed in the patient’s eyes for comfort. Sponges soaked in iced saline, a bag of frozen

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peas, or crushed ice is then applied over the surgical area in an attempt to reduce post-operative edema and ecchymosis. Lower Blepharoplasty Transconjunctival Approach Topical ophthalmic anesthetic is administered to the eyes and corneaoscleral shields are inserted to protect the globes. Two milliliters of local anesthetic, as previously described, is injected transconjunctivally into the central lower eyelid. A small bleb of local is also placed centrally just below the lashes if a traction suture is to be employed. When release of the arcus marginalis and fat transposition or a cheek implant are planned parts of the procedure, an infraorbital nerve block is added to the local placement. Additional transcutaneous lateral canthal local anesthesia may be placed if lateral lid repositioning is performed. As with any surgical procedure, there are a multitude of variations in techniques for lower blepharoplasty. In patients with no significant horizontal lid laxity, and modest or no redundant lower eyelid skin, a transconjunctival approach with an intact lateral canthal angle is used. A 4-0 silk traction suture is placed in the lower lid, and the skin and orbicularis are reflected anteriorly over a cotton swab. A transconjunctival incision is made through the conjunctiva and lower eyelid retractors at a level 2 to 3 mm below the inferior border of the tarsus (Fig. 24.13A). The lower lid retractors may fuse with the orbital septum as far as 2 mm below the inferior tarsal border. The orbital fat does not extend superiorly beyond this point; thus the incision should be made at or below this point. A battery-operated disposable hot cautery, monopolar cautery with a microdissection needle point, or CO2 laser may be used to achieve hemostatic cutting. Once the conjunctiva and lower eyelid retractors have been transected and elevated superiorly and posteriorly toward the globe, the anterior orbital fat becomes visible beneath the orbital septum (Fig. 24.13B). Some surgeons prefer to transect the lower eyelid retractors above the orbital septum, leaving the septum intact during the dissection between the postorbicularis fascia and the septum. This keeps the dissection plane easier to identify, and is particularly valuable when the surgeon plans to do more than fat removal. Keeping the fat behind the septum until the extent of the dissection is reached makes it easier to see into the transconjunctival pocket. Others will prefer to enter directly into the fat pads from the transconjunctival incision allowing faster access to the orbital fat. If the procedure will conclude with fat removal only, this is a faster technique. To assist in exposure, a traction suture of 6-0 Vicryl is placed through the conjunctiva and lower eyelid retractors and clamped superiorly to the drape. A lacrimal rake is inserted for anterior eyelid margin retraction. The assistant simultaneously pulls anteriorly on the lid margin and uses a second hand to place downward traction on the lower eyelid skin (Fig. 24.14). This opens up the plane to dissect on top of the septum down to the orbital rim. The surgical dissection plane remains anterior to the orbital septum until the inferior rim is reached. Once the skin and orbicularis have been safely elevated, the assistant replaces the rake with a Desmarres retractor and places downward tension on the lid instead of anterior traction. This maneuver prolapses the orbital fat anteriorly. Additional local anesthetic is injected into the orbital fat for patient comfort and hemostasis if needed. The septum is opened to expose the fat. The septum is opened inferiorly along the infraorbital rim to expose the fat. If not done so at the time of the initial incision, the incision is extended laterally to the lateral canthal angle and medially to a point just lateral to the plica semilunaris (semilunar fold). Protrusion of fat without tear trough hollowing may be addressed with fat excision or sculpting only, but for the more typical patient, the presence fat protrusion with infraorbital hollowing is addressed with a combination of fat sculpting and transposition. The fat is removed or sculpted using one of the previously mentioned hemostatic cutting

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Figure 24.13 (A) The monopolar cautery has been used to mark the location of the transconjunctival incision to be completed with Wescott scissors. (B) The illustration depicts the surgical anatomy of the lower eyelid after the conjunctiva and lower eyelid retractors have been transected. Source : From Ref. 73.

Figure 24.14 Dissection via a transconjunctival incision with septum button-hole. The Desmarres retractor and conjunctival traction suture provides exposure of the orbital septum. A window or button-hole has been made in the orbital septum exposing the underlying fat. During this stage of the dissection downward traction of the lower eyelid skin by the assistant allows the surgeon to remain in the proper dissection plane and avoid violating the skin.

devices for increased hemostasis (Fig. 24.15). Wescott scissors can also be used, provided the fat is clamped with a hemostat and the base cauterized before or after excision of the clamped fat. The amount of anticipated fat removal is determined in the pre-operative evaluation, with the goal being to eliminate fatty tissue prominence while avoiding a “hollow” appearance. Fat removal may also be problematic because of excessive bleeding. The presence of prominent vessels associated with the medial fat compartment should be anticipated. Fat excision should proceed in a systematic fashion and only fat herniating anterior to the level of the orbital rim is removed. Care must be taken to avoid injury to the inferior oblique muscle when working in the medial and central portions of the lower eyelid. The inferior oblique muscle divides the central and nasal fat compartments and should be recognized by its horizontal orientation in the anterior– inferior orbit. The lateral fat pad is usually divided into two compartments, one adjacent to the central fat pad and another located more laterally and posteriorly. To adequately expose these lateral fat

Figure 24.15 Fat is sculpted using a monopolar microdissection cautery tip.

lobules, the arcuate expanse of the inferior oblique muscle may be divided. Injury to this muscle or its sheath may result in diplopia. During intraoperative assessment, lid contour is assessed by releasing all traction sutures and returning the lid to normal position. Visual as well as palpatory inspection is performed. Raising the head of the bed so the torso of the patient is in an upright position may also aid in evaluating intraoperative results. When the contour is deemed satisfactory, the conjunctiva is closed using two buried, interrupted 6-0 Vicryl sutures— one located nasal to the limbus and one temporal to the limbus to prevent corneal irritation. Alternatively, the conjunctiva may be left open after the lid is returned to its natural position. Transconjunctival Fat Transposition The surgeon makes a pre-operative decision regarding fat removal and repositioning based on the contour of the eyelid. Areas of fullness are debulked and concave areas are filled. This is accomplished with a combination of fat sculpting and transposition. Most commonly, the

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Figure 24.16 (A) The sculpted fat pedicle is imbricated with 6-0 polypropylene suture. (B) The pedicalized, imbricated fat is secured into place by tying the externalized suture over a silicone bolster.

areas of the infraorbital hollowing (tear trough) that will benefit from fat transposition are located medially and centrally. Typically one first removes any excess fat. Once the desired amount of fat is removed, the remaining fat is pedicalized and the orbicularis and arcus marginalis along the orbital rim are released. A periosteal elevator such as the Freer elevator is used to create a plane along the infraorbital rim either below the periosteum, or in the plane of the SOOF. The arcus marginalis, the confluence of the septum and periosteum, is released along the entire inferior orbital rim. This also releases the preseptal orbicularis. The surgeon decides whether to continue in this dissection plane or in a sub-periosteal plane to create a pocket for the fat. Individual preference varies as to which approach encourages better fat retention and contour. The pedicle of fat is then imbricated with a 6-0 double-armed, nonabsorbable polypropylene (Prolene, Ethicon, Somerville, New Jersey, USA) suture (Fig. 24.16A). A free needle can be used in place of the supplied Prolene needle after the fat pedicle is imbricated. The permanent suture is used because with a transconjunctival incision, it is usually not possible to rotate the suture back out through the wound; thus both arms are passed underneath the pocket and through the cheek tissue and out through the skin. The Prolene suture exits the orbicularis and skin slightly below the tear trough that one is trying to fill. One of the benefits of the technique may be a subtle elevation of the lid/cheek transition because of the arcus marginalis release and the upward traction on the orbicularis. During the fat repositioning, the lid position and contour are assessed by replacing the soft tissues and inspecting each. Once satisfactory, the suture is tied over a bolster to protect the skin. The bolster and suture are removed in 4 to 5 days (Fig. 24.16B). The conjunctiva is then closed using two buried, interrupted 6-0 plain gut or Vicryl sutures. Subciliary Approach A standard subciliary incision placed 1.5 mm below the cilia can be initiated with a #15 Bard-Parker blade. The incision is extended medially to within 2 mm of the lacrimal punctum using the #15 blade or Wescott scissors. Lateral to the lateral canthal angle, the incision is directed inferotemporally along a natural skin crease. This lateral portion of the lower lid incision is extended if more skin needs to be removed, but initially, the length needs only to facilitate skin and muscle dissection inferiorly. Once the incision is made, a 6-0 polypropylene or silk suture placed at partial thickness through the tarsus centrally at

the incision line (avoiding skin puncture) is useful for providing counter-traction. Generally, a combined skin and muscle flap method is used. However, it may be advantageous to elevate skin exclusively in the pretarsal orbicularis area, since keeping the muscle layer undisturbed may decrease post-operative changes in orbicularis function. Once the orbicularis muscle has been exposed, blunt-tipped scissors are used to button-hole the preseptal muscle. The muscle is then incised across the full extent of the wound. Dissection is directed inferiorly in the suborbicularis oculi plane until the inferior orbital rim is exposed. Meticulous hemostasis is maintained during this dissection. The entire width of the septum can be incised just above the arcus marginalis, providing exposure of the medial, central, and lateral fat compartments. Alternatively, three small button-hole openings can be made in the septum to allow access to each fat compartment individually. Gentle pressure applied to the globe through the eyelids will accentuate fat herniation. When the first lateral fat pad is excised, gentle retropulsion of the globe can expose a second fat pad posterior to the first. Often this posterior pad needs to be sculpted to avoid residual lower lid fullness temporally. Sculpting should continue with the central and then nasal fat pads. Fat protruding anterior to the rim may safely be removed using the techniques described earlier. Placing the patient in an upright position during surgery allows for better evaluation of the adequacy of liposculpting. When the underlying procedure and any adjunctive procedures are complete, the surgeon turns to wound closure. A careful judgment on the removal of skin must be made. Although every surgeon strives for the perfect result, very few have created post-operative complications by removing too little lower eyelid skin. The same is not true for excess tissue excision. Lower lid skin and orbicularis may be judiciously trimmed by pre-operatively assessing the overlap of tissue to get a gestalt of the excess, and then intra-operatively putting the tissue into maximal tension position with the mouth open and the patient in upgaze. Overlapping tissue with these maneuvers may be thoughtfully removed. The subciliary portion of the wound should not be under tension and can be closed using 7-0 or 6-0 chromic gut, plain gut, silk, or nylon sutures in a running or interrupted fashion. The lateral wound extent is always closed in an interrupted fashion to provide maximal alignment of the closure and distribute wound tension. Non-absorbable sutures are removed in 5 to 7 days. For laser-assisted incisions, the

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Figure 24.17 The lateral canthal tendon is imbricated with polypropylene suture in a mattress fashion and secured to the periosteum of the inner aspect of the lateral orbital rim. In this instance the polypropylene needle has been replaced with a free needle.

sutures should remain for 7 to 10 days. If necessary, additional excess skin may be removed after the surgery using the skin pinch techniques discussed later in this chapter. Subciliary Fat Transposition Access is gained to the orbital septum as detailed above. The inferomedial orbital rim is palpated and the septum is incised at the arcus marginalis, near the origin of the levator labii superioris alaeque nasi muscle. A periosteal elevator is used to create a pre-periosteal or subperiosteal pocket 10 mm inferior to the infraorbital rim incision and spanning the length of the trough to be filled. Care is taken during the dissection to work above or around the infraorbital foramen located 7 to 10 mm below the infraorbital rim. The medial fat capsule is incised to liberate the fat lobules and allow the fat to be advanced anteriorly without creating traction. The fat is fashioned into a mallet-shaped flap with a 5 to 7 mm diameter pedicle and positioned into the pre-periosteal or sub-periosteal pocket. If release is properly performed, there should be no tendency for the fat to recoil posteriorly and extraocular motility should not be restricted. The fat can be secured using a 6-0 polygalactin or nylon horizontal mattress suture that loosely engages the anterior edge of periosteum and part of the fat pedicle. Alternatively, the fat pedicles may be positioned with a resorbable 6-0 Vicryl P-1 suture placed directly into the SOOF or periosteum. The buried suture obviates the need for suture removal, but sometimes causes nodularity/inflammation in the tear trough fat. During the procedure, the amount and position of the fat is assessed by returning the lid to normal anatomical position and assessing the eyelid contour. Canthoplasty When the pre-operative lower eyelid exhibits enough horizontal laxity to require intervention, better access and visibility is a serendipitous side effect of the lateral canthoplasty when used in conjunction with the transconjunctival or subcilliary incision. Primary canthoplasty in association with transcutaneous blepharoplasty may reduce the risk of lower lid malposition (68). Release of the canthus will require a more significant lateral repair with resuspension of the lateral canthal tendon. A 5 to 7 mm horizontal incision is made at the junction of the upper and lower eyelid margins. This is deepened to full thickness using a straight iris scissor with the tips of the blades placed laterally on either

side of the lateral canthal angle. The scissor is then turned vertically to release the lower half of the lateral canthal tendon. The cut lower eyelid margin is pulled laterally to assess the amount of shortening desired to improve lower lid position. This may require excising lid tissue, or simply attaching the lower lid at a slightly higher location on the lateral orbital rim periosteum. A suture, such as 6-0 Prolene, is used to imbricate the lower lid margin including tarsus. The suture is then passed in a mattress fashion through the internal aspect of the lateral orbital rim periosteum at the position to achieve the desired lid position (Fig. 24.17). A free needle may be used if the supplied needle on the Prolene is not robust enough. Prior to tying down the Prolene suture, the gray line is re-approximated with a suture such as 6-0 Vicryl on a P-1 needle. This is passed in a buried fashion from the gray line of the upper lid to the gray line of the lower eyelid to bring the lid margins back into alignment. The gray line suture is tied down first, and then the lateral canthal tendon suture. If additional lateral lid support sutures of 4-0 and 6-0 Vicryl are used, they are tied last. Following this, the horizontal incision is closed in a layered fashion. Orbicularis is closed with 6-0 Vicryl and the skin with gut, polypropylene, nylon, or the surgeon’s skin suture of choice. When laxity of the skin is also present, the lateral repair includes the opportunity to resuspend and tighten the lower preseptal and pretarsal orbicularis. For orbicularis tightening, 4-0 or 6-0 polygalactin typically is used to pull the lateral orbicularis and SOOF in a superior vector to insert into the upper lateral canthal tendon and the deep temporalis fascia. Orbicularis Plication When mild laxity in the skin is present, orbicularis tightening can be performed without canthoplasty or cantholysis. An incision is made lateral to the lateral canthal tendon through the skin and orbicularis. The edge of the orbicularis is identified and a 6-0 Vicryl suture is passed in a buried fashion. Skin and orbicularis are separated to create a tongue of orbicularis. The suture is then used to insert the lateral orbicularis into the lateral canthal tendon and deep temporalis fascia. Creating a lateral orbicularis sling will sometimes result in lateral overlapping of the skin. The surgeon may separate the orbicularis and skin laterally and remove the excess skin. The skin is re-approximated with interrupted 6-0 plain gut sutures. Orbicularis Excision When orbicularis muscle hypertrophy is present, a skin flap can be dissected to expose the muscular bulge. The superior edge of prominent orbicularis mounding often begins 3 to –5 mm below the lash line and is accentuated with smiling. The muscle is reduced by partially and superficially excising muscle tissue layers along the orientation of the fibers, decreasing the anterior to posterior prominence. Bleeding is anticipated but easily controlled in this region with the surgeon’s cautery device of choice. An alternative method uses electrosurgical modification and ablation of the orbicularis muscle to reduce the muscle prominence (69). The skin flap is closed with interrupted 6-0 plain gut sutures. Skin Excision Excess skin, up to 2 mm vertically, may be removed as a small subciliary pinch incision at the end of the blepharoplasty procedure. Alternatively, chemical peeling or laser resurfacing may be used to tighten lower eyelid skin currently with blepharoplasty. If skin excision is desired after a transconjunctival procedure, subciliary incisions are made just below the pretarsal orbicularis using a #15 Bard-Parker blade. The skin is then resected with Wescott scissors. Conservative removal of skin is advocated. The skin incision is closed with interrupted 6-0 plain gut sutures. When a skin-muscle flap is used for lower blepharoplasty, there may be more skin excess or laxity that requires addressing. Intra-operatively

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Figure 24.18 A temporary Frost tarsorraphy places upward traction on the lower eyelid tissues reducing the incidence of post-operative lower eyelid retraction. Source : All photographs courtesy of Jill Foster, MD, and Craig Czyz, DO, unless otherwise indicated.

the skin-muscle flap is draped without traction over the subciliary incision. Skin tightening is accomplished primarily in the horizontal vector. The edge of the skin-muscle flap is draped laterally along the curvature of the lower lid with a gentle amount of traction and the overlap is excised to reduce skin redundancy. The extra “dog ear” of tissue is eliminated by a combination of extending the original laugh line incision (usually not more than 15 mm) and excising a triangle of the skin-muscle flap with the apex at the inferior extent of the lateral incision. In cases where a pinch or skin excision is performed, support of the lower eyelid may be improved with lateral canthoplasty, canthopexy, and/or orbicularis plication. Certain closure techniques may be helpful in supporting the lower lid. Placing steri-strip bolsters across the lower lid at completion of the case will provide mild external support. In cases where the surgeon is concerned about post-operative lower lid retraction, Frost temporary tarsorrhaphy sutures may be considered. In this technique, sutures are passed through the lower eyelid near the margin and then taped to the forehead for support for 1 to 7 days following surgery (Fig. 24.18). POST-OPERATIVE CONSIDERATIONS

Patient Instructions Written post-operative instructions should include information on medication dosage and administration, activity restrictions, wound care, expected wound appearance, and signs or symptoms that warrant medical attention. It is difficult to list all possible restrictions or contraindications; therefore, an explanation of why certain limitations are recommended allows the patient to employ his/her good judgment. It is important to clearly indicate whom to contact in the event of an ocular emergency, such as vision loss. It must also be stressed that the patient seeks medical advice should there be any questions whatsoever. Patients should be contacted by telephone on the evening of surgery and the following day. If a patient reports persistent bleeding, edema, significant pain, decreased vision, fever, erythema, or discharge from the wound, prompt examination is required. Patients are instructed to use ice compresses intermittently as often as possible for the first 48 hours, and can continue them until the initial follow-up exam. Frozen peas are a good substitute to the traditional ice pack as they conform to the architecture of the periorbital area well. It is important to instruct the patients to remove the ice every 15 minutes for a minimum of 5 minutes to avoid thermal damage to the tissues. Similarly, direct application of any frozen item is contraindicated.

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The ice pack or bag of frozen peas should be placed in a towel or gauze. Ophthalmic antibiotic or antibiotic-steroid ointment should be applied to the sutures three to four times per day. Ointment is continued until suture removal or dissolution. The patient may also apply the ointment to the eye, especially if they are experiencing lagophthalmos or generalized ocular irritation. Oral antibiotics can be prescribed, but are not universally considered standard of care. Elevation of the head 30° to 45° during the day, and at night (extra pillows), is recommended. If the patient sleeps on their side, they may experience additional edema and/or ecchymosis on the dependent side. Patients are to avoid bending, heavy lifting, strenuous exercise, or other activities that may entail a valsalva maneuver for at least one week. Airplane travel should be discouraged within the first week to avoid potential exposure to decreased atmospheric pressure, which may enable bleeding to occur more readily. Satisfactory post-operative analgesia may usually be achieved with acetaminophen, although some patients may require narcotics. If there is substantial manipulation of the tissues, especially the orbital fat, narcotics are recommended for initial analgesia. Non-steroidal antiinflammatory agents, including ketolorac (Toradol, Roche Pharmaceuticals, Nutley, New Jersey, USA), should be avoided for three to four days to reduce the risk of orbital hemorrhage. Patients on systemic anticoagulation therapy should be restarted on their regimens as dictated by their cardiologists or primary care physicians. It is important to inform these patients that they are at an increased risk for post-operative hemorrhage due to their systemic anticoagulation requirements. Patients with uncomplicated post-operative recovery are generally seen one week after surgery. Permanent sutures should be removed five to ten days after surgery. Any remaining absorbable sutures can also be removed at this time. Contact lens wear may be resumed one to two weeks after surgery. Patients who wear contact lenses should be advised of this preoperatively, as some may not have eyeglasses. Makeup may be applied to the upper eyelids one to two days after the sutures have been removed or dissolve. Concealer may be applied to the lower eyelids to cover ecchymosis two to three days after surgery. Patients are told to expect the majority of the edema to resolve over two weeks, while the remainder may take months to completely resolve. This timeline is also valid for ecchymosis, which maybe accelerated with pulsed-dye laser treatment (70). Consumption of salty foods or a systemic state of fluid retention may slow resolution of edema in the eyelids. Darkening of the skin in the early post-operative period may represent deposition of hemosiderin and usually resolves spontaneously. Persistent pigmentation may occur as a result of sun exposure while lids are ecchymotic (71). Prolonged sun exposure is discouraged until wound healing is complete. Moderate exercise may be resumed after one week, and any vigorous activities resumed after two weeks. POTENTIAL COMPLICATIONS OF BLEPHAROPLASTY

Recognizing the potential complications associated with blepharoplasty will allow the surgeon to effectively reduce the risk of adverse sequelae. A comprehensive discussion of potential complications can be found in review articles (26,72) or texts (73). This section will provide an overview of the common and more severe complications. The previous sections detail how to reduce the potential of encountering these events. Vision Loss Surgeons should be aware of the catastrophic potential for vision loss following blepharoplasty surgery. The exact frequency of occurrence is not known, but it is estimated to be 0.04% of all blepharoplasties (74). Approximately 75 cases of post-blepharoplasty blindness, mostly associated with lower lid surgeries, have been reported in English language

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journals (72). The most common cause of visual loss in this setting is optic nerve compression from orbital hemorrhage. Mechanisms of visual injury other than hemorrhage include excessive vasospasm from epinephrine in the local anesthetic (75), globe injury while injecting local anesthetic (27), and globe injury from laser-assisted surgery (76). The compressive effects of an orbital hemorrhage, also referred to as retrobulbar hemorrhage, cause an increase in intraorbital and intraocular pressure resulting in a compromised vascular supply to the intraocular tissues and the optic nerve. The most likely source of hemorrhage is historically reported to be from excessive manipulation of anterior orbital fat with subsequent posterior transmission of force causing injury of the posterior orbital vessels (77). However, any lack of homeostasis posterior to the orbital septum is capable of causing a compressive hemorrhage. Systemic risk factors for post-operative hemorrhage include systemic anticoagulants, aspirin, certain supplements, hypertension, atherosclerosis, and bleeding dyscrasias. Post-operative hematomas, orbital or otherwise, usually develop within 24 hours of surgery (78). For this reason, activity restrictions as detailed in the previous section should be emphasized for the immediate post-operative period. Patients should be well informed of symptoms that allude to orbital hemorrhage such as significant pain, asymmetric edema, proptosis, diplopia, and visual acuity changes. Vision loss from hemorrhage is an ophthalmic emergency and emergent orbital decompression with lateral canthotomy and cantholysis should be performed immediately (79,80). An urgent ophthalmic consultation should then be obtained. Lagophthalmos Incomplete eyelid closure can be a temporary or permanent sequela of blepharoplasty. When related to post-operative edema or decline in orbicularis muscle tone secondary to local anesthetic or manipulation, the condition should improve spontaneously within the first one to two weeks after surgery. The mechanism involved in persistent lagophthalmos may be vertical shortening from excess skin removal, inadvertent incarceration of the orbital septum into the wound, persistent orbicularis paresis or septal adhesions. The resulting corneal exposure can give rise to a range of conditions from dryness that is symptomatic but managed with lubricants, to frank ocular surface compromise with potential infection and scarring. Symptoms may include foreign body sensation, blurred vision, tearing, and red eye. These may produce the clinical findings of conjunctival injection, lid swelling, corneal staining with fluorescein (superficial punctate keratopathy), or corneal ulceration. Topical artificial tear supplements in drop, gel, or ointment form may be necessary to protect the cornea. The patient may also use the post-operative ophthalmic ointment for lubrication and prophylaxis. Massage or forced orbicularis closure may reduce mild post-operative lagophthalmos. Severe conditions may require surgical intervention, such as skin grafting or midface lifting. Ptosis Temporary mechanical ptosis may result from post-operative edema. Persistent ptosis as a direct result of surgery is uncommon and may involve injury to the levator tendon (81), anesthetic toxicity of the levator (82), or internal scarring that restricts lid mobility. If significant ptosis develops immediately after upper blepharoplasty, the wound should be explored and the levator muscle and its aponeurosis should be carefully inspected for disinsertion or transection. Diplopia Double vision may be a transient or persistent complication resulting from interference with extraocular muscle function. The occurrence of diplopia following blepharoplasty was estimated to be 0.003% in one study (83) and can be temporary or permanent. Permanent diplopia can occur from upper or lower lid blepharoplasty (84). The extraocular

muscles or their direct nervous and/or vascular supply are disrupted. Vascular supply and innervation to the muscles is quite posterior relative to the dissection plane of the blepharoplasty techniques discussed in this chapter. Transient diplopia may be caused by edema or local anesthetic effects on the extraocular muscles (85,86). Improvement is often spontaneous and should be monitored by an ophthalmologist. In lower blepharoplasty the inferior oblique is the most commonly injured muscle resulting in persistent diplopia (83,87). The portion of the inferior oblique that divides the nasal and central fat compartments is relatively anterior in the orbit. The muscle may be identified prior to modification or removal of fat to ensure safe dissection (88). While not as anterior as the inferior oblique, the inferior rectus muscle can also be injured if dissection is carried posterior to the orbital rim (89). Injury to the superior oblique muscle, its tendon or trochlea, may occur in upper blepharoplasty as a result of overly aggressive nasal fat pad modification (87,90,91). Lacrimal Gland Prolapse and Injury If a prolapsed lacrimal gland is not repositioned during upper lid blepharoplasty, residual lateral lid fullness will likely produce an unsatisfactory result. While a few surgeons routinely resect the prolapsed portion of the lacrimal gland, this practice should be avoided at all costs as it increases the risk of producing a pathologically dry eye (92). Overly aggressive dissection and excision of preaponeurotic fat surrounding the lacrimal gland can result in injury. Identification of tissues prior to aggressive dissection and resection will greatly reduce the incidence of lacrimal gland injury. Dry Eye Dry eye is predominantly a symptom of the complications of lagophthalmos or lacrimal gland injury. However, individuals with preexisting dry eye can have exacerbations of their condition resulting in sequelae of increased severity. Patients who have undergone laser vision correction are at an increased risk for developing dry eye following blepharoplasy (93). In this population of patients extreme care should be taken to avoid lagophthalmos and lower eyelid retraction. Generally, blepharoplasty should not be attempted sooner than six months following laser vision correction (93). Incision Irregularities Eyelid crease asymmetries, due to improper incision design, are unsatisfactory results of blepharoplasty that can be avoided with precise preoperative planning. Webbing in the medial canthal region results from excessive medial skin excision or incision extension inferomedially, causing vertical cicatrix. In the lateral canthal region, webbing is the result of inadequate separation between the upper and lower blepharoplasty incisions or improper closure of a canthoplasty incision. If the conditions do not improve spontaneously or with conservative measures, then surgical intervention is indicated. Various plasties or flaps can be performed based upon the defect. Incision line suture tracts or hypertrophic scarring may be avoided by meticulous skin closure using monofilament sutures and by removing sutures five to seven days after surgery. Tissue adhesives, such as autologous fibrin glue (94) or N-butyl-2-cyanoacrylate (95), may also reduce development of incision irregularities by eliminating the need for sutures or decreasing the duration of suture placement (96). While this concept is appealing, tissue glue is not practical in most cases of cosmetic blepharoplasty due to discomfort, wound dehiscence, and possible failure to evert the wound edges. Keloid formation is also a possible complication; especially in African-American and Hispanic patients (97). If anticipated, keloid formation often can be prevented with immediate silicone elastomer sheeting, reduction of skin tension via taping, or corticosteroid

PERIORBITAL REJUVENATION UTILIZING BLEPHAROPLASTY AND ADJUNCTIVE SURGICAL TECHNIQUES injections (64). Hypertrophic scarring and keloid formation, when not prevented, are treated with local corticosteroid injections, silicone sheeting, pressure dressings, cryotherapy, but may eventually require surgical revision for improved cosmesis (98). Laser therapy may also be of value as a primary or adjunctive treatment modality (99,100). Suture milia are cystic elevations at the sites skin penetration that emerge approximately one week post-operatively and often remit spontaneously over a period of months (101). Milia can occur with most sutures, including silk, mild chromic gut, and polypropylene. Subcuticular closure or early suture removal may reduce the occurrence of milia. A thorough patient history of any previous surgical healing issues is helpful in avoiding these complications. Undercorrection While by definition undercorrection is not a true complication of blepharoplasty surgery, it can be disappointing to the patient. Undercorrection globally refers to inadequate skin, muscle, or fat removal. These findings cause no adverse sequelae, and may be improved with carefully planned “touch-up” surgery. It is common for the judicious novice upper blepharoplasty surgeon to under-resect skin. The decision to resect additional upper eyelid skin should not be made until all post-operative edema has resolved, as persistent edema can mimic dermatochalasis. However, if blatant undercorrection is observed, excess skin may be removed at the initial post-operative visit. If there is apparent undercorrection of steatoblepharon, it is advisable to wait at least three months for complete resolution of tissue edema before proceeding with revisions if known surgical deficiency, such as missing a fat pad, occurred. In general full resolution of post-operative edema may take up to a full year to resolve depending on the invasiveness of the procedure(s). Lower Lid Malposition Malposition of the lower eyelid is one of the most common postblepharoplasty complications (72,102). Clinical findings range from downward eyelid bowing with inferior scleral show, to frank ectropion. Ectropion after blepharoplasty surgery can occur with a transcutaneous or subcilliary approach; however, it has been reported that the likelihood is five times greater following a transcutaneous approach (103). The likelihood of encountering this complication is increased when skin has been removed even with concurrent canthal anchoring (104). The over-resection of skin creates a downward vector that overrides the ability of the horizontal force vectors generated at the canthi to maintain an appropriate eyelid position (105). This complication can largely be avoided by only resecting redundant eyelid skin as marked when the patient gazes upward while their mouth is open. This places the lower eyelid skin on maximal tension in the vertical vector assuring that sufficient skin remains for proper lid positioning. Correction usually involves skin grafting to provide vertical lid height, but midface lift (106) and dermis fat grafting (107) maybe have a role in repair. Other etiologies of post-operative lower lid malposition include incarceration of the orbital septum within the wound, excessive cauterization of the septum or eyelid, hypertrophic scarring, and injury to the facial nerve. Temporary lower lid displacement may result from edema, hematoma, or reduced orbicularis muscle tone (105,108). Conservative measures such as lid massage, orbicularis contraction exercises (109), and artificial tear supplements and lubricants can be instituted. If there is persistent corneal exposure an ophthalmologist should evaluate and monitor the patient. Horizontal lower eyelid laxity not identified during the pre-operative evaluation may lead to post-operative ectropion. If horizontal laxity is present, the lid can usually be repaired by a simple tightening procedure performed at the lateral canthus (110). Identifying the need for horizontal lid tightening and performing corrective procedures before

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or at the time of blepharoplasty reduces the risk of these secondary complications. Canthal Angle Distortion While canthoplasty can be used to correct involutional or surgical lower lid laxity and malposition, the surgeon must be familiar with the limitations and indications of the procedure (111). Improperly performed canthoplasty can result in lower lid malposition or distortion of the canthal angle. Engaging the tarsal/canthal tendon in an improper vector can cause the lid to invert or evert. Re-anchoring the lateral canthal tendon too anterior or posterior on the lateral orbital rim will also result in lid malposition. Improper canthoplasty closure can result in distortion of the canthal angle in addition to exacerbating any lid malposition. These complications all require surgical correction. Sulcus and Nasojugal Deformities Aggressive removal of orbital fat in the upper lid may lead to a sunken or “skeletonized” superior sulcus. This is particularly undesirable in males as it imparts more feminine look. When fat is unevenly sculpted, the sulcus may have an irregular contour. Excessive excision of fat from the lower lids may result in undesirable lower lid concavity and can exaggerate visible contour of the orbital rim and nasojugal (tear trough) deformities. Free fat grafts have been used to correct the volume deficit, but a variable degree of fat absorption is common (112). Recently, dermis fat grafting to the sulcus has been reported (44). Hyaluronic acid fillers can be used as a temporary primary or secondary corrective measure for nasojugal area. Infection Infection after blepharoplasty is extremely rare, occurring at a rate of approximately 0.04% (113). Preseptal cellulitis can be managed with oral antibiotics and clinical monitoring. Should the patient exhibit signs of orbital cellulitis, such as pain, proptosis, decreased ocular motility and vision, immediate ophthalmic consultation should be obtained. The patient should be started on broad-spectrum intravenous antibiotics and a CT scan may be of diagnostic value. REFERENCES

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78. Neuhaus RW. Complications of blepharoplasty. Am Acad Ophthalmol Focal Points 1990; 8(3): 1–12. 79. Yung CW, Moorthy RS, Lindley D, et al. Efficacy of lateral canthotomy and cantholysis in orbital hemorrhage. Ophthal Plast Reconstr Surg 1994; 10(2): 137–41. 80. Zoumalan CI, Bullock JD, Warwar RE, et al. Evaluation of intraocular and orbital pressure in the management of orbital hemorrhage: an experimental model. Arch Ophthalmol 2008; 126(9): 1257–60. 81. Baylis HI, Sutcliffe T, Fett DR. Levator injury during blepharoplasty. Arch Ophthalmol 1984; 102: 570–1. 82. Rainin EA, Carlson BM. Post-operative diplopia and ptosis: a clinical hypothesis base on the myotoxicity of local anesthetics. Arch Ophthalmol 1985; 103: 1337–9. 83. Hayworth RS, Lisman RD, Muchnick RS, Smith B. Diplopia following blepharoplasty. Ann Ophthalmol 1984; 16: 448–51. 84. Syniuta LA, Goldberg RA, Thacker NM, Rosenbaum AL. Acquired strabismus following cosmetic blepharoplasty. Plast Reconstr Surg 2003; 111(6): 2053–9. 85. Rainin EA, Carlson BM. Post-operative diplopia and ptosis: a clinical hypothesis base on the myotoxicity of local anesthetics. Arch Ophthalmol 1985; 103: 1337–9. 86. Perlman JP, Conn H. Transient internal ophthalmoplegia during blepharoplasty: a report of three cases. Ophthalmic Plast Reconstr Surg 1991; 7: 141–3. 87. Harley RD, Nelson LB, Flanagan JC, Calhoun JH. Ocular motility disturbances following cosmetic blepharoplasty. Arch Ophthalmol 1986; 104: 542–44. 88. Jordan DR, Anderson RL, Thiese SM. Avoiding inferior oblique injury during lower blepharoplasty. Arch Ophthalmol 1989; 107: 1382–3. 89. Alfonso E, Levada AJ, Flynn JT. Inferior rectus paresis after secondary blepharoplasty. Br J Ophthalmol 1984; 68: 535–7. 90. Levine MR, Boynton J, Tenzel RR, Miller GR. Complications of blepharoplasty. Ophthalmic Surg 1975; 6: 53–7. 91. Wesley RE, Pollard ZF, McCord CD Jr. Superior oblique paresis after blepharoplasty. Plast Reconstr Surg 1980; 66: 283–6. 92. Lemke BN, Lucarelli MJ. Anatomy of the ocular adnexa, orbit, and related facial structures. In: Nesi FA, Lisman RD, Levine MR, eds. Smith’s Ophthalmic Plastic and Reconstructive Surgery, 2nd edn. St. Louis: Mosby, 1997: 1–75. 93. Lee WB, McCord CD Jr., Somia N, Hirmand H. Optimizing blepharoplasty outcomes in patients with previous laser vision correction. Plast Reconstr Surg 2008; 122(2): 587–94. 94. Mandel MA. Closure of blepharoplasty incisions with autologous fibrin glue. Arch Opthalmol 1990; 108: 842–4. 95. Kosko PI. Upper lid blepharoplasty: skin closure achieved with butyl-2-cyanoacrylate. Ophthalmic Surg 1981; 12: 424–5. 96. Perin LF, Helene A Jr., Fraga MF. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl-2-cyanoacrylate. Aesthet Surg J 2009; 29(2): 87–92. 97. Alhady SM, Sivanantharajah K. Keloids in various races. A review of 175 cases. Plast Reconstr Surg 1969; 44(6): 564–6. 98. Newsome RE, et al. Wound healing, keloids. Emedicine. June26, 2009. July 30, 2009. [Available from: http://emedicine.medscape. com/article/1298013-overview]. 99. Hulsbergen Henning JP, Roskam Y, van Gemert MJ. Treatment of keloids and hypertrophic scars with an argon laser. Lasers Surg Med 1986; 6(1): 72–5. 100. Paquet P, Hermanns JF, Piérard GE. Effect of the 585 nm flashlamp-pumped pulsed dye laser for the treatment of keloids. Dermatol Surg 2001; 27(2): 171–4. 101. Baylis HI, Goldberg RA, Wilson MC. Complications of upper blepharoplasty. In: Putterman AM, Warren LA, eds. Cosmetic Oculoplastic Surgery. Philadelphia, PA: WB Saunders, 1999: 411–28.

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107. Korn BS, Kikkawa DO, Cohen SR, Hartstein M, et al. Treatment of lower eyelid malposition with dermis fat grafting. Ophthalmology 2008; 115(4): 744–51.e2 [Epub 2007 Dec, 11]. 108. Edgerton MT Jr. Causes and prevention of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 1972; 49: 42–52. 109. Kamer FM, Mikaelian AJ. Preexcision blepharoplasty. Arch Otolaryngol Head Neck Surg 1991; 117: 995–9. 110. Lessa S, Nanci M. Simple canthopexy used in transconjunctival blepharoplasty. Ophthal Plast Reconstr Surg 2009; 25(4): 284–8. 111. Della Rocca DA. The lateral tarsal strip: illustrated pearls. Facial Plast Surg 2007; 23(3): 200–2. 112. de la Cruz L, Berenguer B, García T. Correction of nasojugal groove with tunnelled fat graft. Aesthet Surg J 2009; 29(3): 194–8. 113. Lee EW, Holtebeck AC, Harrison AR. Infection rates in outpatient eyelid surgery. Ophthal Plast Reconstr Surg 2009; 25(2): 109–10.

25

Breast augmentation Clark F. Schierle and Laurie A. Casas

INTRODUCTION

PRE-OPERATIVE EVALUATION

Breast augmentation or augmentation mammaplasty is a surgical procedure to enhance the size and shape of the breast and is one of the most frequently performed cosmetic surgical procedures. According to data from the American Society for Aesthetic Plastic Surgery, breast augmentation became the most commonly performed cosmetic surgical procedure, overtaking liposuction for the first time with over 350,000 cases performed. Many women who undergo augmentation mammaplasty report an improvement not only in the appearance of their breasts but also in their overall quality of life. A recent multicenter center revealed high levels of patient satisfaction and psychosocial status following cosmetic surgery (1). The majority of the women seek breast enhancement for either congenital micromastia and asymmetry, for postpartum changes leading to deflated breasts or following breast changes following dramatic weight loss (2).

One must first determine whether the patient is a good candidate for the procedure and whether the patient has realistic expectations. Managing patient expectations is critical to maintain a low re-operation rate within the first 2 years. Typically two consultations are required to evaluate the patient and to determine the exact implant volume, projection, and base width. Restoration of breast volume after childbirth and nursing or dramatic weight loss, correction of congenital micromastia, improvement in symmetry as well as simply desiring a larger breast size to harmonize with the rest of one’s frame are all common pre-operative chief complaints (Fig. 25.1). A thorough medical history and physical examination should be performed. Skin quality, subcutaneous fat thickness, breast volume, and the chest wall should be assessed. The breasts should be assessed for symmetry, carefully noting and pre-operative differences in size, shape, projection, inframammary fold, nipple position, and chest wall curvature. The size, thickness, and origin of the pectoralis muscle should be assessed. A thorough and systematic breast exam of any masses should be performed. In addition, a mammogram may be obtained pre-operatively, especially if the patient is over the age of 35.

HISTORICAL EVOLUTION

Historically there has been great variation across time and cultures of the characteristics of the “ideal” breast (3,4). The first recorded surgical breast augmentation involved the transplantation of a lipoma from the buttock to the breast in an attempt to correct asymmetry and was performed by Czerny in 1895 in Heidelberg, Germany. More recently, Cronin and Gerow first developed the first successful silicone breast implant in the early 1960s, ushering in the modern era of breast augmentation. A decline in the early nineties occurred surrounding the sensationalized controversy surrounding alleged systemic health sequelae resulting from silicone breast implants. This led to the rapid development and popularization of saline filled breast implants, which were for many years the only option available to women for primary cosmetic augmentation. The silicone scare, which plunged the multinational chemical giant Dow-Corning into bankruptcy, was only recently reversed in 2007 after large-scale retrospective cohort analysis failed to demonstrate a link between silicone breast implants and any significant adverse events. Modern silicone and saline breast implants share a highly covalently cross-linked silicone shell which has been demonstrated to dramatically reduce rates of silicone bleed and micro perforation. Today, a wide variety of silicone, saline, and hybrid implants are available in an ever increasing variety of shapes, sizes, and textures to suit the needs of the plastic surgeon providing this procedure in their practice. RELEVANT ANATOMY

The breast overlies the pectoralis major muscle and spans the second through seventh ribs. In the youthful non-ptotic breast, the nipple overlies the fourth rib, corresponding to its innervation by the fourth intercostal nerve. The tail of Spence is an extension of glandular breast tissue draping over the inferolateral border of the pectoralis major muscle and into the axilla. The blood supply to the breast consists of a complex plexus of vessels arising from internal mammary perforators, cutaneous branches of intercostal vessels, lateral thoracic vessels, and contributions from the serratus anterior branch of the thoracodorsal artery. The parenchyma of the breast is suspended from the pectoralis major muscle by the ligaments of Cooper. The glandular tissue develops between the deep and superficial layers of the superficial fascial system and the most inferior extent of this separation defines the inframammary fold.

Implant Size Managing patient expectations while delivering the results the patient desires is the key to a successful outcome. The patient’s current breast size and her perceptions of her breasts should be assessed. Desired breast size can be assessed with discussions of cup sizes, volumes, magazine photographs or the use of a predictive computer imaging system. As much data as possible should be gathered from multiple sources in order to formulate a unified vision of what the patient expects. A pre-operative implant fitting session using sample implants of various dimensions in a sizing bra and then allowing the patient to assess her appearance in a mirror from the front and side while standing up straight and leaning over can be very useful in deciding between different volumes and styles of implants. Patients can typically judge a difference of 15 cm3, so their input is critical in the pre-operative implant selection process. Implant Fill: Saline Vs. Silicone Now that silicone gel-filled implants have once again been approved for use in elective aesthetic breast surgery, women have an option between saline and silicone-filled implants. The more cohesive silicone gel implants (the so-called “gummy bear” implant) which have been manufactured since the 1990s have the advantage of a more natural feel when compared with saline-filled implants. They are less prone to rippling along the lateral and inferior aspects of the breast. Deflation does not occur with silicone implants because if the shell tears, the cohesive gel maintains its structural integrity. One drawback is that silicone implants typically require a larger incision for placement due to the fact that they are inserted at full size. Despite the large body of medical evidence supporting their safety, there are still some women who will simply feel uncomfortable with silicone and will only accept a saline fill. One advantage of saline versus silicone fill is the ability to adjust saline fill volume by 20 to 50 cm3 intra-operatively. In addition, there are styles of saline implant which are adjustable post-operatively by percutaneously adding saline into the remote subcutaneously placed port. A second procedure must then

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(C) Figure 25.1 Managing pseudoptosis with augmentation mammaplasty. (A) Pre-operative frontal view. (B) Post-operative frontal view. (C) Pre-operative lateral view. (D) Post-operative lateral view.

be scheduled for removal of the port. Ideally, however, all decisions regarding volume should be made pre-operatively. Remember that any increase or decrease in implant fill affects projection, base diameter, rippling, etc. such that significant over- or under-filling is not recommended. Implant Shape and Texture Options include smooth and textured implant surfaces and round or “anatomic” shapes with low, medium, and high profiles. Although the data are not conclusive, textured implants may have slightly lower capsular contracture rates. Surgeons who desire greater cohesion between the anatomic pocket and the implant prefer textured implants for their ability to better integrate with the capsule. Surgeons who prefer a less adherent capsule with greater implant mobility may opt for a smooth implant. Of the three interdependent variables of implant base diameter, fill volume, and projection, once two have been selected, the third will be determined by the other two for any given implant manufacturer. For instance, if a decision is made based on appropriate base diameter and a patient’s desired projection, there will be one implant volume which meets those criteria. If a non-round-shaped implant is selected, a textured surface must be used to ensure that the implant remains in the appropriate orientation.

SURGICAL APPROACH

There are three traditional approaches that we advocate: axillary, inframammary, and periareolar. In our opinion, the transumbilical approach requires a steep learning curve and provides less control of the pocket. All three incisions can be 3 to 4 cm in length when using a saline implant which is inserted deflated, while the incision length for a silicone prefilled implant requires an incision ranging from 3 to 6 cm. The inframammary approach provides excellent exposure, does not require transection of colonized breast ductal tissue, and is well hidden in most women. Care must be taken in the initial dissection to avoid disruption of the deep layer of the superficial fascia which helps define the inframammary fold. Overdissection of the inferior pocket results in migration of the inframammary fold cephalad onto the dome of the breast after placement of the implant leaving the patient with an implant that migrates inferior to the crease. The periareolar incision is well camouflaged but requires either direct transection of glandular tissue with introduction of intraductal flora into the surgical field or a circuitous pericapsular dissection, which can limit exposure for dissection of the pocket. This approach is further limited by the size of the patient’s nipples and is rarely well suited if a larger silicone gel-filled implant is utilized requiring a longer incision for placement. The transaxillary approach is typically utilized with the assistance of a surgical endoscope for adequate visualization during

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Figure 25.2 Post-operative shaping. (A) Pre-operative frontal view. (B) Post-operative shaping with ACE wrap, underwire bra with selective tailoring to allow skin expansion. (C) View of customized shaping bra with ACE wrap removed. (D) Post-operative frontal view.

pocket dissection. This approach can result in challenging control of the pocket and is often prone to inadequate pocket dissection, particularly inferomedially at the point of greatest distance from the incision. This approach is well tolerated for the placement of non-prefilled saline implants. Implant Position Implants may be placed in subglandular, subfascial, subpectoral, or dual planes. Subglandular pockets are immediately beneath the glandular parenchyma of the breast. A subfascial approach elevates the superficial layer of deep pectoral fascia off of the muscle with the gland. A subpectoral pocket enters the deep pectoral fascia and places the implant in a pocket beneath the pectoralis major muscle. Finally, the dual plane approach places the superomedial portion of the implant beneath the pectoralis muscle while the inferolateral portion rests in a subglandular or subfascial position. In patients with adequate subcutaneous fat (as demonstrated by the “pinch test”) of at least 2 cm, a silicone implant above the muscle can be considered. If the patient has inadequate tissue coverage over the implant, the patient can develop rippling when leaning forward and often the superior pole of the implant is visible. Placement of the implant in a subglandular or subfascial position provides the most anatomic augmentation of the breast parenchyma; however, patient selection for adequate tissue coverage and implant fill choice are critical. Subpectoral implant placement is necessitated by a patient with extremely low body fat with a suboptimal pinch test and in those patients who choose a saline-filled implant in order to conceal rippling and the characteristic fluid wave in the superior pole of

saline implants when the patient leans forward. The subfascial approach may provide superior pocket control over the subglandular position and provides the theoretical benefit of an anatomic barrier between the flora of the breast parenchyma and the implant. Advocates of the dual plane approach feel that the partial muscle coverage superiorly provides the benefits of the submuscular approach while leaving the inferior portion of the implant subglandular or subfascial avoids the downside of an unnatural inferior pole when the patient contracts their pectoralis muscle demonstrating animation deformities. Surgical Technique The patient is marked pre-operatively with careful attention to defining the boundaries of the planned pocket dissection. Reference markings including midline, breast meridians, and inframammary folds may be made. Local anesthetic with monitored anesthesia care or a general anesthetic may be utilized although techniques involving submuscular dissection are facilitated by muscle paralysis necessitating a secure airway and mechanical ventilation. Regardless of anesthetic choice, local anesthetic with epinephrine, typically diluted in the form of a wetting solution, is introduced around and within the planned dissection pocket to facilitate dissection and hemostasis. In all cases we use triple antibiotic irrigation prior to placing the implant to decrease bacterial contamination and lessen the risk for post-operative capsular contracture. Inframammary Technique With the patient in supine position, an inframammary incision is made through the skin and subcutaneous fat. Dissection is carried

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Figure 25.3 Creation of a new inframammary fold. (A) Pre-operative frontal view. (B) Post-operative frontal view. (C) Pre-operative oblique view. (D) Post-operative oblique view.

cephalad through the superficial layer of the superficial fascia past the confluence of the superficial and deep layers, which forms the inframammary fold. Once past this point, dissection is carried out in a subglandular or subfascial plane until the inferolateral border of the pectoralis muscle is visualized. At this point, subfascial dissection continues in this plane while a dual plane approach would involve elevating the pectoralis muscle and creating a submuscular pocket. The submuscular plane can be developed bluntly proceeding lateral to medial until the internal mammary perforators are reached. If a subpectoral plane is being used, inferomedial pectoralis major fibers are divided with electrocautery under direct visualization to the level of the nipple. Muscle fibers are divided carefully layer by layer until the fascia is visualized. An implant sizer may be used, filled temporarily with air or saline, to assess the extent of pocket dissection and concordance with pre-operative markings. Once the pocket has been satisfactorily dissected, meticulous hemostasis is obtained and the pocket is irrigated copiously with a dilute wetting solution and a triple antibiotic solution to minimize bacterial colonization of the implant. If the deep layer of the superficial fascia was violated upon entry into the breast gland, or if the inframammary fold has been released deliberately in anticipation of repositioning it, sutures are placed in an interrupted fashion to fix the new position of the inframammary fold. These sutures should be placed tangentially to the new inframammary fold curve and spaced evenly to avoid puckering. These are not tied immediately but left long and tagged for tying after the implant has been placed. Sutures re-approximating the glandular capsule are placed in similar fashion and tagged. At this point fresh gloves are used and the surgical field

is irrigated with triple antibiotic solution and the implant is introduced utilizing a no touch technique. Proper orientation and seating are checked for silicone gel implants and saline implants are filled to their appropriate final volume and checked similar fashion. Inframammary fold sutures and capsulorraphy sutures are then tied down. The skin is closed with interrupted deep dermal sutures and a running intracuticular suture.

Periareolar Technique The periareolar approach is limited to women with an adequate size of nipple to tolerate the length of incision necessary to introduce the implant, limiting its use to saline-filled or small silicone-filled implants unless the patients areola is of larger size. The incision is made at the border of the areola to camouflage the scar. Dissection should be carried out in the plane of the breast capsule inferiorly until the inframammary fold is reached. The breast parenchyma is then retracted cephalad and dissection is carried out along the deep layer of superficial fascia as described for the inframammary fold incision technique. To improve exposure and visualization, some surgeons dissect directly through breast gland to reach chest wall. This route transects ductal tissue, increasing the level of bacterial contamination of the surgical field into which the implant will eventually be introduced. Subglandular, subfascial, or dual plane dissection then proceeds as above. This technique does not typically allow adequate access to reposition and fix the inframammary fold. The remainder of the technique including irrigation, hemostasis, implant placement and closure of capsule, and skin are as described above.

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Figure 25.4 Management of nipple areolar asymmetry. (A) Pre-operative frontal view. (B) Post-operative frontal view. (C) Pre-operative lateral view. (D) Post-operative lateral view.

Transaxillary Technique Originally described as an essentially blind dissection using blunt instruments, this approach is now carried out with the use of surgical endoscopy. There is a much greater equipment requirement for endoscopic augmentation mammaplasty. At a minimum, the operating room should be equipped with the following. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

a 10 mm 30º or 45º down-viewing surgical endoscope, high definition digital camera, emory breast retractor handle with integrated suction port, fiber optic cable with a compatible light source, suction tubing, emory insulated cautery dissectors and handles (right- and lefthanded variants), electrocautery generator, some sort of long blunt dissector, anti-fog solution or a camera warming chamber, ceiling mounted or mobile video monitors with recording capability.

The incision is made in curvilinear fashion immediately posterior to the anterior axillary fold which corresponds to the lateral border of the pectoralis major muscle. Axillary tissue is dissected bluntly to avoid injury to cutaneous nerves and taking care to avoid creation of multiple subcutaneous tunnels. Once the lateral border of the pectoralis major muscle is reached pocket dissection is carried out with the assistance of the surgical endoscope and electrocautery in the desired plane. Inferolateral pocket dissection must be carried out with particular care given the long distance between this location and the incision. Adequate pocket dissection

is confirmed with the use of temporary implant sizers. The pocket is irrigated, hemostasis confirmed, and the implant introduced. Capsule and skin are then closed as before. Although the surgical technique and goals are similar, precision in dissection is made much more challenging by the introduction of the endoscopic technique. POST-OPERATIVE CARE

Incisions are splinted with adhesive wound closure strips. Antibiotic ointment and petroleum gauze may be applied to optimize skin moisturization in the post-operative period. We recommend splinting of the implant pocket to prevent migration using a bulky dressing with strategically placed surgical foam, fluffed gauze, elastic bandage wraps, and non-elastic tape. The dressing should be designed to hold the implant in position during the critical initial healing process. Patients are instructed not to engage in any activity which would excessively fire their pectoralis musculature for a period of six weeks. Post-operative shaping with tape and modified underwire brassieres can help guide the expansion of the newly enlarged breast skin envelope (Figs. 25.2 and 25.3). Manual lymphatic drainage and capsule massage are employed to accelerate resolution of tissue edema which will presumably minimize early capsular contracture. A recent multicenter study revealed complication rates significantly lower than published data. At these centers of excellence the re-operation rate (8%) and capsular contracture rate (2%) were both lower than manufacturers’ reported 3-year rates for re-operation (13–21%) and capsular contracture (8.2–9%). These data suggest that experience, meticulous technique, and appropriate post-operative care regimens can favorably affect outcomes (Fig. 25.4).

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REFERENCES

1. Sarwer DB, Infield AL, Baker JL, et al. Two-year results of a prospective, multi-site investigation of patient satisfaction and psychosocial status following cosmetic surgery. Aesthet Surg J 2008; 28(3): 245–50. 2. McCafferty LR, Casas LA, Stinnett SS, et al. Multisite analysis of 177 consecutive primary breast augmentations: predictors for reoperation. Aesthet Surg J. 2009; 29(3): 213–20.

3. Fodor PB, ed. Breast augmentation. In: Be Your Best. Austin, TX: Insight International Press, 2006. 4. Jones G. Breast augmentation. In: Nahai F, ed. The Art of Aesthetic Surgery. St. Louis, MO: Quality Medical Publishing, 2005.

26 Surgical rejuvenation of the neck

Anthony P. Sclafani, E. Ashlie Darr, and Ameet Kamat

INTRODUCTION

Even subtle changes in the neck and jawline can produce dramatic changes in a patient’s appearance. While some of these changes can be addressed with lasers, toxins, fillers, or volumizers for many patients, surgery remains the mainstay of treatment of this area. Proper understanding of the anatomy, adequate diagnosis of the root causes of the aging neck, and selection and technical mastery of techniques is essential for consistently excellent rejuvenation of the aging neck. ANATOMY

The boundaries of the neck include the inferior border of the mandible superiorly, the clavicle and suprasternal notch inferiorly, and the anterior borders of the trapezius muscles laterally. The platysma is a paired muscle that originates from the fascia of the pectoralis major and deltoid muscles and inserts at the inferior border of the mandible. It primarily functions as a protective layer for cervical structures and to stabilize the chest muscles against the jaw during heavy lifting. Central fibers of the platysma insert onto the periosteum of the mandible, while posterior fibers blend with the depressor anguli oris, mentalis, risorius, and the orbicularis oris muscles. Platysma fibers normally decussate superomedially to varying degrees. The platysma is enveloped by the superficial cervical fascia, which is an extension of the superficial musculoaponeurotic system (SMAS), and is tethered to the dermis by fibrous bands and perforating vessels. The contours of the neck are influenced by the submandibular glands, the hyoid bone, the digastric muscles, and fat deposits. Anterior cervical fat is distributed diffusely superficial to the platysma, while the submental fat pad lies in a subplatysmal location beneath the mylohyoid muscle. Facial fat may influence the appearance of the neck by creating jowl ptosis and blunting of the mandibular border. Several nerves in the neck deserve mention, as they are occasionally placed at risk during surgical rejuvenation procedures. The marginal mandibular branch of the facial nerve runs in a subplatysmal plane under the mandible before crossing the inferior mandibular border to supply the muscles of the lower lip and chin. The cervical branch of the facial nerve innervates the platysma muscle, and courses inferiorly from the inferior border of the parotid to run posterior to the mandible. The great auricular nerve courses diagonally across the sternocleidomastoid muscle (SCM) in an inferolateral-to-superomedial direction onto the parotid gland, where it divides to innervate the skin over the parotid, inferior auricle, and mastoid. COMPOSITION OF THE AESTHETIC NECK

Choosing the ideal approach for neck rejuvenation requires a thorough understanding of the anatomic relationships of the skin, subcutaneous tissue, facial muscles, and underlying osseous framework that contributes to the appearance of the aesthetic neck. Ellenbogen and Karlin described five visual criteria of a youthful-appearing neck: (i) a defined inferior mandibular border, (ii) subhyoid depression, (iii) thyroid cartilage visibility, (iv) visible anterior border of the SCM, and (v) a cervicomental angle from 105° to 120° (Table 26.1) (1). Because of the presence of the suprahyoid musculature, creation of an aesthetic cervicomental angle is greatly influenced by the positioning of the chin and the hyoid bone, as well as the draping of skin, muscle, and fat. The most anterior border of the chin in men should lie along a vertical line drawn from the subnasale to the inferior vermilion border in profile view, but may

lie 2 to 3 mm posterior to this plane in women. A small or retrognathic chin creates an obtuse cervicomental angle and may produce the appearance of a shortened neck (nonsurgical correction for small chins may involve injections with hyaluronic acid or calcium hydroxyapatite). At the vertex of the cervicomental angle is the hyoid bone, which is ideally positioned posteriorly and superiorly to achieve optimal neckline definition. Men typically have a lower larynx than women. Additionally, elongation of suprahyoid musculature and traction from inferior musculature may displace the hyoid bone inferiorly over time, creating an overly blunted and obtuse cervicomental angle. Increasing laxity of the soft tissues of the neck occurs with aging due to the combined effects of gravity and compositional changes. Aged skin contains decreased amounts of elastic fibers and hyaluronic acid, and a lesser degree of collagen cross-linking when compared to youthful skin. While changes in the aging skin may be corrected by fractional lasers, chemical peels, and other nonsurgical modalities, surgery is required to effect changes at the deeper levels. The modeling of cervical fat is influenced by genetic factors as well as acquired hypertrophy and ptosis. Fat deposits may disguise low-lying submandibular glands, which may become pronounced following lipectomy. Laxity of the platysma muscle occurring over time promotes sagging of submental contents, which leads to the so-called turkey gobbler deformity. Advances in fat melting technology using lasers and other energy source have helped remodel the fat in this area and minimally invasive liposuction may produce dramatic results both by forming new collagen and by removing fat. Changes may occur in the degree of medial platysmal fiber decussation. Progressive diastasis of the free muscle edges creates the appearance of vertical bands in the neck. It is the changes that produce a long, stringy neck which is one of the hallmarks of aging. PATIENT EVALUATION

Surgical planning begins with an evaluation of the severity of age-related change. The classification system devised by Dedo (2) categorizes the neck based upon the deepest tissue layer involved, and is helpful in selecting appropriate technique (Table 26.2). Class I denotes a younger neck with minimal deformity, which is unlikely to require intervention. Class II is distinguished by minor skin laxity, with maintenance of good muscle tone and minimal fat accumulation. Patients with a class II neck may benefit from rhytidectomy with or without chin augmentation. Class III denotes submental fat accumulation. The addition of liposuction or anterior platysmaplasty is useful in addressing this deformity. Class IV demonstrates a weakened platysma leading to vertical banding. Poor mandibular projection is the hallmark of class V, which is caused by either microgenia or retrognathia. Assessment of occlusal status is essential in accurately diagnosing the problem and selecting appropriate management. Class VI refers to inferior hyoid placement, anterior digastric muscle hypertrophy, or submandibular gland ptosis. Correction of these anatomical variations is particularly challenging, and patients should be counseled in advance on the limitations of surgery. OPERATIVE STRATEGIES

After a thorough evaluation of the specific bony and soft tissue anatomy, surgeons may employ a wide variety of techniques to provide successful rejuvenation of the aging lower face and neck. These techniques vary

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from minimally invasive submental liposuction to those involving extensive dissection, including deep plane facelift procedures. Many of the procedures are used in conjunction with one another, some are used alone, while others are used only as adjuvant procedures. Submental Liposuction Submental liposuction provides a technique of minimally invasive neck contouring. Many surgeons combine this technique with other more invasive procedures such as face/neck lifts and platysmaplasty to achieve maximum contouring of the neck and lower face. The aesthetic goals of certain patients can be met with submental liposuction alone (3). These patients are typically younger, with elastic skin and isolated submental or subjowl fat deposits (4). Post-operative contraction of skin in patients with good skin tone can provide subtle, yet satisfying definition of the cervicomental angle (5). Older patients with increased laxity Table 26.1 Criteria for an Aesthetic Neck (1) 1. Defined mandibular border 2. Subhyoid depression 3. Thyroid cartilage visibility 4. Visible border of the anterior sternocleidomastoid muscle 5. Cervicomental angle between 105° and 120°

Table 26.2 Classification of Neck Deformity (2) Class I II III IV V VI

Deformity Minimal deformity Minor skin laxity Excessive submental fat Platysmal banding Microgenia/retrognathia Low lying hyoid Submandibular gland ptosis Anterior digastric hypertrophy

(A)

would likely benefit from submental liposuction in combination with another more invasive procedure. The benefits of submental liposuction include enhanced patient tolerance, improved safety, and minimal postoperative edema and bruising. The procedure involves small stab incisions in the submentum and subauricular regions. Pretunneling with progressively larger blunttipped cannulae without the use of suction elevates the subcutaneous plane before the insertion of the liposuction cannula. A wetting solution of 0.1% Xylocaine with 1:1,000,000 epinephrine can be injected prior to or during the pretunneling procedure. Aspiration liposuction is then conducted using 1 atm of negative pressure with the open face of a blunt-tipped single port cannula oriented away from the dermis (6) using a bimanual technique. Liposuction is performed conservatively leaving a small amount of fat on the flap to maintain the subdermal plexus. The aspiration is typically done between both SCM muscles laterally, and as far inferiorly as the thyroid notch. Overlapping subauricular and submentally based fan patterns are used to avoid visible ridges and achieve a smooth contour. Care is taken to ensure uniform fat removal so that the flap redrapes naturally with peripheral tapering. After closure of the incisions, an elastic neck garment with fluff is applied for proper compression (7). SMAS Facelift The SMAS facelift is typically conducted after addressing submental and subjowl fat deposits with liposuction as discussed above. Standard temporal, peri-tragal, and post-auricular incisions are made, and may incorporate the previously made liposuction incisions (Fig. 26.1). Traditionally, a retrotragal incision is used only in females, and a pre-tragal incision is made in males to avoid advancing the beard onto the tragus (Fig. 26.2A and B). The postauricular incison in males is made in the postauricular sulcus as opposed to on the conchal bowl in females (8). A subcutaneous dissection is then performed, advancing 4 cm (“short flap”) to 10 cm (“long flap”) from the tragus and pre-auricular incision, to a point as far anterior as a line drawn from the lateral canthus to oral commissure. Using scissors a skin flap can be elevated in the occipital

(B)

Figure 26.1 (A,B) The standard access incision for facelift begins in the temple, skirts around the ear, runs in the postauricular sulcus and, when necessary, extends along or into the occipital hairline. The temporal portion can enter the temporal hair tuft (A), but a pre-trichial incision (A′) is used when significant elevation of the temporal skin would distort/obliterate the sideburn. The occipital incision can enter the occipital hair (B), but if significant posterior skin transposition is anticipated, a pre-trichial occipital incision (B′) is used to avoid hairline. Source: From Ref. 19.

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(A)

217

(B)

Figure 26.2 (A) The post-tragal portion of the facelift incision leaves the preauricular area to run along the internal aspect of the tragus, emerging preauricularly to the run around the earlobe and continue posteriorly. Also shown is marking of medial platysmal bands. (B) In the male patient, the incision remains in front of the tragus, preserving the non-hair-bearing skin on the tragus and preventing posterior migration of the beard onto the ear.

region while taking care to avoid injury to the great auricular nerve. After freeing up the earlobe, the scissors can be directed toward the lower neck through the superficial subcutaneous plane. A vertically oriented strip of SMAS is incised approximately 2 cm anterior to the skin incision, exposing the parotidomassateric fascia, and may curve around the earlobe. Using blunt dissection, the SMAS is elevated (Fig. 26.3) below the zygoma inferiorly to the junction of the platysma. Anterior to the parotid, dissection may continue superficially to the masseter to avoid facial nerve branches. Inferiorly, the lateral aspect of the platysma is then identified and a minimal sub-platysmal elevation is conducted. The SMAS-platysma flap is then secured with a superoposterior vector of traction to the level of the helical root with multiple 3-0 polydioxanone sutures. After realigning and suturing the SMAS-platysma flap, excess SMAS and skin can be excised taking care not to put undue tension on the flap. This superolateral traction typically affects the lower cheek, jowl region, and anterior–superior neck. The incisions are then closed in a two-layer fashion, with careful attention paid to the hair-bearing skin. Post-operative management includes active or passive drains for 24 to 48 hours and compressive dressings (5). Improvements in jawline and neck contour are seen relatively quickly (Fig. 26.4). Rhytidectomy with Lateral SMASectomy Rhytidectomy with lateral SMASectomy was described as an alternative to the SMAS flap rhytidectomy, which required discrete elevation of the SMAS. Prior to its adoption, extensive SMAS dissection anterior to the parotid gland was thought necessary to invoke significant change in overall facial contour. However, this dissection was known to put facial nerve branches at higher risk. Advocates of the lateral SMASectomy approach argued that extensive SMAS dissection was not necessary in most patients and that its risks outweighed the long-term benefits. Lateral SMASectomy is essentially the removal of a portion of the SMAS overlying the anterior edge of the parotid gland. The direction of the SMASectomy is oriented so that vectors of SMAS closure lie perpendicular to the nasolabial fold (Fig. 26.5). This closure effectively brings the mobile medial SMAS up to the level of the more fixed lateral SMAS.

SMAS elevation Skin elevation

Figure 26.3 Standard areas skin and SMAS (shaded area) elevation in an SMAS facelift. Source: From Ref. 19.

The SMAS resection is typically conducted in an inferior-to-superior direction, taking care to stay below the malar eminence and to remain in a plane superficial to the deep fascia and the parotid parenchyma (9). In this way, risk of injury to facial nerve branches is minimized.

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(A)

(B)

Figure 26.4 (A) Pre- and (B) post-operative views of a male patient who underwent SMAS facelift and submental liposuction with platysmaplasty. Especially in men, improvements in the neck should blend appropriately untreated areas of the face to avoid a “surgical” appearance.

SMASectomy Skin elevation

Figure 26.5 Areas of skin elevation and SMAS excision (shaded area) in lateral SMASectomy. Note the more limited elevation compared to the SMAS facelift. Source: From Ref. 19.

The advantages of the lateral SMASectomy technique when compared to full SMAS elevation are numerous. These include decreased likelihood of tearing the superficial fascia, decreased risk of facial nerve injury, and decreased post-operative dehiscence because SMAS

flaps were not elevated. This rapid and relatively safe technique produces contouring of not only the nasolabial fold, but also the jowl and jawline (9). The lateral SMASectomy also generates a more superiorly oriented vector of lift (Fig. 26.6). Deep Plane Facelift Technique The deep plane facelift addresses both the neck and lower face, and can be enhanced with less-invasive procedures such as submental liposuction, platysmaplasty, cervical suspension, injectable fillers, and augmentation mentoplasty. The deep plane facelift is typically conducted under general anesthesia, with all incision lines marked out while the patient is in an upright position. After the injection of local anesthesia, submental liposuction may be conducted in the manner described previously. Some surgeons will also then perform a platysmaplasty through a variety of techniques detailed below. Others prefer to avoid central fixation of the platysma, in the belief that it will create difficulties with lateral traction during the facelift. Platysmaplasty may therefore be deferred to the end of the procedure (6). For the deep plane facelift, standard temporal, pre- and post-auricular incisions are made, which may extend into the temporal hairline and over the occiput. A short subcutaneous flap is then elevated that extends up to about 3 cm anterior to the tragus staying posterior to a line drawn from the angle of the mandible to the lateral canthus (5,8). A J-shaped vertical strip of SMAS is then excised taking care to stay posterior to the course of the temporal branch of CN VII (5). The sub-SMAS plane is then entered and elevated inferiorly, dividing the osseocutaneous and fasciocutaneous ligaments (zygomaticocutaneous ligament, mandubulocutaneous ligament, etc.) down to the subplatysmal plane approximately 3 to 5 cm below the margin of the mandible. The division of these ligaments allows for complete mobilization of the deep plane flap. The flap is also elevated over the medial extent of the zygomaticus muscle in a superior-to-inferior fashion to avoid injury to the zygomatic branch of CN VII. The subplatysmal flap can be elevated far medially, but does not have to be carried across midline (Fig. 26.7). Traction is then applied to the platysma-SMAS flap in a superolateral direction with

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(A)

219

(B)

Figure 26.6 (A) Pre- and (B) post-operative views of a patient who underwent lateral SMASectomy with platysmaplasty, as well as malar implants.

Skin elevation Composite elevation

Figure 26.7 Areas of skin-only elevation (shaded area) and skin, SMAS and platysma elevation in the deep plane facelift. Dissection proceeds medial and superficial to the zygomaticus major muscle. Source: From Ref. 19.

interrupted absorbable sutures to create an initial vector along the axis of the mandibular ramus. The facial vector is usually along a line joining the helical root to oral commissure. Redundant skin may then be excised at this point without creating tension in the flaps. Closure is

then conducted in multiple layers. Following closure, many surgeons feel that it is important to ensure adequate drainage via passive drains placed at the infraauricular incisions. A compressive dressing is then applied for the next 24 hours to 1 week (6,8). Corset Platysmaplasty Platysmaplasty is considered to be particularly useful in patients with platysmal banding in order to establish a more defined cervicomental angle and jawline. Ideal candidates include those with good skin elasticity, moderate neck ptosis, and thin skin. The procedure can be conducted under local anesthesia in qualified patients, removing the associated morbidity with general anesthesia (10). As with many techniques, platysmaplasty is often employed in conjunction with submental liposuction. Not only does this union allow for improved defatting of the neck, liposuction also aids in undermining the cervical skin in a relatively atraumatic fashion. Corset platysmaplasty can be used in concert with laterally based facelift techniques. In the upright position, the anterior borders of the SCM muscles, the jawline, jowls, left and right bands of platysma muscle, and thyroid cartilage are identified and marked out on the skin (10). The classic submental stab incision used during submental liposuction is extended approximately 4 cm. After dividing soft tissue bridges between the dermis and underlying platysma, the medial edges of the platysma are identified. In patients with particularly heavy platysmal bands, a strip of muscle from each side can be excised and the subsequent raw edges cauterized. Each side of the muscle can then be horizontally transected at the level of the hyoid (Fig. 26.8A). A running suture of 3-0 polydioxanone is then used to bring the two edges of platysma together in the midline from the submental zone down to the thyroid notch. The running suture is then returned superiorly with wider tissue bites and tied in the submental region (7). This is the corset portion of the procedure, which creates a double-layer plication producing a smooth midline surface and superior tightening of the cervicomental angle (Figs. 26.8B and 26.9A,B). This anterior approach not only contours the submental region, but it also may correct submandibular ptosis. Oblique plication of the platysma

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in bilateral submandibular regions tightens the lateral platysma muscle, thus elevating ptotic submandibular glands. One technique employs a running locking suture from proximal to distal and a running “baseballtype” stitch from distal to proximal. This can be augmented with the use of interlocking sling sutures from the right and left submental crease to the opposite mastoid process (10). The incision is then closed with absorbable deep and superficial 6-0 polypropylene sutures. A post-operative compressive garment is then worn with frequent surveillance to ensure proper skin redraping (7).

(A)

Submental W-Plasty Submental W-plasty is a technique employed in patients with skin laxity that was not addressed with a traditional face/neck lift procedure. It is typically reserved for older men committed to maintaining a beard to camoflauge the scar. The procedure involves the direct vertical excision of redundant submental skin and subcutaneous fat with closure of the vertical scar (oriented 90° from relaxed skin tension lines) with a running W-plasty. After measuring the amount of redundant skin with soft tissue calipers, the area is marked and injected with local anesthesia.

(B)

Figure 26.8 Corset platysmaplasty. (A) Horizontal incision of the medial platysma after resection of the medial edge allows muscle expansion and better redrapage. (B) Muscle suturing at the midline reestablishes a unified and continuous muscular sling. Double layer of sutures allows wider tissue purchases in the second layer, tightening muscle more. Source: From Ref. 19.

(A)

(B)

Figure 26.9 (A) Pre- and (B) 6 days post-operative views of patient who underwent submental liposuction and corset platysmaplasty. A complete SMAS facelift with treatment of the anterior neck as well had been recommended, but the patient wished to return to work within 5 days of the procedure. Note the improvement in the jawline and neckline, although some residual skin laxity and redundancy persists.

SURGICAL REJUVENATION OF THE NECK

221

The redundant skin is then excised in a typical fusiform pattern with subsequent excision of redundant adipose tissue. The platysma is then plicated in the midline, allowing the skin to properly redrape, but maintaining enough redundancy to perform the W-plasty. The incision line is held under tension for proper alignment of the peaks of one side of the incision with the troughs of the opposite side. The limbs can be made at an ideal length of 5.5 mm at 55° angles. Skin is excised at a 90° angle to the skin through the dermis into the subcutaneous fat with subsequent wide undermining to decrease tension on the closure (Fig. 26.10A). Tension is also removed by closing the incision with alternating deep dermal buried absorbable sutures at the midpoints of the limbs. The epidermis can then be closed with eversion of edges with interrupted non-absorbable sutures (Fig. 26.10B) (6).

narrow tapered tunnel. This is to limit any implant migration due to micromotion (6). Many materials are commercially available for implantation, but vulcanized silicone with or without PTFE covering is most common. Some have recommended silicone extended anatomical chin implants (McGhan Medical, Santa Barbara, California, USA) may be preferred because of their natural post-operative contour (6). Nonsurgical “chin implants” may be obtained with injections. One drawback of these injections is their lack of permanence. However, they may serve to provide both the patient and surgeon with a preview of a permanent correction. In addition, injections with fillers such as hyaluronic acid or calcium hydroxyapatite are frequently of adequate size and duration to provide high degrees of patient satisfaction. Injections also have the benefit of being adjustable to some extent.

Augmentation Mentoplasty Correction of soft tissue laxity by facelift procedures is often limited by skeletal deficiencies present in many patients. In the past, mandibular deformities may have been treated with more aggressive mandibular osteotomies with genioplasty and rigid fixation (6). However, the decreased morbidity associated with alloplastic augmentation has made augmentation mentoplasty a much more feasible option in most patients. Chin implantation has been shown to replace mandibular volume loss, extend mandibular projection, and create a more youthful jawline (7). Chin implants can typically be placed through either a submental incision or an intraoral incision. The more popular submental approach through a 2-cm submental incision in the midline is thought to avoid disinsertion of the mentalis muscle origin and allows placement of the implant along the inferior mandibular margin. After incision, cautery is used to divide the underlying platysma and then blunt dissection is used to expose the mandibular periosteum. Vertical paramedian incisions are made through the periosteum 1 cm lateral to the midline, and periosteal pockets are dissected along the lateral lower submandibular border sufficient to accommodate the implant. The implant is placed into the lateral subperiosteal pockets and allowed to lie above the midline periosteum (7). Preservation of this intact bridge may prevent osseous erosion and remodeling in the area of maximal stress of the implant against the mandible. Some surgeons opt to use a supraperiosteal dissection instead. It is important to remember that even more important than the plane of dissection is the creation of a

Barbed Sutures As an alternative to the traditional facelift, a newer, less-invasive technique involves the use of barbed suspension sutures. Over the past several decades, suspension suturing has been conducted with a variety of materials from polytetrafluoroethylene (Gore-Tex; W. L. Gore and Associates, Flagstaff, Arizona, USA) to autologous tissue. Today, many barbed sutures are permanent with small repeating projections from the shaft of a typical polypropylene suture. Typically, the barbs are oriented in one direction, giving the suture almost double its tensile strength. The suture is placed into the tissue in the opposite direction of the barb allowing it to initially pass beyond the tissue without engaging. It is then pulled in the opposite direction causing the barbs to directly engage and anchor themselves to the fatty fibrous adipose tissues underneath the dermis and epidermis. This produces an inflammatory response over the first 3 to 7 days, after which a fibrous capsule develops around each barb. The fibrous capsule further anchors the tissue and provides some durability in elevation. In theory, the use of barbed sutures is a less-invasive way to provide elevation of ptotic facial and neck soft tissue. Early results have been generally inconclusive in terms of longevity and overall long-term safety. Complications are usually minor and include thread expulsion, hypercorrection, hemorrhage, skin dimpling, asymmetry, ecchymosis, and granuloma formation. Further acceptance is pending double-blinded randomized trials at fixed intervals to establish objective usage guidelines and average longevity of efficacy (11).

(A)

(B)

Figure 26.10 (A) Fusiform skin excision with W-plasty allows excision of redundant skin, contouring of submental fat at the cost of a vertical midline scar. (B) Meticulous closure is essential to produce an acceptable scar. This technique is most appropriate in older men who plan on maintaining beards. Source: From Ref. 19.

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Cervical Suspension Cervical suspension is an adjuvant procedure that addresses cervicomental angle blunting from a heavy neck or unfavorably positioned hyoid bone. The technique involves suspension of the platysma and deeper neck structures using a transcervical expanded polytetrafluroroethylene suspension sling. The sling is elevated and secured to the mastoid fascia (6). This technique improves jawline definition and submandibular tissue support. It also uniquely allows for secondary adjustability.

of platysmal banding. Relaxation of the medial platysmal edges will lengthen the muscle, allowing it to redrape more aesthetically into the cervicomental angle. In addition to the redraping, injections in this location also minimize the depressor effects of the platysma on the lower face. These injections may be combined with injections into the mentalis. Ideal patients for this procedure are older patients who are poor surgical candidates or who have already had a previous facelift procedure, and younger patients with strong platysmal bands who are not yet candidates for a major facelift procedure (7,13). Additionally, chemodenervation of the depressor anguli oris can help efface deep labiomandibular sulci (“marionette folds”).

NONOPERATIVE STRATEGIES

COMPLICATIONS

The aging face and neck develop specific and predictable changes. Traditionally, these changes have been addressed with the classic neck/ facelift. Recently, however, there has been a greater recognition and a greater emphasis on the role of volume loss in facial aging. Also, with the changing demographics of patients seeking facial plastic surgery and turbulent economic times, less-invasive procedures with decreased procedural morbidity and recovery periods, albeit with less dramatic change, may be performed. It is important for the facial plastic surgeon of today to tailor specific treatments for individual patients (7).

While uncommon, several complications (Table 26.3) may result from surgical rejuvenation of the neck. Mastery of the anatomy, meticulous care in surgical technique, proper patient selection, and careful postoperative management are critical in prevention. Rhytidectomy techniques may result in hematoma, nerve injuries, infection, skin flap necrosis, hypertrophic scarring or keloid formation, alopecia, earlobe deformities, parotid gland sialocele, and neck contour irregularities. Hematoma (Fig. 26.11) is the most common complication of rhytidectomy, and is more common in men (3.97%) than in women (1–3%) (14). This has been attributed to the increased vascularity

Non-permanent sutures are presently undergoing clinical trials and are expected to be available for facial suspension in the near future.

Injectable Soft Tissue Fillers The use of soft tissue augmentation in the aging neck and lower face has typically been directed at the nasolabial folds, labiomandibular grooves, and vermilion borders and substance of the lips. Injectable fillers can be divided into autologous and synthetic products. Autologous fat transfer has been used for many years in facial/neck augmentation due to its ease of harvest and little risk of hypersensitivity (12). However, the major problems arise with its variable rate and high degree of absorption, especially in mobile areas of the face, and risk of irregularity. Despite the unpredictable results of fat transfer, the smooth contour and feel of the tissue post-transfer still make it a popular option for certain patients (7). Currently, cross-linked non-animal source hyaluronic acid derivatives are the standard for facial soft tissue injectables. Restylane and Perlane (Medicis Aesthetics, Phoenix, Arizona, USA), Juvederm Ultra and Ultra Plus (Allergan, Irvine, California, USA), and Prevelle Silk (Mentor Corp, Santa Barbara, California, USA) are preparations of hyaluronic acid that are currently approved by the Food and Drug Administration for facial soft tissue augmentation. These products are cross-linked hyaluronic acid derivatives developed from a Streptococcus species biofermentation process (12). The clinical efficacy of these products in the perioral area is thought to be roughly 5 to 7 months (Restylane, Juvederm Ultra and Prevelle Silk), while larger particle hyaluronic acid derivatives (Perlane and Juvederm Ulta Plus) may last between 9 and 18 months. Radiesse (calcium hydroxylapatite suspended in water, glycerin, and carboxymethylcellulose, BioForm, Franksville, Wisconsin, USA) has gained increasing popularity with nasolabial fold correction, but should be used with caution in areas with highly mobile or thin skin. Despite some early reports of a high incidence of subcutaneous nodules, the effects of Radiesse are thought to last 12 to 15 months (7). Botulinum Toxin A Botulinum toxin A was first approved in 1989 to treat blepharospasm and strabismus, and is now used to treat multiple conditions in the head and neck (12). Its effectiveness is derived from its ability to treat hyperactive muscles. Botulinum toxin A is a metalloprotease that exerts its effect intracellularly, preventing the exocytosis of acetylcholine, thus blocking neuromuscular transmission and muscular contraction. In the neck, botulinum toxin A has been used effectively in the treatment

Table 26.3 Complications of Rhytidectomy Hematoma Nerve injury Infection Skin flap necrosis Hypertrophic scar/keloid Alopecia/hairline distortion Pixie ear deformity Parotid injury Cobra deformity Platysmal banding Submandibular gland ptosis

Figure 26.11 Small pre-auricular hematoma 5 days after facelift. Sutures behind the earlobe were removed and the hematoma evacuated. The patient healed without sequella.

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SURGICAL REJUVENATION OF THE NECK associated with hair follicles in bearded skin. Other risk factors for hematoma include smoking, nonsteriodal anti-inflammatory drugs (NSAID) or aspirin use, and hypertension. Pressure dressings and/or drains are used post-operatively to minimize hematoma development. Most hematomas

Figure 26.12 Hypertrophic scarring and step-off of the occipital hairline 6 months after facelift performed at another institution.

are small collections (Fig. 26.10), and may be managed by gently expressing the fluid from the incision after removing one or two sutures. An 18-gauge needle may be used to aspirate small hematoma contents that are sufficiently liquefied, typically 5 to 9 days post-operatively. Major hematomas are typically identified within the first 12 hours following surgery and require urgent exploration, clot evacuation, and hemostasis to prevent pressure-induced skin flap necrosis. Signs of hematoma development include unilateral increasing pain, edema, severe internal or buccal ecchymosis, and bleeding from the incision site. Proper management is essential to minimize scarring, infection, and skin discoloration that may result. As discussed previously, the locations of the great auricular, marginal mandibular, and cervical nerves place them at risk for injury during surgical rejuvenation of the neck. The great auricular nerve is the most commonly injured nerve, occurring in 7% of facelift patients (15). It courses in a subplatysmal location posterior and parallel to the external jugular vein, and therefore may be injured inadvertently while obtaining hemostasis. Injury to the facial nerve motor branches is far less common, occurring in approximately 0.3% to 2.6% (16). The marginal mandibular nerve and the temporal branch are the most commonly injured branches. Careful dissection is necessary, especially around the midportion of the zygomatic arch, where the temporal branch is tightly bound down by the SMAS attachment to the zygoma. The cervical branch can be transected superolaterally before the nerve dives deep to the plastysma muscle. Injury to this branch may be confused with marginal mandibular branch injury, and may be distinguished by the preserved ability to evert the lower lip. Most nerve injuries are neuropraxic and result only in paresis. Recovery is common.

Table 26.4 Techniques for Surgical Rejuvenation of the Neck Incisions

Vectors

Submental liposuction

Submental and subauricular stab incisions

N/A

SMAS flap facelift

Temporal, post-tragal/pretragal, and post-auricular

Superior and posterior

Rhytidectomy with lateral SMASectomy

Temporal, pre-auricular, and post-auricular

More superiorly oriented vector than other facelift techniques

Deep-plane facelift

Temporal, post-tragal/pretragal, and post-auricular

Corset platysmaplasty

Submental

Superolateral along axis of mandibular ramus, line joining helical root and oral commissure To the midline

Submental W-plasty

Vertical submental

To the midline

Augmentation mentoplasty

Submental or intra-oral

N/A

Barbed sutures

None

Superior lateral

Cervical suspension

Adjunct to rhytidectomy

Superior–posterior to mastoid fascia

Advantages

Disadvantages

Patient tolerance, safe, decreased post-op edema and bruising Addresses lower face, can be combined with less-invasive procedures

Cannot address increased skin laxity, limited results

Less operative time, Less risk of facial nerve injury, less risk of post-op dehiscence, addresses nasolabial fold, jawline, and jowl Addresses both lower face and neck, can be combined with less-invasive procedures, robust flap Addresses platysmal banding, less invasive Addresses increased skin laxity, removes redundant skin, less invasive Decreased morbidity than mandibular osteotomies, can extend mandibular projection, less invasive Less invasive, can address lower face and neck, local anesthesia Adjustable, addresses poorly positioned hyoid

Higher risk of facial nerve injury with anterior dissection, less results in neck, does not address nasolabial fold Less results in the neck

Higher risk of facial nerve injury

Does not address lower face, larger incision More visible scar, may compromise vascular supply to skin Migration

Inconclusive long term safety and longevity, thread expulsion, hypercorrection, asymmetry, dimpling Limited improvement

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Less than 1% of patients experience infection (17) due to the rich vascular supply of the face and neck. Routine use of prophylactic antibiotics, while common, has not been shown definitively to reduce infection rates. Culture-guided IV antibiotics or incision and drainage in cases of frank abscess are appropriate therapy. When an implant serves as the nidus of infection, it will almost always require removal, with potential for reimplantation once infection has resolved. Skin flaps are supplied randomly by the subdermal plexus, which may become compromised leading to skin flap necrosis. This typically occurs in the most distal areas, such as the periauricular skin. Risk factors include overly thin flaps, smoking, hematoma formation, excess tension at the skin closure, and diabetes mellitus. Cyanosis is the initial sign of impending necrosis, followed by skin sloughing. Partialthickness sloughing may be managed with occlusive dressings and ointments, but full-thickness involvement requires careful debridement and healing by secondary intention. Scarring or pigmentary changes are the unfortunate sequelae. Hypertrophic scarring (Fig. 26.12) and keloid formation can occur, especially in the retroauricular area. Risk factors include race, prior history of hypertrophic scar or keloid, and excessive tension on the skin closure. Primary treatment includes intralesional steroid injections at 3- to 4-week intervals, with excision typically reserved for refractory cases. Alopecia can be related to poorly planned incisions (Fig. 26.12) or excessively tight skin closures that lead to hair follicle injury. Loss of the temporal hair tuft may occur when the anterior facial skin is redraped over the sideburn area with use of a standard vertical preauricular incision. Prevention involves the use of pretrichial incisions designed to preserve the hairline or trichophytic techniques that promote hair growth along the incision site. Attention must also be made to preservation of the occipital hairline, which may be altered by skin redraping or distorted due to scarring. Management of alopecia may include excision of the hairless patch of skin with primary closure or hair transplant. Improper incision design, excessive flap tension, or scarring may additionally lead to pixie ear deformity, characterized by inferior stretching of the lobule. Correction typically requires surgical advancement flaps and anchoring sutures to the conchal bowl. During the creation of an SMAS flap or during platysmal elevation, dissection should be kept above the parotidomasseteric fascia to avoid parotid gland injury, which can lead to a sialocele or pseudocyst (18). This typically presents as a bulge at the mandibular angle. Intra-operative identification of parotid injury requires repair of the injured duct. Subcutaneous accumulation of saliva impairs healing by preventing adherence of the flap to underlying tissues. Conservative management consisting of anticholinergics, cyst aspiration, and compression dressings most often leads to resolution. For large or persistent pseudocysts, closed suction drainage may be required. Submental contour deformities may result from overaggressive submental liposuction. These include the so-called cobra deformity, which is a relative overabundance of fat along the mandible and jowl combined with a suprahyoid depression. Similarly, excessive fat removal may unmask nondecussating platysmal fibers leading to vertical banding or accentuate fibrous connections to the dermis known as pseudobanding. Failure to address the anterior platysma during SMAS rhytidectomy may lead to submandibular gland ptosis by creating laxity of the platysmal sling that normally elevates the glands.

CONCLUSIONS

Rejuvenation of the neck relies on generating a smooth jawline, a cervicomental angle, and a contoured yet not skeletonized cervical neck. Each patient must be analyzed individually, as patients should be offered the least invasive method which adequately generates the improvement in neck appearance they seek. Modern surgery of the neck (Table 26.4) should be tailored to the individual needs of the patient, and should provide a smooth, youthful and aesthetically pleasing neck, and jawline. Providing an aesthetically pleasing face without addressing the adjacent neck provides a marked contrast and should be avoided whenever possible. REFERENCES

1. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg 1980; 66(6): 826–37. 2. Dedo DD. A preoperative classification of the neck for cervicofacial rhytidectomy. Laryngoscope 1980; 90: 1894–6. 3. Gryskiewicz JM. Submental suction-assisted lipectomy without platysmaplasty: pushing the envelope to avoid a face lift for unsuitable candidates. Plast Reconstr Surg 2003; 112: 1393–405. 4. Kamer FM. Isolated platysmaplasty: a useful procedure but with not important limitations. Arch Facial Plast Surg 2003; 5: 184–88. 5. Wall SJ, Adamson PA. Surgical options for aesthetic enhancement of the neck. Facial Plast Surg 2001; 17(2): 109–15. 6. Adamson PA, Litner JA. Surgical management of the aging neck. Facial Plast Surg 2005; 21(1): 11–20. 7. Sclafani AP, Kwak E. Alternative management of the aging jawline and neck. Facial Plast Surg 2005; 21(1): 47–54. 8. Sykes JM. Rejuvenation of the aging neck. Facial Plast Surg 2001; 17(2): 99–107. 9. Baker D. Rhytidectomy with lateral SMASectomy. Facial Plastic Surg 2000; 16(3): 209–13. 10. Jacob CI, Kaminer MS. The corset platysma repair: a technique revisited. Dermatol Surg 2002; 28: 257–62. 11. Villa MT, White LE, Alam M, Yoo SS, Walton RL. Barbed sutures: a review of the literature. Plast Reconstr Surg 2006; 121(3): 102–8. 12. Fedok FG. Advances in minimally invasive facial rejuvenation. Curr Opin Otolaryngol Head Neck Surg 2008; 16: 359–68. 13. Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg 1999; 103: 656–63. 14. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg 2005; 116(7): 1973–85; discussion 1986–7. 15. Pitanguy I, Ceravolo MP, Dègand M. Nerve injuries during rhytidectomy. Considerations after 3,203 cases. Aesthet Plast Surg 1980; 4: 257–65. 16. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Plast Reconstr Surg 1979; 64: 781. 17. Moyer JS, Baker SR. Complications of rhytidectomy. Facial Plast Surg Clin NA 2005; 13: 469–78. 18. McKinney P. Management of parotid leakage following rhytidectomy. Plast Reconstr Surg 1996; 98: 795–801. 19. Sclafani AP, ed. The New York Eye & Ear Infirmary Handbook of Otolaryngology. Singapore: World Scientific Publishing Company, 2011.

27

Intense pulsed light Andreas Boker, David H. Ciocon, and David J.Goldberg

BACKGROUND AND SCIENCE

Intense pulsed light (IPL) devices are non-laser high intensity light sources which make use of a high-output flashlamp to produce a broad wavelength output of non-coherent light, usually in the 500 to 1200 nm, range. Light pulses generated by most modern devices are produced by bursts of electrical current passing through a xenon gas-filled chamber (1). The lamp output is then directed toward the distal end of the handpiece, which in turn releases the energy pulse onto the surface of the skin via a sapphire or quartz block. Individual systems use different cooling systems such as a cryogen spray, contact cooling, or forced refrigerated air to protect the epidermis in contact with the conduction crystal of the handpiece (2). Individual light pulses have a specific duration, intensity, and spectral distribution allowing for a controlled and confined energy delivery into tissue. IPL use in dermatology relies on the basis that certain targets for energy absorption (chromophores) are capable of absorbing energy from this broad spectrum of light wavelength (absorptive band) without exclusively being targeted by their highest absorption peak. The working basis of the IPL rests on the principle of selective photothermolysis, in which thermally mediated radiation damage is confined to a chosen epidermal and/or dermal pigmented target at the cellular or tissue structural levels (3). Tissues surrounding these targeted structures, including overlying or immediately neighboring cells, are spared, potentially reducing non-specific, widespread thermal injury. The three main chromophores (hemoglobin, water, and melanin) in human skin all have broad absorption peaks of light energy, allowing them to be targeted by a range as well as a specific wavelength of light. Therefore, monochromaticity of the light beam is not a prerequisite for selective heating of target structures in human skin. The broad wavelength range discharged from an IPL device leads to the simultaneous emission of green, yellow, red, and infrared wavelengths allowing the various chromophores to be targeted concurrently. Most of the currently available IPL emission devices, however, can be limited at the lower end of the emission spectrum by using dichrocic or “cut off ” filters to more selectively target desired cellular or structural elements. Although most IPL devices have one or two cutoff filters, available cutoff filters include 515, 550, 560, 570, 590, 615, 645, 690, and 755 nm, and function by blocking emission of shorter wavelength light. Apart from wavelength, a wide range of other treatment parameters including pulse duration, pulse sequences, and pulse delay time may be customized on most devices, affording users greater versatility and precision. Therefore, one attractive feature of IPL devices is their ability to treat various targets with the same device by applying different filters. Another well-recognized advantage of IPL devices is the relatively large footprint of their spot size and their resulting treatment speed, allowing one to limit the total number of pulses per treatment to a minimum and affording a swift treatment of large anatomical areas. Nonetheless, the larger handpieces and spot sizes can pose a potential maneuverability disadvantage when treating uneven skin surfaces. The first report of use of an IPL device in dermatology dates back to 1996, when it was successfully utilized to treat a cohort of 80 patients with treatment resistant facial port wine stains (PWS) in Germany (4,5). The device employed, a light source emitting noncoherent light with a wavelength spectrum of 515 to 1200 nm, had been originally developed for the treatment of a wide range of benign

vascular lesions, including telangiectasias and reticular varicose leg veins (6). Soon after, the same authors published two cases of effective permanent removal of terminal hair in two patients who underwent multiple treatments with IPL to their beard area (7). This initial report was followed by several more standardized studies that demonstrated the safety and efficacy of IPL for long-term hair removal (8,9). The first IPL device obtained FDA clearance in 1995 for treatment of lower extremity telangiectasias. Since then, its favorable cost and versatility in contrast to many single-spectrum lasers has led to its rapid proliferation and use in a number of different clinical settings. Despite early claims of having too many side effects and too little efficacy, innovations in technology have resulted in the development of more powerful, predictable, and reliable devices enhancing their usefulness in skin rejuvenation. To date there are over 10 different manufacturers producing various forms of IPL light devices (Table 27.1). CLINICAL USES

Vascular Lesions (Figs. 27.1 and 27.2) There are multiple well-established and effective laser treatments for targeting blood vessels in the skin, with the pulse dye laser being the workhorse in many practices nationwide. However, one limitation of the latter is the need to achieve purpura in several clinical scenarios to achieve acceptable results. In contrast, one of the main advantages of IPL technology is the absence of post-operative purpura, which minimizes post-procedure downtime substantially. Rather than inducing immediate purpura, the goal of treating vascular lesions with IPL is to raise the blood vessel temperature high enough to cause its coagulation, leading to its destruction and replacement by fibrous granulation tissue. Because of its polychromaticity, IPL can target oxyhemoglobin (predominantly found in clinically red lesions), deoxygenated hemoglobin (predominantly in blue lesions), and methemoglobin, with absorption peak wavelengths of 418 nm, 542 nm, and 577 nm respectively (3). The successful treatment of vascular lesions with IPL depends on the type and size of vessels targeted, with cherry angiomas and superficial telangiectatic veins typically demonstrating the best response. In contrast to the pulse dye laser which delivers a 585-nm wavelength at a relatively short-pulse duration (450 µs) thereby limiting its depth of penetration to a maximum depth of 1.5 mm, the broader wavelength range emitted by IPL devices and delivered through variable pulse durations and multiple-pulse sequences enables deeper-seated vessels and cavernous vascular lesions to be targeted (10). Ideally, the pulse duration should be compatible with the vessel diameter and be about equal or below the thermal relaxation time for that dimension cutaneous blood vessel, so that the surrounding tissue is barely harmed (11). Modern IPL devices provide pulse durations up to 100 ms, which enable delivery of light energy to vessels over longer periods of time, resulting in gentle, uniform heating, or even coagulation across the entire vessel, while reducing vessel rupture and its associated purpura and hyperpigmentation (4,12). The diameter of the targeted vessels is an important consideration when choosing the treatment settings of the IPL device to adequately account for epidermal relaxation times. For standard-sized small vessels in the papillary dermis with a diameter of 100 µm (0.1 mm), the thermal relaxation time is approximately 10 ms; for larger vessels of 300 µm (0.3 mm) in diameter, the thermal relaxation time is approximately 100 ms. Assuming that the thermal

225

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Table 27.1 Commonly-used Intense Pulsed Light (IPL) Sources Optical spectrum (nm)

Name

Manufacturer

Lumenis one

Lumenis

515–1200

IPL quantum StarLux 300 and 500 LuxG handpiece

Lumenis Palomar

560–1200

BBL

Fluence (J/cm2)

Number of stacked pulses

Pulse duration (ms)

Spot size (mm2)

515, 560, 590, 615, 640, 695, 755 560, 590, 640

10–40

1–3

3–100

120, 525

15–45

2,3

6–26

272

500–670 & 870– 1200

N/A

Up to 70

1

10–200

150

N/A

Up to 26

1

10–100

736

Novalis Medical

400–700 and 870–1200 525–1200 550–1200

N/A N/A

Up to 48 10–30

1 2

10–100 30, 50, 70

736 528

Cynosure

400–1200

Up to 16

1

5–50

210, 460, 828

Sciton

420–1400

500, 560, 650 (as separate handpieces) 420, 515, 560, 590, 640, 695

5–30

1–3

5–150

225, 675

LuxV handpiece LuxY handpiece Clareon with SR handpiece PhotoLight and Photosilk Plus

Optional f ilters

Figure 27.1 Angiomas before intense pulsed light (IPL) treatment.

Figure 27.2 Improvement in angiomas after intense pulsed light treatment.

relaxation time of the human epidermis (average thickness of 100 µm or 0.1 mm) is 10 ms, the treatment of smaller vessels should ideally be done with multiple pulses with at least 10 ms delay times between pulses to allow for adequate epidermal cooling.

IPL systems have been used effectively in the treatment of cavernous hemangiomas, venous and capillary malformations, facial and leg telangiectasias, and poikiloderma of Civatte (4,5,13,14). When treating PWS especially those with a nodular component with external light sources, an old challenge has been targeting deeper-seated vessels located at the base of such lesions. It has been shown that using a 585-nm wavelength PDL source, most energy is deposited in the superficial vessels and that this decreases the amount of light available to deeper vessels (shadowing effect) (15). Thus, clinical response of lightening in PWS with PDL is dependent on vessel depth, diameter, and wall thickness. With IPL in contrast, the variable pulse durations and the multiple split light pulses cause additive heating leading to coagulation of vessels of different diameters, and theoretically, better concurrent heating of superficial and deeper vessels. A 5 to 100 ms delay between pulses allows the epidermis to cool down preventing its damage. In most clinical studies for PWSs, IPL treatments were well tolerated. Side effects were infrequently observed and included temporary erythema, superficial blistering, hypopigmentation, and hyperpigmentation (4,16). Other vascular lesions commonly targeted by IPL are telangiectasias and cherry angiomas of various anatomical locations. (17,18). The most frequently used intervals between treatments reported in the literature vary between 3 and 8 weeks. In a study of 1000 consecutive patients with facial telangiectasias or vascular marks treated from 1998 to 2005 with the Photoderm VL, IPL was shown to be a fast, safe, and effective modality. In this study, large facial veins were treated in triple-pulse mode using the 590 nm cutoff filter with pulse times of 2.4, 3.0, and 3.5 ms; a delay of 30 and 25 ms; and an energy flow of 50 to 56 J/cm2. Red fine telangectasias were usually treated in double-pulse mode using the 570-nm cutoff filter with pulse times of 2.8 and 4.5 ms, a delay of 30 ms, and energy levels of 38 to 42 J/cm2. Spider lesions were treated with the same settings as for large veins using a white screen with a varying size hole (1–4 mm) to hit the arteriolar part of the lesion. Perilesional erythema, blanching, and vessel clearance were considered optimal treatment end points. IPL has also been shown to be an effective treatment for the telangiectasias and background erythema/flushing seen in patients with erythematotelangiectatic rosacea. Recently, it has been shown that IPL is at least equally effective as nonpurpuragenic PDL in reducing both signs and symptoms of rosacea (19).

INTENSE PULSED LIGHT Hair Removal (Figs. 27.3 and 27.4) The application of light-based technology for hair removal is also based on the principle of selective photothermolysis, using melanin as the target chromophore. Since melanin is found in the hair follicle epithelium as well as throughout the epidermis, it is important to selectively target the pigment deposits inside the hair shafts while leaving the epidermal melanin aggregates untouched. However, melanin’s absorption peak is best at lower wavelengths, making deeper penetration of light to the base of the hair follicle more challenging. The use of longer wavelengths to deliver more energy to deeper layers of the skin can be used to target larger, more dense melanin collections in hair follicles (20). Once melanin absorbs the light energy, it is transformed into thermal energy causing necrosis of the hair follicle (21). The hair follicle in the anagen phase is the most responsive to this treatment, given the fact that the hair shaft contains the largest amount of melanin. As a result, hair color and size are important determinants to predicting the efficacy of hair removal using IPL. Coarser, darker hair tends to absorb more energy and responds better than lighter fine hair. In fact, blond hair will typically not respond to IPL or laser treatment and is better addressed with alternate hair removal modalities that target hair follicles independent of their pigment content (22). To protect the epidermal melanin from thermal injury, IPL pulses can be divided into synchronized millisecond pulses separated by short thermal relaxation times.

Figure 27.3 Lentigines before intense pulsed light treatment.

Figure 27.4 Improvement in lentignes after intense pulsed light treatment.

227

IPL can be used to treat unwanted hair in a variety of anatomic locations. The large spot size makes it easy to treat larger surface areas such as the back, chest or legs, which would otherwise be cumbersome to treat with smaller spot-sized devices. Pre-treatment patient counseling and managing individual patient’s expectations is an integral part of successful light-assisted or laser hair removal. It is important for patients to understand that multiple treatment sessions will be needed and that their hair will gradually become finer and sparser. Treatment with the IPL device is generally well tolerated by most people when using standard energy settings. Priming the skin with topical anesthetic creams for an hour prior to treatment will further help alleviate some of the discomfort but is not always necessary. Although rarely observed in the hands of an experienced user, potential complications from IPL hair removal with excessive energy or improper technique include hyperpigmentation, hypopigmentation, folliculitis, and paradoxical hypertrichosis (23). To avoid such complications, it is essential to use the appropriate energy settings and to ensure complete contact between the crystal square of the handpiece and the skin. For some commercially available systems, it is wise to apply a water-based conduction gel to enhance this contact. Furthermore, the risk of residual dyschromia is greater in darker skin types and should be taken into account when selecting the fluence and pulse duration prior to treatment. In these cases, it is recommended that the highest available filter (755 nm) be used with interpulse delays of 50 to 100 ms to allow sufficient time for the epidermis to cool to minimize thermal damage (24). Recently, a handheld, low-fluence, home-use IPL device (Silk’n, Home Skinovations, Kfar Saba, Israel) has gained FDA approval for treatment of unwanted facial hair. Although this technology appears to be safe, results from clinical studies suggest that its effectiveness is lower than in-office treatments performed with lasers or IPL devices at higher energies (25). Pigmented Lesions and Dyschromia (Figs. 27.5 and 27.6) Among the variety of methods used to treat photoaged skin, IPL has gained significant interest because of the patient’s rapid recovery after the procedure. Dyschromia, especially of the face, is a common complaint of patients seeking photorejuvenation with laser or light technology. Localized epidermal melanocyte, melanin, or ecstatic vessel aggregates enhance the color contrast with the surrounding skin giving it an uneven, heterogeneous tone. Breaks in the homogeneous color palette of the skin are perceived by the human eye as “imperfections” and has been shown to be one of the principal defining features of “old”

Figure 27.5 Unwanted hair before intense pulsed light treatment.

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appearing skin (26). Solar lentigines are hyperchromatic macules typically resultant of chronic sun exposure. Ultraviolet (UV) light induces and aggravates them and they have been associated with an increased risk of skin cancer. Various modalities, including cryotherapy, lasers, and topical and chemical peeling agents have been reported to treat solar lentigines with varying success. When utilizing a light source for treatment of pigmented skin lesions, the localization of the pigment target is a key determinant for the selection of the appropriate therapeutic wavelength. Wavelengths in the range of 630 to 1100 nm accounts for both a preferential absorption of melanin over hemoglobin as well as an effective dermal penetration depth. The mechanism of action of IPL for treating pigmentary lesions is thought to be the result of rapid differentiation of keratinocytes induced by thermal heating. This process results in an upward transfer of melanosomes along with necrotic keratinocytes, resulting in their elimination as the microcrusts are removed from the skin surface. These effects have been demonstrated in vivo using both reflectancemode confocal microscopy and optical coherence tomography, which allow precise visualization of melanosomes in the skin in horizontal and vertical dimensions, respectively (27). Ephelides, senile, and solar lentigines are among the many examples of pigmented lesions that have been successfully treated with IPL (28,29). As discussed earlier, telangiectasias are also easily treated by this modality, making IPL a good treatment for of overall dyschromia regardless of its origin. With the use of different filters, the IPL device is capable of emitting wavelength spectra in the ranges of 500 to 670 nm and 870 to 1400 nm, allowing it to target vascular and pigmented lesions respectively. Filtering wavelengths between 670 and 870 nm aids in preservation of the melanin-rich epidermis and improves the ratio of vascular to pigment destruction (30). As such, lower cutoff filters can be used to treat superficial pigmentation, such as freckles, and higher cutoff filters for deeper lesions, such as nevus spilus (31). IPL has also been used with varied success in Asian patients with refractory melasma (32). The effect of IPL treatment for dyschromia is cumulative, and repeat treatments (typically 3–6) every 3 to 4 weeks are generally necessary for complete clearance. As expected, darker lesions and those where the pigment is localized to deeper layers of the dermis typically respond slower and require a higher total number of treatments. In these cases, despite adequate treatment regimens, lesions are often persistent. It is important to carefully assess each patient’s skin type preoperatively and adjust the IPL settings appropriately to avoid complications. In darker skin types, there is a risk of inducing hyperpigmentation. The immediate endpoint from IPL treatment of dyschromia should be visible darkening of the treated brown spots. These typically crust over 24 to

48 hours and peel off within 7 days. This process can be accelerated by having patients apply a moisturizer twice a day or by performing microdermabrasion of the treated area 1 to 2 days following treatment.

Figure 27.6 Improvement in unwanted hair after intense pulsed light treatment.

Figure 27.8 Improvement in acne after PDT with an intense pulsed light.

Photodynamic Therapy (Figs. 27.7 and 27.8) The combination of IPL and photodynamic therapy (PDT) sensitizers, such as 5-aminolevulinic acid (ALA) (Levulan, DUSA Pharmaceuticals, Wilmington, Massachusetts, USA), has shown promise in the

Figure 27.7 Acne before PDT with an intense pulsed light.

INTENSE PULSED LIGHT treatment of conditions such as actinic keratoses (33), early skin cancers, nodular acne (34), and severely photodamaged skin (35). The principle for this beneficial interaction rests on the fact that protoporphyrin IX delivered to the skin by topical application of ALA can be excited by polychromic light. After ALA penetrates the altered stratum corneum and is preferentially absorbed by rapidly dividing cells in the epidermis, it is converted enzymatically into the endogenous photosensitizer protoporphyrin IX (PpIX). After illumination with the proper wavelength, the absorbed energy leads to the generation of cytotoxic singlet oxygen and free radicals, which irreversibly damage the cell (36,37). The major absorption bands for protoporphyrin IX include 410, 504, 538, 576, and 630 nm, all contained within the emission spectrum of most IPL systems. It is therefore accepted that activation of ALA is much more effective using IPL than with conventional 410 nm blue light. The first report of “photodynamic photorejuvenation” using IPL and 5-ALA for addressing actinic keratoses (AKs) was published by RuizRodriguez et al. in 2002. This case series of 17 patients with AKs showed that two treatments with a 1-month interval using topical application of 20% ALA for 4 hours on AK lesions followed by treatment with IPL for photorejuvenation resulted in complete clearing of 89% of lesions after a 3-month follow-up period (38). Several studies addressing additional components of photorejuvenation have followed suit, with most showing that 5-ALA plus IPL is associated with improvement of mottled hyperpigmentation and global photoaging, and to a slightly lesser extent, an improvement in fine lines (39–41). Furthermore, evidence suggests that IPL combined with 5-ALA leads to greater dermal remodeling due to increased type I collagen synthesis compared to treatment of IPL alone (42). PDT in combination with IPL had also been used for treating patients with acne and rosacea. The mechanism for improvement in these conditions is due to the enhanced absorption of ALA by sebaceous glands. Photoactivation with IPL then damages the sebaceous gland leading to a reduction in the total number of active sebaceous glands (43,44). Several studies have demonstrated a significant reduction of inflammatory acne lesions for up to 10 weeks after a single treatment with IPL and ALA (45–47). PDT therefore has the potential to offer a unique way of improving acne by selectively damaging the pilosebaceous unit and killing P. acnes with little damage to the surrounding skin. More recently, methyl aminolevulinate applied 3 h under occlusion prior to photoactivation with IPL was proven to be effective in treating squamous cell carcinoma in situ and superficial basal cell carcinomas (48). Rhytids and Skin Tightening (Figs. 27.9 and 27.10) Fine superficial wrinkles in the skin are the result of a combination of intrinsic and extrinsic aging processes that affect the skin with the passage of time. Intrinsic aging results in the gradual reduction of extracellular matrix proteins such as collagen and hyaluronic acids in the dermis due to a chronologic senescence of dermal fibroblasts. Extrinsic aging of the skin is mainly the result of long-term exposure to UV radiation from the sun, which leads to further breakdown of collagen fibers by oxygen radicals. The overall result is a decrease in dermal structural support and volume, leading to a reduction in skin torsion extensibility, thereby causing the overlying redundant epidermis to wrinkle. In recent years, there has been a surge of non-invasive rejuvenation modalities aimed at the treatment of fine wrinkles and tightening of lax skin, using a variety of external laser and light sources. A series of four to six IPL treatments termed “photorejuvenation” has recently been popularized and is available in many dermatology practices nationwide (49). The principle behind tightening of the skin using IPL rests on the theory that heating collagen fibers with high intensity light energy leads to their contracture. This may account for the textural change described in skin

229

treated with IPL which has been reported as a secondary observation in several studies (50). Furthermore, the thermal stimulation of dermal fibroblasts by the higher wavelengths within the IPL spectrum has been shown to result in increased synthesis of extracellular matrix proteins, leading to at least partial replacement of the lost dermal volume. Specifically, wavelengths in the 1200-nm spectrum are absorbed by water in the dermis, triggering a cytokine reaction which in turn stimulates the formation of new collagen I, III, and elastin (51). Histologic evaluation of the effects of five subsequent IPL treatments with 570 to 645 nm wavelengths showed epidermal thickening of 100 to 300 μm, a decrease in horny plugs, new rete ridge formation, a decrease in the proportion of degenerated elastic fibers, and new dermal collagen formation (52,53). The most commonly targeted wrinkles are those in the perioral and periorbital regions, with finer, more superficial lines typically responding better than deeper furrows. Results are often subtle and require multiple treatment sessions. Recent studies suggest that combining localized or full-face IPL treatments with concomitant botulinum toxin injections for dynamic rhytids produces better results than IPL treatment alone (54). The first report of the benefits of such a combination was published by Carruthers and Carruthers in 2004, showing that combined IPL–BTX treatment was associated with improvements not only in

Figure 27.9 Rhytids before intense pulsed light treatment.

Figure 27.10 Improvement in rhytids after intense pulsed light treatment.

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rhytids but also in telangiectasias, lentigines, apparent pore size, and skin texture (55). The basis for this synergy is thought to be the results of the immobilization of dermal matrix proteins achieved by paralyzing the underlying musculature, leading to smoother collagen lay down. Medico Legal Issues and Conclusion Initially many companies and physicians did not consider IPL devices to be the same as laser devices. Although FDA classification of IPL and lasers are identical, the decision as to who could use IPL devices was thought to be more lax. Thus, even if a state required only physicians to use cutaneous lasers, it was argued that perhaps a medical assistant could use the IPL. In general this is not the case. If only a physician can use a laser in a certain state, the same rule would apply to an IPL. Conversely, if a physician extender in a particular state can use a laser, he/ she can also treat with an IPL. Since most physician extenders are employed by their physician, a physician extender sued for negligence will invariably be sued at the same time. The physician supervisor will almost always be liable for the misdeeds of the employee physician extender as long as that physician extender is performing within the scope of his/her duties. IPLs, although unable to be used for the diversity of skin conditions currently treated with today’s lasers, are incredibly diverse in their application. IPLs may be the device of choice for a physician who wishes to treat a variety of cutaneous entities with a single device. CONCLUSION

IPL is a highly versatile, safe, and effective modality for the treatment of vascular and pigmented lesions, hypertrichosis, epidermal, and dermal atrophy associated with photoaging, as well as acne, rosacea, actinic keratoses, and non-melanoma skin cancers. As our understanding of the biologic efficacy of various wavelength distributions evolves so to will the range of IPL technology, particularly with regard to different wavelength filters, pulse durations, pulse frequencies, and cooling modalities to protect from side effects. The end result will be a widening domain of IPL’s clinical applications and indications. It will be incumbent on clinicians who use these devices with regularity for such new and emerging indications to report their clinical experiences, in order to sustain our continued understanding of the technology’s long-term safety and efficacy profile. REFERENCES

1. Raulin C, Greve B, Grema H. IPL technology: a review. Lasers Surg Med 2003; 32: 78–87. 2. Weiss RA, Sadick NS. Epidermal cooling crystal collar device for improved results and reduced side effects on leg telangiectasias using intense pulsed light. Dermatol Surg. 2000; 26(11): 1015–8. 3. Anderson RR, Parrish RR. Selective photothermolysis: precise microsurgery by selective absorption of pulse radiation. Science 1983; 220: 524–7. 4. Raulin C, et al. Treatment of a nonresponding port-wine stain with a new pulsed light source (PhotoDerm VL). Lasers Surg Med 1997; 21(2): 203–8. 5. Raulin C, et al. Treatment of essential telangiectasias with an intense pulsed light source (PhotoDerm VL). Dermatol Surg 1997; 23(10): 941–5; discussion 945–6. 6. Hellwig S, Schroter C, Raulin C. Behandlung essesntieller Teleangiektasien durch das Photoderm” VL. Z Hautkr 1996; 71: 44–7. 7. Raulin C, Werner S, et al. Effective treatment of hypertrichosis with pulsed light: a report of two cases. Ann Plast Surg 1997; 39(2): 169–73. 8. Gold MH, Bell MW, et al. Long-term epilation using the EpiLight broad band, intense pulsed light hair removal system. Dermatol Surg 1997; 23(10): 909–13.

9. Weiss RA, Weiss MA, et al. Hair removal with a non-coherent filtered flashlamp intense pulsed light source. Lasers Surg Med 1999; 24(2): 128–32. 10. Haedersdal M, Efsen J, et al. Changes in skin redness, pigmentation, echostructure, thickness, and surface contour after1 pulsed dye laser treatment of port-wine stains in children. Arch Dermatol. 1998; 134: 175–81. 11. Kimel S, Svaasand LO, et al. Differential vascular response to laser photothermolysis. J Invest Dermatol 1994; 103: 693–700. 12. Schroeter CA, Neumann HAM. An intense light source: the Photoderm VL flashlamp as a new treatment possibility for vascular skin lesions. Dermatol Surg 1998; 24: 743–8. 13. Raulin C, Raulin SJ, et al. Treatment of benign venous malformations with an intense pulsed light source (PhotoDermTVL). Eur J Dermatol 1997; 7: 279–82. 14. Raulin C, Careen A, et al. Treatment of port-wine stains with a noncoherent pulsed light source: a retrospective study. Arch Dermatol 1999; 135: 679–83. 15. Lucassen GW, Verkruysse W, et al. Light distributions in a port wine stain model containing multiple cylindrical and curved blood vessels. Lasers Surg Med 1996; 18: 345–57. 16. Li YH, Chen JZ, et al. Efficacy and safety of intense pulsed light in treatment of melasma in Chinese patients. Dermatol Surg 2008; 34(5): 693–700; discussion 700–1. 17. Angermeier MC. Treatment of facial vascular lesions with intense pulsed light. J Cutan Laser Ther 1999; 1: 95—100. 18. Clementoni MT, Gilardino P, et al. Intense pulsed light treatment of 1000 consecutive patients with facial vascular marks. Aesthetic Plast Surg 2006; 30(2): 226–32. 19. Neuhaus IM, Zane LT, Tope WD. Comparative efficacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea. Dermatol Surg 2009 [Epub ahead of print]. 20. Anderson RR. Laser tissue interactions. In: Goldman MP, Fitzpatrick RE, eds. Cutaneous Laser Surgery. St. Louis: Mosby Year Book; 1994:. 9–10. 21. Sadick NS, Christopher R, et al. High-intensity flashlamp photoepilation: a clinical, histological, and mechanistic study in human skin. Arch Dermatol 1999; 135: 668–76. 22. Gold MH, et al. Long-term epilation using the EpiLight broad band, intense pulsed light hair removal system. Dermatol Surg 1997; 23(10): 909–13. 23. Radmanesh M, Azar-Beig M, et al. Burning, paradoxical hypertrichosis, leukotrichia and folliculitis are four major complications of intense pulsed light hair removal therapy. J Dermatol Treat 2008; 19(6): 360–3. 24. Goldman MP, Weiss RA, Weiss MA. Intense pulsed light as a nonablative approach to photoaging. Dermatol Surg 2005; 31(9 Pt 2): 1179–87. 25. Alster TS, Tanzi EL. Effect of a novel low-energy pulsed-light device for home-use hair removal. Dermatol Surg 2009; 35(3): 483–9. 26. Matts PJ, et al. Color homogeneity and visual perception of age, health, and attractiveness of female facial skin. J Am Acad Dermatol 2007; 57(6): 977–84. 27. Yamashita T, Negishi K, et al. Intense pulsed light therapy for superficial pigmented lesions evaluated by reflectance-mode confocal microscopy and optical coherence tomography. J Invest Dermatol 2006; 126(10): 2281–6. 28. Kawada A, Asai M, Kameyama H, et al. Videomicroscopic and histopathological investigation of intense light therapy for solar lentigines. J Dermatol Sci 29: 91–6. 29. Kawada A, Shiraishi H, et al. Clinical improvement of solar lentigines and ephelides with an intense pulsed light source. Dermatol Surg, 2002; 28(6): 504–8.

INTENSE PULSED LIGHT 30. Ross EV, Smirnov M, et al. Intense pulsed light and laser treatment of facial telangiectasias and dyspigmentation: some theoretical and practical comparisons. Dermatol Surg. 2005; 31(9 Pt 2): 1188–98. 31. Moreno Arias GA, Ferrando J. Intense pulsed light for melanocytic lesions. Dermatol Surg 2001; 27: 397–400. 32. Wang CC, Hui CY, et al. Intense pulsed light for the treatment of refractory melasma in Asian persons. Dermatol Surg 2004; 30(9): 1196–200. 33. Kalla K, Merk H, Mukhtar H. Photodynamic therapy in dermatology. J Am Acad Dermatol 2000; 42: 389–413. 34. HongcharuW, Taylor CR, Chang Y, et al. Topical ALA photodynamic therapy for the treatment of acne vulgaris. J Invest Dermatol 2000; 115: 183–92. 35. Gold MH, Bradshaw VL, et al. Split-face comparison of photodynamic therapy with 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone for photodamage. Dermatol Surg. 2006; 32(6): 795–801; discussion 801–3. 36. Penq Q, Berg K, Moan J, Kongshaug M, Nesland JM. 5-aminolevulinic acid-based photodynamic therapy: principles and experimental research. Photochem Photobiol 1997; 65: 235–51. 37. Kloek J, Akkermans W, Beijersbergen van Henegouwen GM. Derivatives of 5-aminolevulinic acid for photodynamic therapy: enzymatic conversion into protoporphyrin. Photochem Photobiol 1998; 67: 150–54. 38. Ruiz-Rodriguez R, Sanz-Sanchez T, Cordoba S. Photodynamic photorejuvenation. Dermatol Surg 2002; 28: 742–4. 39. Dover JS, Bhatia AC, et al. Topical 5-aminolevulinic acid combined with intense pulsed light in the treatment of photoaging. Arch Dermatol. 2005; 141(10): 1247–52. 40. Avram D, Goldman MP. Effectiveness and safety of ALA–IPL in treating actinic keratoses and photodamage. J Drugs Dermatol 2004; 3:S36–S39. 41. Gold MH, Bradshaw VL, Boring MM, et al. Split-face comparison of photodynamic therapy with 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone for photodamage. Dermatol Surg 2006; 32: 795–801. 42. Marmur ES, Phelps R, Goldberg DJ. Ultrastructural changes seen after ALA–IPL photorejuvenation: a pilot study. J Cosmet Laser Ther 2005; 7(1): 21–4. 43. Pollock B, Turner D, et al. Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action. Br J Dermatol. 2004; 151(3): 616–22. 44. Divaris DXG, Kennedy JC, Poittier RH. Phototoxic damage to sebaceous glands and hair follicles of mice after systemic administration

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of 5-aminolevulinic acid correlates with localized protoporphyrin IX fluorescence. Am J Pathol 1990; 136: 891–7. 45. Gold MH, Bradshaw VL, et al. The use of a novel intense pulsed light and heat source and ALA–PDT in the treatment of moderate to severe inflammatory acne vulgaris. J Drugs Dermatol 2004; 3(Suppl 6): S15–S19. 46. Santos MA, Belo VG, Santos G. Effectiveness of photodynamic therapy with topical 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: comparative study. Dermatol Surg 2005; 31(8 Pt 1): 910–5. 47. Yeung CK, Shek SY, et al. A comparative study of intense pulsed light alone and its combination with photodynamic therapy for the treatment of facial acne in Asian skin. Lasers Surg Med 2007; 39(1): 1–6. 48. Downs AM, Bower CB, et al. Methyl aminolaevulinate-photodynamic therapy for actinic keratoses, squamous cell carcinoma in situ and superficial basal cell carcinoma employing a square wave intense pulsed light device for photoactivation. Br J Dermatol. 2009; 161(1): 189. 49. Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg 2000; 26: 835–42. 50. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin: 5 years results with intense pulsed light of the face, neck, and chest. Dermatol Surg 2002; 28(12): 1115–9. 51. Wong WR, et al. Intense pulsed light effects on the expression of extracellular matrix proteins and transforming growth factor beta-1 in skin dermal fibroblasts cultured within contracted collagen lattices. Dermatol Surg 2009. 52. Hernández-Pérez E, Ibiett EV. Gross and microscopic findings in patients submitted to nonablative full-face resurfacing using intense pulsed light: a preliminary study. Dermatol Surg. 2002; 28(8): 651–5. 53. Zelickson B, Kist D. Pulsed dye laser and photoderm treatment stimulates production of type-1 collagen and collagenase transcripts in papillary dermis fibroblasts. Lasers Surg Med Suppl 2001; 13: 132. 54. Khoury JG, Saluja R, Goldman MP. The effect of botulinum toxin type A on full-face intense pulsed light treatment: a randomized, double-blind, split-face study. Dermatol Surg. 2008; 34(8): 1062–9 [Epub May 6, 2008]. 55. Carruthers J, Carruthers A. The effect of full-face broadband light treatments alone and in combination with bilateral crow’s feet botulinum toxin type A chemodenervation. Dermatol Surg 2004; 30(3): 355–66.

28

Fat melting devices Kimberly Finder

INTRODUCTION

Liposuction was introduced into the United States in the early 1980s, but not until dermatologist Jeffrey Klein developed the use of dilute tumescent local anesthesia did it truly take off. Dr Klein’s idea of using tumescent anesthesia during liposuction truly revolutionized the procedure and made it what it is today. Since Dr. Klein’s seminal work, liposuction has undergone incremental improvement and change. The introduction of ultrasound in the 1990s and power-assisted reciprocating cannulas in the early 2000s were notable, but incremental changes. The approach to removing fat had not fundamentally changed. Today, we are witnessing a revolution in liposuction and fat removal. The use of tumescent fluid remains, but new innovations are fundamentally changing the means by which fat is removed. Since 1997, according to the American Society for Aesthetic Plastic Surgery, liposuction had been the number one cosmetic surgical procedure performed in the United States. In 2008 breast augmentation surpassed liposuction for the first time. The total number of liposuction procedures dropped 25% between 2007 and 2008, more than the overall drop in all cosmetic procedures (1). The economy surely has had an impact, but consumers are also seeking alternative ways to reduce unwanted fat, such as injections to dissolve fat and non-invasive treatments. All liposuction today is performed with the use of tumescent fluid, but despite publishing that technique in 1987 many liposuction surgeons continue to use systemic anesthesia (2). That is slowly changing with more surgeons abandoning systemic anesthesia in favor of local anesthesia, and the advent of laser-assisted liposuction may be one of the reasons. Lasers have long been of interest and intrigue to the esthetic consumer public, and are integral to the practice of most esthetic physicians. In recent years lasers to assist in liposuction, and to treat fat independently of liposuction, have been introduced to the marketplace. The newest enhancement technique to liposuction is the use of lasers to liquefy fat and aid in skin contraction, as well as newer techniques for delivering ultrasound energy. To understand liposuction today, one has to understand how these new innovations fit in with liposuction and fat removal strategies. ENERGY-BASED OPTIONS TO REDUCE FAT

There are three categories of energy-based options to reduce fat. 1. Ultrasound 2. Stand-alone lasers 3. Lasers used in conjunction with liposuction Lasers for fat reduction can be divided into those that create significant heat and those that don’t, the low-level laser, the so-called cold laser. Ultrasound Energy Ultrasound energy is created when electrical energy is converted to high frequency sound energy by ultrasonic generators. The energy from the generator is transmitted to a transducer that converts it into mechanical vibrations, which in turn create cavitation. This causes the formation of microbubbles in the liquid/fat medium of the wetted subcutaneous tissue. Fat cell disruption occurs and there is an emulsification of the released fat (3).

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Ultrasound devices for both internally and externally applied ultrasound energy became available in the 1990s, but the use of ultrasound energy came and went in popularity due to many practical and safety concerns with its use. A so-called third generation of ultrasound energy was FDA-approved in September 2002 (VASER; Sound Surgical Technologies LLC, Louisville, Colorado, USA). VASER stands for vibration amplification of sound energy at resonance. VASER differs from prior ultrasound technologies for liposuction (4). Smaller diameter solid probes, 3.7 mm or less, are used compared to the 5 mm diameter probes used with older ultrasound methods. Probes are designed to dissipate energy at their ends, but also along the grooved sides making the energy less concentrated at the tip. The energy is delivered as pulses rather than continuous waves. Aspiration of emulsified fat is undertaken after the delivery of ultrasound energy rather than concurrent to it. The VASER technique involves the initial placement of a precise amount of wetting solution relative to the expected amount of aspirate for proper application of the ultrasound energy. After introduction of the wetting solution, the ultrasound energy is applied to the tissue in a precise manner before the final extraction of emulsified fat (4). Table 28.1 summarizes the advantages and disadvantages of VASER technology. Laser Energy Science of Lasers In 1960 Theodore Maimam, working at the Hughes Research Laboratories, used a ruby crystal to produce light amplification by the stimulated emission of radiation (LASER), creating the first laser (5). By the late 1960s, early pioneers were beginning to experiment with the use of lasers in medicine. The 1970s and 1980s were a time of ongoing development of such lasers as the CO2 laser for surgical cutting and skin resurfacing, and the excimer laser for LASIK, but it wasn’t until the 1990s when laser research, cutaneous surgery, and esthetics collided that the field took off. Today, lasers are found in almost every medical discipline. In some, they are only an adjunct to time-tested treatments while in others they have been truly revolutionary. To better understand lasers in liposuction, it is necessary to understand some of the science underlying their use. Lasers emit photonic monochromatic, coherent light energy. Monochromatic or single wavelengths of light are selected for specific targets for absorption. The nature of the target, the chromophore, determines which wavelengths have the best potential to have an effect. Tissue structures have different absorption spectra, that is, how well they will absorb energy at different wavelengths. In addition, other practical factors are applicable, such as the ability to engineer a device to emit a particular wavelength and deliver it to the target chromophore. In liposuction, there are two targets for laser energy. The most obvious target is fat itself. The less obvious target is the water found in the skin and connective tissue of the subcutis. Water is the target chromophore designed to effect skin tightening. Lasers in liposuction have the dual goal of reducing fat and enhancing skin tightening and tissue contraction after the elimination of fat. When laser energy is absorbed by a target, photonic energy is converted into infrared energy and this generates heat that causes a thermal effect. This is referred to as selective photothermolysis (6).

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FAT MELTING DEVICES In liposuction, heat generated from laser energy is absorbed by the fat cells, causing them to overheat and rupture. This allows them to be more easily removed during subsequent suctioning. When water is the chromophore, structures such as skin and connective tissue that have relatively high water content are heated, which can enhance tightening and contraction. Power is the amount of photonic energy a laser generates and is measured in watts. Therefore, a 40-W laser will generate twice as many photons and twice as much photonic energy as a 20-W laser. Another term commonly used is joules, which is the amount of watts delivered in one second. The energy output of a particular laser will affect how fast a target can be heated in order to achieve the desired effect. This can be important when considering the practical impact a laser has on the clinical situation. Another issue when evaluating a laser is whether it is pulsed or continuous. This is much like the difference between a light that is on continuously and a strobe light. In a pulsed laser, the energy is emitted in bursts. Given that energy can be measured as the total energy delivered over a second, this means that a continuous laser, which is on for the entire second, will deliver the same amount of energy at all points. This is called average power. A pulsed laser will have moments when the laser is on and moments when the laser is off. This means that the energy when the laser is on is higher than the average power being delivered. The energy delivered when the laser is on is called peak power. The peak power of a pulsed laser can be many times greater than the average power delivered by a continuous laser. See Table 28.2 for an example. Practically, this means that a continuous laser will deliver its energy at a lower and constant rate, whereas the pulsed laser will deliver that energy in bursts of higher power. Continuous lasers provide a more gradual heating and pulsed lasers provide multiple pulses of high power. Ultimately, higher peak power means quicker heating, but it can be less safe, depending on how the laser is moving in tissue while it pulses. A new understanding of laser energy has been emerging. These are the low-level or so-called cold lasers, discussed in the next section. Here the mechanism of action is not heating or selective photothermolysis, but instead appears to be a form of biomodulation where the laser energy triggers biochemical changes in tissue (7). These changes appear to occur at very low-energy levels.

Table 28.1 Advantages and Disadvantages of VASER Advantage

• • • •

Proven emulsification of fat Specificity of energy for fat. Surrounding structures, such as nerves and blood vessels are spared. Track record of use since 2002. Thousands of procedures have been performed safely. Less traumatic to suction emulsified fat. If the VASER energy is effectively applied, emulsified fat can be removed less traumatically than intact fat.

Disadvantage

•

• •

Relatively steep learning curve and strict usage parameters. Significant details that must be adhered to with the use of VASER. One must learn the appropriate selection criteria for probes, proper amount of tumescent fluid—too little or too much is an impediment to best use. Probe movement and positioning are crucial for safe and effective use, as well as the amount of energy to be applied per volume of infused solution. Potential for skin burns. Incision sites and surrounding skin must be protected from burns. Deeper structures can be at risk of injury with systemically anesthetized patients with a hot instrument.

Cold Lasers The first laser for laser-assisted liposuction was approved by the FDA in 2004. It is a low-level 635 nm laser (Erchonia EML; Erchonia Medical, McKinney, Texas, USA). This cold laser delivers its milliwatt-range energy transcutaneously, and is applied before suctioning. Low-level lasers have been used for many other applications, such as pain management and wound healing before being applied to fat reduction. Neira et al. (8,9) have reported effects of low-level laser treatment (LLLT) on fat. Neira et al. (9) demonstrated intact fat cells pre-treatment by scanning electron microscopy and 80% disruption at 4 minutes exposure, and nearly 100% disruption at 6 minutes exposure to the 635-nm milliwatt-range device. Magnetic resonance imaging also showed changes in the adipose tissue becoming more coalescent after 4 minutes of exposure, with an intensifying of that effect at 6 minutes and a disorganization of septae. Jackson et al. (10) reported using the Erchonia EML 635 nm, 14 mW laser on a group of 36 test-patients compared with a placebo group undergoing liposuction. One investigator performed the liposuction and treatment assessments, while a different investigator performed the real or fake laser treatment with the patient blinded. They found that 43% more of the test group than of the placebo group recorded a discomfort level post-procedure of less than 30 on a Visual Analog Scale from 0 to 100 exceeding their pre-study success criteria. They also found that the LLLT significantly enhanced the ease of performing liposuction, reduced the time in surgery, enhanced the ease of facilitating fat extraction, enhanced the emulsification of fat, decreased swelling, and decreased the need for the use of pain medication post-procedure. In the fall of 2009 LLLT received FDA approval as a stand-alone treatment (Zerona; Erchonia Medical, McKinney, Texas, USA). This is a similar 635 nm 15 mW laser with a unique apparatus for transcutaneous delivery of the energy. Patients lie under rotating, scanning laser lights that are positioned 8 inches above the skin for 40-minute treatments. Repeat treatments are delivered within 72 hours for a course of six to nine treatments. In a double-blind, randomized, placebocontrolled study 67 volunteers were treated with either low-level laser or placebo three times per week for 2 weeks (11). Compared to baseline, changes in total circumference measurements between groups were statistically significant at week 1 (4.556 cm), week 2 (7.208 cm), and 2 weeks post-procedure (6.586 cm). The exact mechanism of action of low-level laser light has not been elucidated; however, histological evidence shows the opening of a pore in the fat cell releasing fat into the interstitium. The presence of tumescent solution may facilitate laser beam penetration and intensity to

Table 28.2 Pulsed Laser versus Continuous Laser Laser 1 Type Pulses/sec (Hz) Pulsewidth Time on/sec Power/pulse (peak power) Power/ms Peak power to average power

How long the pulse is on Total laser time Power during one pulse Power during one millisecond Compare pulse to continuous

Laser 2

Laser 3

Continuous N/A N/A

Pulsed 40 250 µs

Pulsed 10 5 ms

1s N/A

10 ms 0.5 W

50 ms 2W

0.02 W

2W

0.4 W

Same

100× greater

20× greater

Example of differences between three types of lasers. Assume 20 W total power for each laser.

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improve fat liquefaction (8,9) The cause of the opening of this pore is probably through a biochemical mediation (7). Heat-producing Lasers In 1994, a study using a 40-W 1064 nm Nd:YAG laser on 51 patients was reported (12). The energy was delivered via a 600 µm fiber inserted into 4- or 6-mm cutting cannulas. Though potential advantages such as less surgeon fatigue due to fat melting, and less blood loss through hemostasis were mentioned, the conclusion was that there was little benefit over liposuction without using a laser. Interestingly, as early as 1994 the authors also suggested that there may be a marketing advantage with patients for a surgeon who has a laser over a surgeon who does not have one for laser-assisted lipolysis. Badin et al. (13) reported a series of 245 patients treated with a 1064-nm laser, with a laser fiber projecting from the distal end of a 1-mm cannula. The lipolysis effect was demonstrated as thermal damage to membranes of fat cells. Researchers from Wellman Laboratories (Boston, Massachusetts, USA) and Palomar Medical Technologies (Burlington, Massachusetts, USA) reported at the 2001 Annual Meeting of the American Society for Lasers in Medicine their study on selective photothermolysis of lipid-rich tissue (14). They found bands at 915, 1205, 1715, and 2305 nm where lipid-rich tissue has approximately 50% more absorption than aqueous tissue (Fig. 28.1). By thermographic measurements, they observed selective heating of lipid-rich tissue and postulated their results could help develop a laser-assisted treatment of unwanted fatty tissue. It was not until October 2006 that the first heat-producing laser for laser-assisted liposuction was approved by the FDA, a 1064-nm fiberoptic laser (Smartlipo; Cynosure Inc., Westford, Massachusetts, USA). Since then other FDA-approved laser devices utilizing 1064 nm wavelength, as well as 1319/1320 nm, 924 nm, and 975/980 nm have become available (Table 28.3). Histological evaluations of tissue from laser-assisted lipolysis have been done. Ichikawa et al. reported scanning electron microscopy results that showed degenerated cell membranes, vaporization, liquefaction, carbonization, and heat-coagulated collagen fibers after ex vivo application of 1064 nm laser cannula (Smartlipo, DEKA, Italy) in a manner similar to a clinical application, but without suctioning (15).

Water

924 nm @ 25W 924 nm Laser heats fat directly

Fat

The controls which were similarly cannulated without applying laser energy showed round, non-deflated adipocytes. Adipocyte destruction appears to be dependent on a combination of laser wavelength and sufficient energy to elicit a thermal response (16–19). In an in vitro experiment conducted at Palomar Medical Technologies, cuvettes of fat were exposed through a water interface to either 25 W of a continuous laser at 924 nm, or 25 W using a pulsed Smartlipo MPX. The Smartlipo was split between 10 W at 1320 nm and 15 W at 1064 nm. The 924 nm laser heated the fat directly, while the 1320 nm/1064 nm combination heated the water which indirectly melted the fat (Fig. 28.1). This is due to the difference in absorption characteristics of fat versus water. The absorption spectra of both fat and water are presented (Fig. 28.2).

Table 28.3 Comparison of Available Lasers for Fat Melting Wavelength (nm)

Laser

Company

AccuSculpt

Lutronic Corp.

1444

LipoLite

Syneron, Medical Ltd. Sciton, Inc.

1064

Cynosure, Inc.

1064/1320

Osyris Medical USA Palomar Medical Technologies, Inc. Elemé Medical, Inc. Erchonia Medical Inc. Erchonia Medical Inc.

980

ProLipo Smartlipo MPX Lipotherme SlimLipo

SmoothLipo LipoLASER Zerona

1064/1319

924/975

980

Pulsed/ Nd:Yag Pulsed/ Nd:Yag Pulsed/ Nd:Yag Pulsed/ Nd:Yag Continuous/ diode Continuous/ diode

Continuous/ diode Continuous/ diode Continuous/ diode

635 635

Water

Type

Fat

1320 nm @ 10W 1064 nm @ 15W 1064/1320 pulsed laser heats water (boils) Water heats fat

Figure 28.1 Comparison of water and fat absorption at two different wavelengths. Source: Courtesy of Palomar Medical Technologies.

Power (W)

12 W 40 W 46 W 25 W 40 W

25 W Low level (mW) Low level (mW)

235

FAT MELTING DEVICES 1000

16 930

1320

1064

14 100

10

10

8 1

6

Flat absorption (mu_a)

Water absorption (mu_a)

12

4 0.1 Water 0.01 800

Fat

2 0

845

893

947

1008

1077

1157

1250

1358

1488

1644

1838

Wave length (nm) Figure 28.2 Absorption spectra of water and fat. Source : Data from Refs. 22, 23.

An important question is whether utilizing laser-assisted liposuction garners a benefit for patients over liposuction performed without laser assistance. A prospective, randomized, matched, doubleblind, controlled clinical trial compared laser-assisted liposuction with suction-assisted liposuction performed on 25 consecutive female patients by one surgeon (20). The laser (SmartLipo; Deka, Calenzano, Florence, Italy) was used on only one side with both sides being subjected in a similar fashion with suctioning to a similar endpoint. The authors analyzed multiple parameters (pain, ecchymosis, edema, skin retraction, and cosmetic results) and found there were no major clinical differences between the two techniques, except pain, which was rated as less on the laser-assisted sides. However, they did find that on histopathologic examination there was 90% conserved architecture of the adipocytes in the suctionassisted liposuction sides, while there was a 90% disruption of the adipocytes and rupture of the nuclear cellular membrane on the lasertreated sides. Both sides showed intact capillary vessels. Table 28.4 summarizes the advantages and disadvantages of laser-assisted liposuction. Water-assisted Liposuction Finesse and patience is required on the part of the surgeon when performing liposuction. Placing the tumescent anesthetic solution can be tedious, requiring time and the use of 18 gauge, or smaller, instruments to comfortably introduce the solution into an awake patient. This leads many surgeons to opt for general anesthesia or intravenous sedation to allow them to place the anesthetic solution faster. Since the development of tumescent solution, there has been little change in the process of infusing the solution until now. A novel method for introducing tumescent fluid, called water-assisted liposuction (WAL) was approved by the FDA in the fall of 2008. This device, by the proprietary name of Body-Jet (Human Med, Mecklenburg-West Pomerania, Germany), was in development since 2000 (21). Although not a fat melting technique, this is a unique and potentially revolutionary innovation in the method of preparing and suctioning fat. WAL is carried out with a novel cannula system. An injector, 300 µm in diameter, is inserted through an infusing style cannula, delivering fan-shaped pulses of tumescent fluid. This injector is part of a handpiece base that has a dual tubing attached for both infusion and suction.

Table 28.4 Advantages and Disadvantages of Laser-Assisted Liposuction Advantage

• • • • • •

Less surgeon strain by prepping the fat Easier to penetrate dense and fibrous tissue Easier to penetrate previously suctioned tissue Faster procedure (but only if laser prep makes suctioning faster) Theoretically less blood loss due to coagulation of vessels Theoretical increase in skin tightening

Disadvantage

• • • •

Costs (of device, disposables, and service) Risk of skin burns/organ perforations Slower procedure (if laser prep does not makes suctioning faster) Renders fat unusable for fat grafting/transfer

Figure 28.3 Aspirated fat/fluid with water-assisted liposuction. Source : Courtesy of Kimberly Finder, MD.

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Table 28.5 Advantages and Disadvantages of Water-Assisted Liposuction Comment

Table 28.6 Issues when Considering a Technology Issue Acquisition cost

Advantage Faster infiltration of local anesthetic

Less overall dose of lidocaine

More body sites treated within safe lidocaine limits Patient comfort

Less bloody aspirate Less bruising Initial training Fat harvesting

An average abdomen can be infiltrated with a base of anesthetic solution in a matter of 5 or 10 min. Even a challenging fibrous broad back can be infused in 15 or 20 min. Using concentrations of lidocaine between 0.025% and 0.05% in the infusate, makes it easier to keep the dose of lidocaine within safety guidelines. With lower concentrations of lidocaine being employed, more body sites can be treated within safety guidelines Greater comfort due to a high degree of precision in anesthesia and the ability to administer local anesthesia as needed during the suctioning. Being able to deliver further lidocaine during suctioning without stopping allows for better management of the patient who feels occasional hot spots or begins to feel discomfort. The continuous, or near-continuous infusion of dilute epinephrine greatly minimizes bleeding Possible with the continued infusion of dilute epinephrine and a gentle suction technique. May be a more comfortable entrée to liposuction for novice liposuction surgeons. Novel fat harvesting system for fat grafting allows for collecting less damaged fat cells

Disadvantage Costs of the device Cost of disposables Learning curve

Larger diameter cannulas

Complacency regarding safety

Requires a capital investment. Cannulas are unique for the system. The proprietary tubing system is unique for the system. This technique requires experienced surgeons to adjust to a new paradigm for infusing fluid and suctioning while simultaneously delivering further fluid. The rate of movement during suctioning may be much slower than many surgeons are used to. The cannulas range from 3.5 to 4.8 mm diameter. This may be larger than many surgeons are accustomed to using. With the injector in the bore of the cannula, it is difficult to use a cannula smaller than 3.5 mm. The author has found that using a larger diameter (4.2 mm) cannula has been very well tolerated by patients. Safety of liposuction involves not just the safe total dosage of local anesthesia, but other factors, such as the amount of body surface that has been manipulated by suctioning. It is possible for the surgeon to become complacent given the ability to suction more areas due to lower lidocaine levels.

Each pulse is a constant pressure similar to that generated by a powerful shower head, but the rate of pulse delivery can be adjusted for slower or faster delivery. This method of infusing solution is analogous to a power-wash system rather than the drip-hose method usually employed with tumescent liposuction. In my experience of having now performed over 300 procedures, this pulsed method of placing fluid is extremely well tolerated.

Disposable costs

Service costs

Ease of operations

The company

The technology

Comment What is the cost of acquiring the technology and of becoming proficient in its use (training costs)? What do the disposables such as fibers and tips used during a procedure cost? Can they be acquired from elsewhere? In some systems, the manufacturer makes most of their revenue on disposables. What is the cost of service? What is the likelihood of needing service? What is the cost of any warranty agreements? In some systems, the total service costs can be as great or greater than the acquisition cost. How easy is it to use? How easy is it to train others to use it? Not just the physical operation, but also ease of determining settings and use parameters. What is the reputation of the company? Are they responsive? Will they still be around in five years? Does the technology make sense? Is there good science and research behind it? Or is this just a fad?

The recommended solution concentration is 500 mg lidocaine per 1000 mL of normal saline solution with the addition of epinephrine for hemostasis and sodium bicarbonate for buffering of the acidic lidocaine. Rather than truly tumescing the subcutaneous fat, only about one-fifth to one-third of the usual volume of solution is placed as a base solution prior to beginning the aspiration phase of the procedure. It isn’t necessary to wait for saturation of the tissue with lidocaine for painless aspiration of the fat. Suctioning of the fat can be commenced immediately with the concurrent administration of the pulsed-delivered anesthetic solution. With suctioning the administered lidocaine solution can be reduced to 250 mg per 1000 ml normal saline. The same injector/tubing apparatus is used during the suctioning by replacing the infusion style cannula with a suction cannula. The technique of suctioning is one of a gentle to and fro movement, described as moving a bow across a violin, without exerting significant manual pressure to move the cannula. The force of the water spray should allow the cannula to pass through the subcutaneous tissue by creating a water path for the cannula to follow. The rate of the water pulses can be increased or decreased depending on the need for greater hydro-dissection to assist in cannula movement. The cannula can be moved faster as the hydro-dissection is more complete. The surgeon has the discretion to pulse the solution with a simple foot pedal. Once the suction has been turned on, suction is attained by covering/uncovering a handpiece port. Figure 28.3 is an example of aspirated fat and infranatant solution extracted with the BodyJet WAL system. The advantages and disadvantages of WAL are summarized in Table 28.5. Putting it All Together in My Practice I have a Body-Jet system and laser, the SlimLipo laser. I use Body-Jet for more than 95% of my cases of liposuction. For small cases such as a touch-up, neck or arms I may not use the Body-Jet. For those cases, I will use my power-assisted method with a traditional approach to

FAT MELTING DEVICES infusing the tumescent anesthesia. It required about ten cases to adjust to the Body-Jet method. My decision to use the laser on a liposuction case is based on the need of the patient. I use my laser in about 85% of my cases. Situations where I find using the laser helpful for fat removal preparation include those previously discussed. I use it on any body site where good skin tightening is not assured, or may not be optimal with only liposuction, such as obviously loose skin or stretch marks. There are situations when laser use doesn’t seem to offer a benefit, such as a perimenopausal or menopausal woman who still has good skin tone and whose fat, due to a decrease in connective tissue architecture, is so easy to remove that it feels as though the cannula is moving through butter. I am frequently asked which method I prefer, the Body-Jet or the SlimLipo laser. There is no choice to be made as they are complementary. The Body-Jet is a system for infusing and suctioning, a task that is still essential regardless of the use of a laser for liposuction assistance. In choosing a new technology for your practice, there are many different issues that need to be considered. Table 28.6 summarizes some of those considerations. REFERENCES

1. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank: Statistics. 2009. [Available from: http://www. surgery.org/sites/default/files/2008stats.pdf]. 2. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987; 4: 263–7. 3. DiGiuseppe A. Ultrasound-assisted liposuction: physical and technical principles. In: Shiffman MA, DiGiuseppe A, eds. Liposuction Principles and Practice. Berlin (Germany): Springer-Verlag; 2006: 229–38. 4. Cimino WW. VASER-assisted lipoplasty: technology and technique. In: Shiffman MA, DiGiuseppe A, eds. Liposuction Principles and Practice. Berlin (Germany): Springer-Verlag; 2006: 239–44. 5. Townes CH. The first laser. In: Garwin L, Lincoln T, eds. A Century of Nature: Twenty-One Discoveries That Changed Science and the World. Chicago, IL: The University of Chicago Press; 2003: 105–14. 6. Parrish JA, Anderson RR. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220: 524–7. 7. Maloney R. Primary biochemical mechanism of low-level-laser therapy for the non-invasive reduction of subcutaneous adiopose tissue. 2008. [Available from: http://www.docstoc.com/docs/5602035/ Primary-Biochemical-Mechanism-of-Low-Level-Laser-TherapyFor-The-Non-Invasive-Reduction-of-Subcuratneous-AdioposeTissue]. 8. Neira R, Arroyave J, Ramirez H, et al. Fat liquefaction: effect of lowlevel laser energy on adipose tissue. Plast Reconstr Surg 2002; 110(3): 912–22.

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9. Neira R, Jackson R, Dedo, D, Ortiz CL, Arroyave JA. Low-level laser-assisted lipoplasty appearance of fat demonstrated by MRI on abdominal tissue. Am J Cosmet Surg 2001; 18(3): 133–40. 10. Jackson RF, Roche G, Butterwick KJ, Dedo, DD, Slatterly KT. Low-level laser-assisted liposuction: a 2004 clinical study of its effectiveness for enhancing ease of liposuction procedures and facilitating the recovery process for patients undergoing thigh, hip, and stomach contouring. Am J Cosmet Surg 2004; 21(4): 191–8. 11. Maloney R, Shanks S, Jenney E. Low level laser therapy as a noninvasive approach for body contouring: a randomized, controlled study. Presented at the American Society for Laser Medicine and Surgery Twenty-Ninth Annual Meeting; Apr 1–5, 2009; National Harbor, MD. 12. Apfelberg DB, Rosenthal S, Hunstad JP, Achauer B, Fodor PB. Progress report on multicenter study of laser-assisted liposuction. Aesth Plast Surg 1994; 18: 259–64. 13. Badin A, Moraes L, Gondek L, Chiaratti M, Canta L. Laser lipolysis: flaccidity under control. Aesth Plast Surg 2002; 26(5): 335–9. 14. Manstein D, Erofeev AV, Altshuler GB, Anderson RR. Selective photothermolysis of lipid-rich tissue. Presented at the American Society for Laser Medicine and Surgery Twenty-First Annual Meeting; Apr 18–22, 2001; New Orleans, LA. 15. Ichikawa, K, Miyasaka, M, Tanaka R, et al. Histologic evaluation of the pulsed Nd:YAG laser for laser lipolysis. Lasers Surg Med 2005; 36: 43–6. 16. Reszko AE, Magro CM, Diktaban T, Sadick NS. Histological comparison of 1064 nm Nd:YAG and 1320 nm Nd:YAG laser lipolysis using an ex vivo model. JDD 2009; 8(4): 377–82. 17. Khoury JG, Saluja R, Keel D, Detwiler S, Goldman MP. Histologic evaluation of interstitial lipolysis comparing a 1064, 1320 and 2100 nm laser in an ex vivo model. Lasers Surg Med 2008; 40(6): 402–6. 18. Mordon S, Blanchemaison Ph. Letter to the editor. Lasers Surg Med 2008; 40: 519. 19. Mordon SR, Wassmer B, Reynaud JP, Zemmouri J. Mathematical modeling of laser lipolysis. Biomed Eng Online 2008; 7: 10. [Available from: http://www.biomedical-engineering-online.com/ content7/1/10]. 20. Prado A, Andrades P, Danilla S, et al. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg 2006; 18(6): 1032–45. 21. Man D, Meyer A. Water jet-assisted lipoplasty. Aesthetic Surg J 2007; 27(3): 342–6. 22. Palmer KF, Williams D. Optical properties of water in the near infrared. J Opt Soc Am 1974; 64: 1107–10. 23. van Veen RLP, Sterenborg HJCM, Pifferi A, et al. Optical Absorption of Fat. 2007. [Available from: http://omlc.ogi.edu/spectra/fat/].

29 Ablative fractional laser resurfacing Vic A. Narurkar

INTRODUCTION

Ablative laser resurfacing was introduced in the 1990s for facial resurfacing and has generally been considered the gold standard of device-based laser resurfacing, with the pulsed carbon dioxide laser being the prominent device for this indication. However, despite impressive clinical results, the side effect profile of ablative laser resurfacing reduced its popularity. These effects included hypopigmentation, hypertrophic scarring and persistent erythema (1). Moreover, off-facial areas were generally avoided with this indication due to higher risks of these side effects. Non-ablative fractional resurfacing (NFR) was introduced to overcome many of these limitations and has become a widely utilized modality of skin resurfacing. However, there are some limitations to NFR including disappointing results with deeper perioral rhytids and periorbital rhytids, improvement in skin laxity, and the need for multiple treatments. To overcome some of these limitations, ablative fractional laser resurfacing was introduced. This chapter will review the various fractional ablative devices, their indications, patient preparation, complications, and future directions. TECHNOLOGIES FOR ABLATIVE FRACTIONAL LASER RESURFACING

There are three wavelengths (Table 29.1) which are utilized for fractional ablative laser resurfacing—the 2940 Er-YAG wavelength, the 2790 Er-YSSG wavelength, and the 10,600 nm carbon dioxide wavelength (2,3). The greatest clinical experience with fractional ablative laser resurfacing is with the 10,600 nm wavelength. The common premise to all of these wavelengths is the fractional delivery of ablative laser energy. However, unlike non-ablative fractional laser resurfacing, there is a presence of epidermal compromise. The variable factors in fractional ablative laser resurfacing include energy and density, with lower fluencies and lower densities indicated for milder photodamage and higher energies, and higher densities for more severe photodamage. There is a critical threshold where fractional ablative laser resurfacing can approach traditional ablative laser resurfacing. As with non-ablative fractional laser resurfacing, the pattern of delivery of fractional ablative laser resurfacing varies based on stamping methods and random rolling methods (4). The typical microthermal zone created by a fractional ablative laser consists of a tapered ablative zone surrounded by eschar and a thermal coagulation zone. The depth of the zone varies from 300 µm to 1.5 mm and the width of the zone varies from 140 to 300 µm (5). Histological re- epithelialization is markedly accelerated compared to traditional ablative laser resurfacing with an average of 48 to 72 hours. CLINICAL INDICATIONS

The general consensus of fractional ablative laser resurfacing devices is their use in lighter skin types (Fitzpatrick skin types I–III), although some reports indicate safety in darker skin types. The primary area for treatment is the face, although the neck and chest can be treated. Extreme caution should be used when using these device off the face, as hypopigmentation and hypertrophic scarring (although less than ablative laser resurfacing) can ensue. The primary indications of ablative fractional laser resurfacing (Table 29.2) are moderate-to-severe photo damage, actinic keratoses, surgical and traumatic hypertrophic scars, severe acne scars, moderate-to-deep perioral and periorbital rhytids, and moderate cheek skin laxity (6–9). Single laser treatments will produce impressive results but a second treatment may be necessary,

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particularly if the condition is more severe, such as very deep perioral rhytids and very severe scars (10). PATIENT SELECTION FOR FRACTIONAL ABLATIVE LASER RESURFACING

Although there are reports that ablative fractional laser resurfacing is safe in a variety of skin types, the author limits this indication to skin types I to III, as there have been reports of hypopigmentation with ablative fractional laser resurfacing. Post-inflammatory hyperpigmentation may also ensue but is generally reversible. The author also limits the treatment to facial areas and prefers non-ablative fractional laser resurfacing for non-facial areas, especially with the introduction of dual non-ablative fractional laser wavelengths of 1550 and 1927 nm in a single treatment. Finally, “blended” AFR and NFR treatments are the most common indication, where more aggressive treatments with AFR is performed on perioral and periorbital areas and the rest of the face is treated with non-ablative fractional laser resurfacing. Patients prefer this modality as there is considerably less recovery and risks (Fig. 29.1). PATIENT PREPARATION, TREATMENT, AND POST-TREATMENT CARE FOR FRACTIONAL ABLATIVE LASER RESURFACING

All patients are advised to discontinue topical retinoids and exfoliating agents one week prior to treatment. Prophylaxis for oral herpes simplex is indicated for all patients and extended if the patient gives a documented history of oral herpes simplex. A short course of a broad spectrum oral antibiotic is also given in the peri-operative period as well as a single dose of oral diflucan to prevent candidal outbreaks. The greatest challenge in ablative fractional laser resurfacing is pain control. With mild settings, topical anesthesia and nerve blocks are usually adequate. However, with aggressive settings more aggressive pain control is necessary. Tumescent anesthesia has been used, as well as the use of intravenous sedation with the presence of an anesthesiologist. The technique of ablative fractional laser resurfacing is absolutely critical, particularly when using aggressive settings or treating off the face. Care must be taken to deliver the energy without significant overlap to avoid bulk heating. Lower fluencies and lower treatment densities are advisable off the face. Treating anatomic units in sequence is recommended. If treatment is performed on eyelids and the periorbital area, nonreflective metal corneal shields need to be placed. Immediately following the treatment the patient will experience oozing, pinpoint bleeding, and crusting. A petrolatum-based ointment is recommended to be used multiple times a day to keep the wound moist. Dilute vinegar and water soaks are also recommended. The erythema and edema becomes most pronounced at 24 to 48 hours, but shows a rapid resolution within 3 to 5 days (Fig. 29.2). Emolliation should be continued until re-epithelialization is complete, and should be followed with a mild unscented moisturizer. Strict photoprotection is also indicated during the recovery phase. The most critical time for healing is within the first few days so any sign of infection should be noted and immediately addressed to prevent adverse sequelae. If there is greater than expected erythema or textural change, close follow-up should be performed to prevent the development of scarring. CLINICAL RESULTS

Edema can persist for several weeks and final results are best noted at 3 months following a single treatment (Fig. 29.3). We usually do not

ABLATIVE FRACTIONAL LASER RESURFACING

239

Table 29.1 Wavelengths for Ablative Fractional Laser Resurfacing Wavelength

Examples

2790 Er-YSSG 2940 Er-YAG

Cutera Pearl Alma Pixel; Sciton ProFractional; Palomar Lux 2940 nm Deka SmartXide DOT; Fraxel RePair; Juvia CO2; Lutronic eCO2; Lumenis Activ/Deep FX

10,600 CO2

Table 29.2 Indications for Ablative Fractional Lasers Moderate-to-severe photodamage Surgical and traumatic scars Acne scars Moderate-to-deep perioral and perioral rhytids Skin laxity Actinic keratoses

Figure 29.1 Blended ablative fractional laser resurfacing of perioral area and nonablative fractional laser resurfacing elsewhere.

(A)

(B) Figure 29.2 Healing of ablative fractional laser resurfacing.

(A)

(B) Figure 29.3 Three months after single ablative fractional laser resurfacing treatment.

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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT traditional ablative mode. However, since many indications such as aggressive photoaging require more aggressive treatments, this may be a necessary risk of this procedure. CONCLUSIONS

Ablative fractional laser resurfacing is a relatively new method for addressing moderate-to-severe photoaging, scars, and skin laxity with a single treatment. The most widely utilized wavelength is the 10,600 nm wavelength, followed by the 2940 Er-YAG and most recently introduced 2790 nm YSSG wavelength. A common feature to all of these wavelengths is the creation of a tapered ablative wound, allowing for more rapid re-epithelialization. The healing is generally complete within 5 to 7 days and the prolonged erythema which was seen with traditional laser resurfacing is generally not seen. While the risks compared to traditional ablative laser resurfacing are reduced, they have not been completely eliminated. REFERENCES

Figure 29.4 Hypopigmentation and hypertrophic scarring after fractional ablative CO2 laser resurfacing of the neck.

repeat treatments until the third month. Improvement can ensue for up to one year following a single ablative fractional laser resurfacing treatment. It is very important to remind the patient to wait for adequate results, as some rhytids will reappear and then soften over the course of treatment. COMPLICATIONS

When ablative fractional laser resurfacing was first introduced, there were no reports of any permanent complications. As this technology becomes used more readily, complications have been increasing, but still not to the extent of ablative laser resurfacing. However, it has only been about two years since the introduction of commercial devices for fractional ablative laser resurfacing, so time will tell if there indeed is a lower risk. Complications include infection with herpes simplex, bacterial and yeast infections, hypertrophic scarring, and hypopigmentation (Fig. 29.4). They are greater on non-facial skin, particularly the neck and chest (11). Some physicians have proposed that complications are related to technique, as too much overlap can produce bulk heating and change a “fractional” mode of ablative delivery to a more

1. Bernstein LJ, Kauvar AN, Grossman MC, et al. The short- and longterm side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997; 23: 519–25. 2. Hunzeker CM, Weiss ET, Geronemus RG. Fractionated carbon dioxide laser resurfacing- or experience with more than 2000 treatments. Aesth Surg Journal 2009; 29(4): 317–22. 3. Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med 2006; 38: 169–76. 4. Brightman L, Brauer J, Anolik R, et al. Ablative and fractional ablative lasers. Dermatol Clinics 2009; 27(4): 479–91. 5. Hantash BM, Bedi VP, Kapadia B, et al. In vivo histological evaluation of a novel ablative fractional resurfacing device. Lasers Surg Med 2007; 39(2): 96–107. 6. Chapas AM, Brightman L, Sukai S, et al. Successful treatment of acneiform scarring with CO2 ablative fractional resurfacing. Lasers Surg Med 2008; 40: 381–6. 7. Haedersdal M. Fractional ablative CO2 laser resurfacing improves a thermal burn scar. J Eur Acad Dermatol Venereol 2009 (Epublication). 8. Gotkin RH, Sarnoff DS, Cannarozzo G, et al. Ablative skin resurfacing with a novel microablative CO2 laser. J Drugs Dermatol 2009; 8: 138–44. 9. Kotlus BS. Dual depth fractional carbon dioxide laser resurfacing for periocular rhytidosis. Dermatol Surg 2010; 36(5): 623–8. 10. Cohen SR, Henssler C, Johnston J. Fractional photothermolysis for skin rejuvenation. Plast Reconstr Surg 2009; 124(1): 281–90. 11. Fife DJ, Fitzpatrick RE, Zachary CB. Complications of fractional CO2 laser resurfacing: four cases. Lasers Surg Med 2009; 41: 179–84.

30 Non-ablative devices Vic A. Narurkar

INTRODUCTION

Non-ablative devices for facial and non-facial rejuvenation share the common feature of an intact stratum corneum during and after treatment. The rationale for the development of these devices is to direct energy-based sources primarily to dermal and subdermal targets for a variety of cutaneous laser applications such as skin resurfacing, treatment of pigmented and vascular lesions, and skin tightening. This chapter will review non-ablative energy-based devices. NON-ABLATIVE PHOTOREJUVENATION

The main desire for the development of non-ablative devices for skin rejuvenation stemmed from the undesirable side effects of traditional laser resurfacing. While ablative laser resurfacing was highly effective, it produced several risks such as hypopigmentation, prolonged erythema, textural change,and permanent scarring (1). The rationale behind non-ablative skin rejuvenation stemmed from histologic observations of a variety of energy-based sources promoting neocollagenesis. However, the actual clinical benefits of the neocollagenesis remain controversial. Non-ablative devices for photorejuvenation are best divided into those primarily targeting water as the main target and those targeting hemoglobin and melanin (Table 30.1). The former have generally yielded mild to modest results in terms of clinical outcomes, as the main goal for these devices has been the improvement of rhytids. The latter have become a workhorse in most practices, as the treatment of vascular and pigmented lesions, or “photofacial” treatment, is a very popular treatment with excellent treatment outcomes. Lasers that target water as the main chromophore include the long pulsed 1064 nm laser, the 1320 nm laser, the 1450 nm laser, and the 1540 nm laser. The premise behind all these wavelengths is the deep penetration of these near and mid-infrared wavelengths, allows for neocollagenesis, which ultimately, in theory, leads to softening of rhytides. While histologic effects of these devices are quite impressive, the clinical results of a true “resurfacing” are modest, at best. One device, the 1450-nm laser, has found a different clinical benefit, as a side effect—the treatment of active acne and acne scars. The modification of sebaceous glands by this laser capitalized on the treatment of active acne, while the neocollagenesis effects of the mid-infrared wavelength improves acne scars (2). At this juncture, these lasers are generally not utilized for skin resurfacing. The term “photofacial” was introduced in the 1990s as a method to simultaneously treat pigmented lesions and vascular lesions (3). Some collateral heating produced from light sources used for photofacials produced neocollagenesis, and hence the term photorejuvenation was coined for this approach. As with non-ablative infrared lasers, the effects of skin resurfacing are mild to modest at best. The initial devices used for photofacials were pulsed light sources with filters without any contact cooling. Of note, the original clinical application of these pulsed light sources was the treatment of leg veins, but the results were disappointing and benefit of treating facial veins and benign pigmented lesions was noted with these pulsed light sources. The first generation of these pulsed light sources was bulky and did not have contact cooling. They have evolved considerably, and now offer portable devices with contact cooling and more selective filters. While pulsed light was being utilized for “photofacials,” pulsed dye lasers, originally developed for the treatment of port wine stains, were

rapidly gaining popularity for the treatment of cosmetic vascular lesions. A “side effect” seen clinically while treating facial vascular lesions was the improvement in fine rhytids, which led to the use of these lasers for the treatment of periorbital rhytids (4). As with all nonablative devices, the results were generally disappointing. Simultaneously, other visible and near infrared lasers were also being utilized for this purpose, such as the Q-switched 1064 nm laser, the Q-switched 755 nm laser, the pulsed 532 nm potassium titanyl phosphate (KTP) laser, and the long pulsed 1064 nm laser. It is now generally accepted that these single wavelength lasers are best utilized for the treatment of vascular and pigmented lesions, and the resurfacing effects are generally disappointing. Enhancement of pulsed light sources and visible wavelength lasers can be performed with short contact photodynamic therapy. Topical 5-amino levulanic acid is applied for 60 to 90 min before treatment with pulsed light or pulsed dye laser treatment. Enhancement of photorejuvenation (5) with a variety of light sources has been reported, requiring fewer treatments and also leading to a greater “resurfacing” effect (Fig. 30.1). Another photosensitizer, Metvix (MAL) is also being investigated for this application. The optimal patient for non-ablative photorejuvenation is Fitzpatrcik skin type I to IV who presents primarily with facial telangiectasias and lentigines. Darker skin types can be treated, but lower energies and devices with contact cooling are advised to prevent permanent pigmentary anomalies such as hypopigmentation. Facial and non-facial skin can be treated, but lower energies need to be utilized on non-facial skin. A series of three to five treatments is generally necessary. The best devices for non-ablative photorejuevnation are visible light sources, with intense pulsed light (IPL) and pulsed dye lasers being the most uniformly used. Post-treatment, there is an appearance of “coffee grounds” like skin in areas where pigmented lesions were present. Vascular lesions may show coagulation, but rarely show true purpura, with lower fluencies and pulse stacking. Some argue that purpurogenic fluencies result in better outcomes but the appearance of purpura is not well tolerated by the patient. For simultaneous treatment of pigment and vessels, IPL is the best device. In summary, visible and mid-infrared laser and light sources are generally disappointing as monotherapy for skin resurfacing. They are better suited for the treatment of vascular and pigmented lesions, which is termed “photofacial.” Enhancement of the photofacial can be performed using short contact photodynamic therapy. NON-ABLATIVE FRACTIONAL LASER RESURFACING

The disappointing results of skin resurfacing coupled with the risks and recovery of traditional ablative laser resurfacing has led to the development of non-ablative fractional lasers. Fractional photothermolysis is an extension of selective photothermolysis (which is the main mechanism of treating vascular and pigmented lesions). In order for a device to meet the criteria of a true non-ablative fractional laser, three criteria have to be fulfilled—(a) the device has to create microthermal zones of damage to the treated tissue, (b) there is an extrusion of contents of the skin for a true resurfacing, and (c) reepithelialization has to occur within 24 hours (6). Non-ablative fractional laser resurfacing has rapidly changed the landscape of skin resurfacing in general and is now considered the gold standard for a variety of clinical applications. It has also expanded skin resurfacing to non-facial skin.

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Table 30.1 Non-ablative Devices for Photorejuvenation

Table 30.3 Non-ablative Devices for Skin Tightening

Device and wavelength

Unipolar radiofrequency Bipolar radiofrequency with pulsed light and laser Bipolar radiofrequency with vacuum Unipolar and bipolar radiofrequency Focused ultrasound

Target

KTP Lasers at 532 nm, long pulsed Pulsed dye lasers at 585 and 595 nm Long pulsed and Q-switched 1064 nm lasers 1320 nm laser 1450 nm laser Pulsed light sources

Hemoglobin and melanin Hemoglobin Water (some off peak hemoglobin) Water Water Hemoglobin and melanin

Figure 30.1 Before and after photodynamic therapy for photoaging.

A variety of lasers employ the principles of non-ablative fractional laser resurfacing (NFR) (Table 30.2). NFR creates microscopic patterns of laser wounds that produce spheroid segments of epidermal necrotic debris with relative preservation of the stratum corneum. This energy can be delivered in a random scanning mode (Fraxel family of lasers) or in a stamped fashion (Starlux 1540 and Affirm lasers). A series of three to five treatments are necessary with most devices because of the percentage coverage. A recently introduced 1927 thulium non-ablative wavelength may necessitate fewer treatments (Fig. 30.2). The clinical indications of NFR are skin resurfacing of the facial and non-facial areas for moderate photodamage and fine rhytids, acne scars, surgical and traumatic scars, therapy resistant melasma, and striae (7). Deep rhytids will show some response, but are best treated with ablative fractional resurfacing or combination therapies. Non-ablative fractional lasers are truly color blind and all skin types can be treated safely. Lighter skin types can be treated with more aggressive fluencies and treatment densities, while darker skin types are best treated with lower fluencies and lower treatment densities. Pretreatment with hydroquinones is recommended in skin types that show a propensity for hyperpigmentation. Post-inflammatory hyperpigmentation may occur but usually resolves. Transient flares of acne have been reported. Immediately post-treatment patients will experience erythema and edema, which become mostly pronounced at 24 hours and can persist up to one week, especially with more aggressive settings. Compared to ablative fractional resurfacing, the down time is limited to edema and erythema.

Table 30.2 Non-ablative Fractional Laser Resurfacing Devices Wavelength (nm) 1440 1540 1550 1927

Method of delivery Stamped pattern Stamped pattern Random scanning Random scanning

Figure 30.2 Before and after single treatment with non-ablative 1927 and 1550 nm laser.

NON-ABLATIVE SKIN TIGHTENING

While surgery remains the gold standard of the treatment of skin laxity, many patients are seeking alternative treatments and many patients are not ideal candidates for a surgical option. Nonsurgical approaches to skin tightening remain one of the most controversial topics in aesthetic medicine. The “purists” argue that there is no role for these devices, while over zealots will promote “facelift” like results. The truth is probably somewhere in the middle, and we are finally optimizing these devices for more predictable outcomes. A summary of devices is listed in Table 30.3. The most widely studied and utilized technology for non-ablative skin tightening is unipolar radiofrequency. The first device, Thermacool, was introduced in 2001(8), using monopolar radiofrequency with capacitive coupling to deliver the radiofrequency through a thin membrane in the treatment tip. The energy was distributed over a threedimensional volume of skin, allowing uniformed heating at deep dermal and subcutaneous depths to cause collagen contraction and subsequent collagen remodeling. The initial results were disappointing, especially because of pain control and variability in response. New treatment algorithms were introduced in 2006 using multiple passes and lower fluencies for more predictable outcomes and reduced discomfort. Since then, a variety of treatment tips for different areas, both facial and non-facial, have been developed, and most recently a vibratory tip which capitalizes on the “gaited” theory of pain was introduced. The vibration is sensed before delivery of the radiofrequency energy allowing for greater pain control. Combined electrical and optical energy (9) uses bipolar radiofrequency and optical energy from lasers and light sources. The theory

NON-ABLATIVE DEVICES

Figure 30.3 Before and after unipolar radiofrequency for eyelids.

Figure 30.4 Complication due to inadequate cooling with infrared Titan device used for skin tightening.

behind this approach is a synergistic approach to the treatment of photoaging (with lasers and light sources) and laxity (with bipolar radiofrequency). Recently, a sublative fractional mode of energy was introduced to enhance the safety and reduce bulk heating. Hybrid monopolar and bipolar radiofrequency devices utilize two mechanisms of radiofrequency-induced tissue heating, allowing for both superficial and deep heating. Cellulite and fat reduction have also been proposed with these devices, due to both superficial and deep heating (10). Broadband light sources in the infrared region employ the principles of deep dermal heating that uses a light source. Epidermal protection is afforded by contact cooling. The latest addition in the armamentarium of non-ablative skin tightening is the use of intense focused ultrasound, which recently received FDA clearance. Short pulses of energy in the microsecond domain are delivered using megahertz focused ultrasound, which creates welldefined areas of thermal coagulation within the deep dermis without disrupting the epidermis and papillary dermis (11). Since ultrasound is “color blind” as there are no chromophores, like all of these tightening devices, the energy can be delivered safely in all skin types.

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Figure 30.5 Combination of single treatment with 1550 nm fractional laser resurfacing and unipolar radiofrequency.

Figure 30.6 Combination therapy with photofacial, onabotulinum toxin A, and hyaluronic acid fillers.

Patient selection is critical for optimal treatment outcomes. The optimal patient is one that has mild-to-moderate laxity without underlying structural defects. Younger patients may respond better than older patients. Patients who will not do well with skin tightening devices are those with underlying laxity of facial musculature and excessive amount of skin laxity. The eyelid area seems to produce the most consistent results and a great option for those who are not ideal candidates for a surgical approach (Fig. 30.3). Complications of skin tightening technologies include subcutaneous atrophy using the old radiofrequency protocols, superficial burns and deep burns, and scars with devices that have poor contact cooling (Fig. 30.4), as bulk heating can ensue with deep infrared light sources with suboptimal epidermal protection. INTEGRATIVE NON-ABLATIVE DEVICES IN A PRACTICE: A PRACTICAL APPROACH

While there is elegant histology, a myriad of clinical studies and publications—the practicing core aesthetic physician asks the question— what devices are going to be appropriate in the practice and how does one integrate these devices in the armamentarium of complimentary

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aesthetic procedures. Photorejuvenation for the treatment of vascular and pigmented lesions is the most popular treatment, followed by nonablative fractional resurfacing and third, skin tightening. Therefore, a stepwise approach to integrating these devices into a practice is advisable. While monotherapy can produce excellent clinical outcomes, combination therapy remains the mainstay of patient satisfaction. These devices are excellent counterparts to dermal fillers and botulinum toxins. Timing and synergy are the key for optimal outcomes. Moreover, these devices in combination with each other also produce better outcomes. A perfect example of combining devices for optimal outcomes is the combination of non-ablative fractional laser resurfacing and monopolar radiofrequency skin tightening (Fig. 30.5). The former device addresses the facial canvas anomalies as the primary target with some improvement in laxity while the latter primarily addresses skin laxity but may show delayed and variable responses. The synergy of the two technologies is being investigated and there may be “synergistic” skin tightening when both devices are used in combination. Another winning combination is the use of botulinum toxins and dermal fillers in combination with all of the devices (Fig. 30.6). The botulinum toxin addresses dynamic rhytids, the devices will address facial canvas anomalies and laxity, and dermal fillers will restore volume and facial shaping. Same day botulinum toxin and photofacial are advisable but same day fractional laser resurfacing and botulinum toxin are not advisable as there may be enhanced diffusion of the botulinum toxin after fractional laser resurfacing. Dermal fillers can be performed on the same day as any procedure and none of the devices “melt” fillers. There is some anecdotal evidence that enhanced longevity of dermal fillers may ensue after fractional laser resurfacing. CONCLUSIONS

Non-ablative energy-based devices can be divided into three categories: (a) visible and near infrared sources for photorejuvenation, (b) non-ablative fractional laser resurfacing (NFR), and (c) skin tightening devices. Photorejuvenation devices are best utilized for the treatment of telangiectasias and lentigines—the so-called photofacial—show minimal improvement of rhytids. NFR devices are optimal for skin

resurfacing of mild-to-moderate photodamage for facial and nonfacial skin. Skin-tightening devices are best suited for nonsurgical candidates and those who show mild laxity. All devices will produce optimal outcomes when combined together or with botulinum toxins and dermal fillers. REFERENCES

1. Bernstein LJ, Kauvar AN, Grossman MC, et al. The short- and longterm side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997; 23: 519–25. 2. Jih MH, Friedman PM, Goldberg LH, et al. The 1450 nm diode laser for facial inflammatory acne vulgaris: dose response and 12 month follow-up study. J Am Acad Dermatol 2006; 55: 80–7. 3. Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial full face intense pulsed light treatments. Dermatol Surg 2000; 26: 835–42. 4. Reynolds N, Thomas K, Baker L, et al. Pulsed dye laser and nonablative wrinkle reduction. Lasers Surg Med 2004; 34(2): 109–13. 5. Nestor M, Gold M, Kauvar A, et al. The use of photodynamic therapy in dermatology: results of a consensus conference. J Drugs Dermatol 2006; 5: 140–54. 6. Manstein D, Herron GS, Sink RK, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004; 34: 426–38. 7. Narurkar VA. Nonablative fractional laser resurfacing. Dermatol Clinics 2009; 27(4): 473–8. 8. Bogle MA. Radiofrequency energy and hybrid devices. In: Alam M, Dover JS, editors. Procedures in cosmetic dermatology series: nonsurgical skin tightening and lifting. Philadelphia: WB Saunders 2008: 21–32. 9. Sadick NS, Makino Y. Selective electro-thermolysis in aesthetic medicine: a review. Lasers Surg Med 2004; 34: 91–7. 10. Mayoral FA. Skin tightening with a combined unipolar and bipolar radiofrequency device. J Drugs Dermatol 2007; 6: 212–15. 11. Alam M, White L, Majzoub R, et al. Safety and efficacy of transcutaneous ultrasound for forehead, cheek and neck tissue tightening. Lasers Surg Med 2007; S19: 19.

31

Cosmeceuticals Jeanine Downie

The word cosmeceuticals strikes a cord of fear and confusion in the souls of many dermatologists. What products should I offer for sale? Will my patients purchase them? What will compliment my practice? How can I be sure the product will work on my patient? Cosmeceuticals are a great way to build and compliment a cosmetic practice and to be an additional source of business income. That is why everyone engaged in the business of dermatology should consider selling a few products to patients. The best approach is to sell products that compliment their practice population and philosophy. If your practice is light on cosmetic procedures and mostly medical, you should consider selling sunscreens, and perhaps two types of facial moisturizers: one for acne-prone skin that may become dry with treatment, and a more emollient barrier repair product for patients with inflamed and dry skin. An antioxidant or two to complement the protection of sunscreens might also be a good plan. However, if your practice emphasizes cosmetic dermatology and cosmetic procedures, you should expand your products as your cosmetic patients will want to extend and maintain the benefits from your in-office cosmetic procedure. A face sheet is the best way to outline and explain the treatment protocol so the patient fully understands and will be more compliant at home. The face sheet is rough outline that should be customized to each patient. It should begin with a facial wash, a day antioxidant, a sunscreen and then other topical prescriptions as needed. At night, again a facial wash is recommended, followed by a night cream or serum that is tailored to the condition being treated. Other prescription products may be added later. Finally, I recommend a mask for many patients with acne, aging concerns, and with post-inflammatory hyperpigmentation. The oxygen radical absorbance capacity (ORAC) assay was originally developed by the USDA to evaluate the ORAC of foods and cosmetic products by measuring scavenging activity against the peroxyl radical, the most commonly found radical in biologic systems. ORAC is largely replacing the environmental protection factor (EPF), which provides a measure of antioxidant ability based on a substance’s photoilluminescence, results of sunburn cell assay, primary and secondary oxidative products, and ultraviolet B (UVB)-irradiated keratinocytes. The EPF was originally described in relation to Prevage MD, which scored higher in this assay than did kinetin, vitamin C, vitamin E, and dimethylethanolamine (DMAE). The ORAC scores for a sampling of categories and specific items are listed in Table 31.1. Some of the popular, effective products on the market are described in the following sections. Selling them can be quite easy or very difficult. The doctor’s plan is really what matters here. Involve your staff, test products, do inventory, restock often, and believe in what you sell. Almost everyone leaves my practice with a sunscreen in hand. This is the easiest and the most important product of all products. Preach a more even skin tone, decreased wrinkles or less skin cancer. Be consistent and make sure that you wear it yourself. Antioxidants are also critical. Patients have become more aware of what antioxidants do and how they perform on the skin. Explain that free radicals can cause substantial damage to the skin. In the 1950s, Harmon discovered that free radicals cause skin damage. Free radicals are unpaired electrons in the outer chemical ring of a molecule. Antioxidants can provide the needed electrons to free radicals to prevent them from causing substantial damage to the skin. Antioxidants appear to have significant effects on signaling pathways that are

involved in skin damage. They appear to protect against photodamage and may prevent inflammation and wrinkles. Table 31.2 provides a list of the daily antioxidants. FACIAL CLEANSERS

Facial cleansers are another important part of the cosmeceutical compliment. Cleansers act as surfactants that decrease facial sebum, bacteria, and environmental dirt. They can also hydrate or conversely strip the skin. Facial cleansers have been debated for years as to whether or not they actually deliver active ingredients to the skin. The main debate is over the short amount of contact time with the cleanser to the skin. I am on the side of those scientists and clinicians who believe that short contact with an effective active ingredient in the form of a cleanser does improve the skin. Glycolic acids, salicylic acids, soy, and coffeeberry are among the products I recommend in the form of a cleanser. Facial scrubs can be harsh and I recommend a very limited amount. The more coarse, particulate scrubs may cause abrasions and physical damage to the top layers of the skin when used too vigorously. Additionally, loofahs and other harsh sponges are not recommended as they can trap bacteria and lead to superficial skin infections. Table 31.3 reviews popular and effective facial cleansers. FACIAL MOISTURIZERS

Facial moisturizers are another cornerstone of cosmeceuticals. Moisturizers function to restore the hydration of the epidermal barrier. They have either humectant, emollient, and/or occlusive properties. For purposes of cosmeceuticals, we usually recommend emollients and humectants. Humectants attract and trap water from the humid environment to the stratum corneum. The most effective humectants are propylene glycol and glycerol. Emollients are usually lipids which enhance the stratum corneum by filling the crevices between corneocytes. This leads to increased skin softness, smoothness, enhanced texture, and improved barrier repair. There is a need for a concise discussion with the patient to determine their skin type and their specific set of antiaging/hydration needs. Tables 31.4 and 31.5 review some of the facial moisturizers with antiaging active ingredients in them. EYE CREAMS

Eye creams are detailed in Table 31.6. Many of the most popular eye creams and face creams have key ingredients to enhance the skins radiance. Specifically, film-forming moisturizers work to improve skin texture and tone by increasing surface smoothness and thereby increasing light reflectance from the face. This technology requires dimethicone which creates a film over the skin surface and retains transepidermal water loss. In addition to this, a protein film adds to the hydration of the fine lines around the eyes. These film-forming moisturizers also fill in air spaces. Therefore, they alter the interface between the stratum corneum and the epidermis underneath. Optical reflective pigments are also found in many cosmeceutical products for the eye area. The reflective pigments consist of small, colored particles of fish scale bismuth oxychloride, or mica. These alter light reflection on the skin surface by diffusing light in different directions and create an appearance of more even skin color. Hyaluronic acid filling spheres are more expensive and the newest of the

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Table 31.1 Measuring Antioxidant Capacity ORAC Category Teas (green/black) Fruits Vegetables Specific items Coffeeberry Green tea Pomegranate Vitamin C Vitamin E Ferulic acid

507–4796 104–5770 150–1770

three technologies. These products are used in the periocular and lip areas. The mechanism of action for those products involves water attraction and subsequent tissue expansion that smoothes fine lines and wrinkles. When the fold around the eyes is filled in, it creates a more youthful, glowing appearance. TONERS AND MASKS

15,000 3000–5000 3000 200 200 200

Source : From Ref. 15.

Table 31.2 Daily Antioxidants 1% Idebenone (Prevage MD) 15% Glycolic, green tea, pomegranate (Vivite Daily Antioxidant Facial Serum) 1% Coffeeberry(Revaleskin Day Cream) 1.5% Coffeeberry (Revaleskin Intense Recovery Cream) Antioxidant with skin brighteners (Vivite Vibrance Therapy) Growth factor (GF) (Skin Medica TNS Essential Serum, Neocutis Biorestorative Cream or Gel) Vitamin C serum (DCL Vitamin C Serum, Dr Mary Lupo Vivifying Serum C) Skinceuticals CE Ferulic

Table 31.3 Facial Cleansers Glycolic wash 12%, 15%, 20% (MD Forte Facial Cleanser I, II, III) Glycolic wash (MD Forte Glycare Cleansing Gel) Coffeeberry (RevaleSkin Facial Cleanser) Glycolic wash (Glytone Cleansing Gel) Chamomile/anti-irritant syndet (Vivite Replenshing Hydrating Cleanser) Glycolic acid 15%, salicylic acid, exfoliating microbeads (Vivite Exfoliating Cleanser) Growth factor (GF) (Skin Medica Cleanser) Glycolic acid (Neostrata Cleanser) Pat Wexler, M.D. Facial Cleanser Dr. Mary Lupo Gentle Purifying Cleanser

Table 31.4 Glycolic Moisturizers Glycolic moisturizers 12%, 15%, 20% (MD Forte I II and III Face Cream) Glycolic moisturizers 12%, 15%, 20% (MD Forte I, II, III Skin Rejuvenation Lotion) Glycolic, green tea, pomegranate (Vivite Daily Antioxidant Facial Serum)

Table 31.5 Miscellaneous Moisturizers Copper lotion (Neova Manganese Brightening Complex) Superoxide dismutase cream (MD Forte Replenishing Hydrating Cream) Superoxide dismutase cream (Vivite Replenishing Hydrating Cream)

Table 31.6 Eye Creams Glycolic eye cream (MD Forte Eye Cream) 10% Glycolic eye cream with peptides (Vivite Eye Cream) 1% Coffeeberry (RevaleSkin Eye Cream) Growth factor (GF) (TNS Illuminating Eye Serum, Lumiere by Neocutis)

Astringents and masks provide mechanical exfoliation and can be irritating to the skin. These products may contain a number of cosmeceutical ingredients. Masks are used to combat photoaging, improve texture, and fight acne. Many masks contain kaolin, glycolic, salicylic acids, sulfur, honey, or green tea in them. They usually contain polyvinyl alcohol to allow them to peel off. Clay-based masks are rinsed off. Masks are also used to improve skin hydration, exfoliate, and unclog pores. Toners are used after cleansing the face to remove additional sebum and debris from makeup. Toners are alcohol or non-alcohol based. They are used to fight acne predominately. Different formulations may contain salicylic acid, tannins, witch hazel, tea tree oil, and/or aloe vera. Side effects may include contact dermatitis and they should in fact be used carefully so the skin does not get irritated. CELLULITE CREAMS

Cellulite appears to be influenced by estrogen as over 90% of all women have it to varying degrees. There is apparently no topical cream that can significantly decrease the appearance of cellulite. Topical products have been designed to alter fat breakdown mechanisms. However, as cellulite appears to be caused by fat herniation through fibrous bands, only machines like endermologie offer some fleeting temporary relief. Topical creams have attempted to change the structure of the adipocyte, slow down lipogenesis or increase lipolysis. Fat breakdown is stimulated by beta-adrenergic receptors. Agents that stimulate betaadrenergic receptors may breakdown fat. These anticellulite cosmeceutcials include caffeine, theobromine, theophylline, and aminophylline. Agents that inhibit alpha-adrenergic receptors and prevent the inhibition of lipolysis include phentolamine, yohimbine, and piperoxan. Additional studies need to be performed to prove clinical efficacy. At this time no effective cellulite creams exist. NIGHT CREAMS AND SERUMS

The skin cells naturally renew themselves at night, while you sleep. This is part of the innate, restorative processes of the largest organ in the body. Obviously, the need to use a night cream versus a night serum depends on the individual patient’s skin type, level of skin sensitivity, overall antiaging, and moisturization goals. Prescription products work very well at night, tretinoin in particular, but must be used carefully in dry or sensitive skin. Many physicians sell cosmeceuticals in their office that contain retinol, I prefer the prescription products Retin A Micro 0.04%, Tazorac cream 0.05%, Differin lotion 0.1%, or Differin gel 0.3%. Tretinoin and retinols build collagen and therefore decrease fine lines and wrinkles in a statistically significant amount over time. Unfortunately, they may be irritating and must be spaced out in patients with sensitive skin. Table 31.7 references many of the night creams. Stress to your patients that night time is the time for their skin to repair and renew. Make sure your staff uses and recommends new night cream and serums as they become available on the market. Discuss in great detail with patients how to apply and stress that many night cosmeceutical products can be used in combination with prescription acne medications, if necessary. SUNSCREEN

Sunscreen helps prevent further damage from UVA and UVB exposure. This is the ultimate cosmeceutical and many feel it is a drug. UVA rays

COSMECEUTICALS

Table 31.7 Night Creams/Serums

Table 31.8 Sunblocks

Growth factor (GF) (Skin Medica TNS Recovery Complex) Vitamin A & E cream (Skin Medica Dermal Repair) 20% Glycolic cream (Vivite Night Renewal Facial Cream) 1% Coffeeberry (Revaleskin Night Cream) Growth factor (Skin Medica TNS Essential Serum)

MD Forte Aftercare Spf 30 Skin Medica Spf 50 Environmental Defense Vivite Facial Moisturizer with Spf 30 Neutrogena Dry Touch Spf 85 Anthelios SX and XL Alyria Lotion Spf 30

promote collagen breakdown, fine lines and wrinkles and immediate burning. UVB rays also contribute to collagen and elastin breakdown. Both UVA and UVB rays lead to premature aging and potential skin cancers. Sunscreen with a sun protection factor (SPF) of 15 confers 93.5% protection from the sun rays. An SPF of 30 gives one 96.5% protection from the sun rays. An SPF 45 gives you about 97% protection. After SPF 45 the percentage protection levels off according to the Skin Cancer Foundation research. Therefore, an SPF of 70 may give you 97.3% protection but it is not that much more significant in value for photoprotection. I strongly recommend patients wear a matte sunscreen like those noted in Table 31.8. Matte sunscreen on the face usually ensures the patient will wear it. One of the reasons The Skin Cancer Foundation research has shown that only 33% of all American adults wear sunscreen on a somewhat regular basis is because they feel sunscreens are too greasy. I am fond of saying sunscreens do not work in the bottle, only if they are put on your skin. For the body I recommend all sunscreens with broad spectrum protection again, such as Neutrogena SPF 45 with Helioplex, Aveeno SPF 45 continuous protection and Ocean Potion SPF 70 with Solaplex. These products all have ingredients that stabilize UVA blockers (Parsol 1789) so it does not breakdown as fast. All sunscreens should be reapplied every two hours and a two ounce shot glass should be used on all sun-exposed areas. Sunscreen should be applied twenty minutes before going out into the sun. Skip areas, along clothing lines, at the top of the forehead, on the ears should be avoided as sunburn can be a problem in these areas. SPECIFIC COSMECEUTICAL INGREDIENTS

Green Tea This is among the most rapidly growing herbal products. Use of tea extracts is apparent in cosmeceutical formulations and in dietary supplements. The polyphenolic compounds in tea provide the same protective effect for internal organs as they do for the skin. Polyphenols regulate biochemical pathways that are critical in inflammatory responses, cell proliferation, and responses of tumor promoters. Green tea has been shown in clinical studies to have both antioxidant and anti-inflammatory effects in both animal and human skin. Green tea may also have antiaging effects by scavenging free radicals and decreasing inflammation. Scientists have determined that the key active ingredient in green tea is epigallocatechin-3-gallate (EGCG). Green tea works well as an antioxidant, a sunscreen, and an anti-inflammatory. To summarize, green tea decreases radical oxygen species, it prevents lipid peroxidation and DNA damage. It also induces apoptosis and reverses photoaging over time. Table 31.9 includes some antiaging botanical agents containing antioxidants. Coffeeberry Harvested from the unripened fruit of the Coffea Arabica plant, coffeeberry extract contains many known active components, including the polyphenols caffeic acid, quinic acid, ferulic acid, condensed proanthocyanidins , chlorogenic acid, and trigonelline. It is considered to be one of the richest sources of antioxidants and has been extensively researched for its skin rejuvenation properties. In clinical studies done by Stiefel Laboratories, they indicate that coffeeberry out performs green tea extract, vitamin C, and vitamin E. This was shown on the ORAC scale as it ranks higher than the aforementioned products

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Table 31.9 Antiaging Botanical Agents Containing Natural Antioxidants Soy Mushroom extract Feverfew Green tea Pomegranate Mangosteen Rosemary Propolis Olive oil Grape seed extract Lavender Source : From Ref. 1.

in terms of antioxidant activity by 10 to 15 times more. Clinical laboratory studies have proven that the extract protects against both UVA and UVB radiation which enhances its ability to treat photoaging. Also in clinical trials, coffeeberry has demonstrated help for the treatment of erythema and dyschromia. Further research is ongoing in the area of skin cancer prevention, as further assessment is needed to clearly delineate the benefits in this area. Soy Topical use of soy has been shown in clinical trials to decrease hyperpigmentation, moisturize the skin, delay hair regrowth, enhance skin elasticity, and control oil production. It is also being researched for its potential to prevent skin cancers and decrease skin aging through the estrogenic and antioxidant effects of its metabolites. Specifically, soybean trypsin inhibitor (STI) and Bowman-BIrk inhibitor (BBI) inhibit keratinocyte protease activated receptor (PAR-2). PAR-2 is involved in the regulation of pigmentation. Clinical studies have indicated that modulation of PAR-2 activation by STI and BBI (both serine protease inhibitors) induce melansome transfer and produce reversible depigmentation. Table 31.10 highlights the multiplicity of benefits of natural ingredients. The other major components of soy are phospholipids, such as essential fatty acids and phosphatidylcholine. The other minor components of soy include essential amino acids, phytosterols, isoflavones, potassium, iron, saponins, and calcium. The most biologically active isoflavones are the phytoestrogens known as daidzein and genistein. Genistein is a potent antioxidant that inhibits lipid peroxidation, ultraviolet light B, and chemical induced carcinogenesis. Topical estrogens have been shown to promote collagen synthesis and increase skin thickness. In addition, lecithins, soy lipids, and phytosterols have been shown to replenish moisture and restore barrier function. Peptides Three classes of peptides used in topical antiaging regimens include neurotransmitter inhibiting peptides, carrier peptides, and signal peptides. Peptides are sequences of amino acids that imitate the amino acids in both collagen and elastin. As peptides are large molecular weight compounds, many clinical studies have shown that they have a limited ability to penetrate the stratum corneum. However, despite

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their limited penetration ability, peptides are believed to increase collagen and elastin synthesis. Neurotransmitter inhibiting peptides include the hexapeptide argireline cacetyl–glutamyl–glutamyl– methoxy–glutaminyl–arginyl–arginylamide is supposed to function like botulinum toxin. Argireline is similar to the N-terminal domain of synaptosome associated protein 25 KDA (SNAP-25). SNAP-25 blocks the formation of the N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) protein complex that is needed for docking vesicles of acetylcholine release. Therefore, this synthetic peptide is marketed to provide muscle relaxation and wrinkle reduction. Unfortunately, it does not have the same effects as botulinum toxin as it cannot effectively penetrate the skin due to the molecular kilodalton size to reach the deeper muscles. Carrier proteins, such as the tripeptide glycyl-L-histidyl-L-lysine are peptides that facilitate the delivery of metals to the skin by facilitating copper uptake by the cell. Copper is a critical cofactor for lysyl oxidase, which is the enzyme needed for collagen synthesis. The tripeptide also increases the level of tissue inhibitor of metalloproteinases (TIMP-1 and TIMP-2) and increases levels of matrix metalloproteinase-2 (MMP-2). Signal peptides are short chain amino acids. These augment communication between cells. Lysine–threonine–threonine–lysine– serine (PALKTTKS) is a signal peptide found in type I pro collagen. Proctor + Gamble research on Regenerist which has PALKTTKS in it has shown it stimulates in vitro synthesis of collagen type I, IV, and fibronectin. Growth Factors Growth factors (GF) are naturally occurring cytokines and proteins. They regulate tissue repair growth, cell development, and intercellular signaling. GF are produced by all cell types including skin cells such as fibroblasts, keratinocytes, placental cells, lymphocytes, and mast cells. Cytokines are associated with immune system cells and play a key role in modulation of inflammation and skin remodeling is complex. Inflammation leads to the generation of enzymes and reactive oxygen species that degrade the extracellular matrix. GF then induce dermal fibroblasts to imitate extracellular matrix production (ECM) and skin repair. GF developed for skin care

Table 31.10 Multiplicity of Benefits of Natural Ingredients Firmness and tone Restore firmness and suppleness Protect against loss of firmness and tone

• •

Even Tone, Texture, and Color Maintain/improve Red, blotchy Smooth, even texture

• • •

Antiaging Even tone/texture/color Sensitive/reactive skin Moisturization Firmness/tone

• • • •

Moisturization/dry itchy skin Restore and soothe dry itchy skin Prevent dry itchy skin

• •

Sensitive/reactive skin Calm/soothe stressed reactive skin Keeps skin balanced despite internal/external stresses

• •

Acne

• • • •

Chronic and acute skin conditions Soothe & heal

•

Eye care Dark circles Eye puffiness

• •

External aggressions Sun care Cleansing Facial treatments Pollutants

• • • •

Source : From Ref. 2.

Sebum reduction Redness reduction Appearance and size Scars and marks

products include epidermal growth factor (EGF), transforming growth factor (TGF), and platelet-derived growth factor (PDGF). ECF is found in plasma, sweat, semen, urine, and saliva; it stimulates epidermal re-epithelialization and differentiation. ECF has been used for the treatment of surgical wounds and burns. TGF augments the production of extracellular matrix proteins for epithelial repair, accelerates wound healing, and promotes angiogenesis. GF provide signaling between cells in close proximity to each other. GF may bind to multiple cell surface receptors to produce biological effects inside the cells. GF are now known to penetrate the skin in small amounts through hair follicles, sweat glands, and through postprocedure compromised stratum corneum. Only a superficial penetration of GF is required to imitate a cascade down to the deep dermis. Topical GF bind the receptors on epidermal keratinocytes secrete endogenous GF that can stimulate dermal fibroblasts. Optimal properties of topical GF included stability in the final product to ensure better delivery into the skin, physiological balance to work in concert to remodel the dermis, high concentration as penetration into the skin is concentration dependent and being naturally secreted by fibroblasts to ensure the precise three-dimensional structure of GF. Controversy surrounds whether or not larger GF can penetrate the stratum corneum. More studies are being performed currently; however, with newer delivery systems both immunoflourescent tagging and punch biopsy specimens have proved that liposomal transdermal delivery, phonophoresis, and microporation are working to deliver GF to deeper areas within the stratum corneum. Hydroxyacids The principal hydroxyacids are alpha hydroxy acid such as glycolic acid and beta hydroxy acid such as salicylic acid; hydroxy acids chemically exfoliate the stratum corneum and may improve texture, tone, acne, and fine lines. Topical hydroxy acid exfoliation also improves skin barrier and may improve photoaging. Polyhydroxy acids are not as significant. The most popular PHA includes gluconic acid, lactobionic acid, and galactose. The term chemoexfoliation is used when synthetic or natural products are used to slough cohesive corneocytes. The most popular are alpha hydroxy acids (AHAs). They are carboxylic acids which are synthetic products or products derived from plants. At high concentrations, these AHAs cause cleavage of the desmosomal attachment sites of basal layer of the skin, leading to epidermolysis. This effect can then produce varying degrees of exfoliation in the skin. At low levels, the AHAs reduce corneocyte adhesion. The types of AHAs include glycolic acids (derived from sugarcane) citric acid (derived from citrus foods), lactic acid (derived from sour milk), tartaric acid (derived from grapes), mandelic acid, and malic acid. AHAs help to treat a wide variety of both dermatologic and cosmetic indications. These include aid in the mechanism of skin moisturization. AHAs increase the synthesis of dermal, GAGS increase the density of collagen and improve the quality of elastic fibers. Glycolic acid and lactic acid can also inhibit tyrosinase activity, which suppresses melanin formation. Beta hydroxy acids (BHAs) include salicylic acid, beta-lipohydroxy acid, and tropic acid. Salicylic acid is lipophilic and can penetrate the follicular infundibulum and decrease sebum. It is used over the counter and in prescription strength chemical peels to improve acne, texture, and tone. Polyhydroxyacids (PHAs) are less irritating than AHAs. The polyhydroxy acids include lactobionic acids, gluconic acid, and galactose. PHAs are molecules that are larger molecules with slower skin penetration and slower absorption. PHAs are therefore less irritating and can be used for patients with seborrheic dermatitis and atopic dermatitis.

COSMECEUTICALS

TOPICAL THERAPIES FOR HYPERPIGMENTATION

Hyperpigmentation is due to an increased number of melanocytes or increased production of melanin. The mechanism of action of depigmenting agents varies. Some typical products decrease tyrosinase synthesis, others inhibit tyrosinase synthesis, and still others are toxic to melanocytes. There are limited safe, reliable, and effective skin depigmenting agents. Topical therapies for hyperpigmentation include: hydroquinone, kojic acid, azelaic acid, glycolic acid, retinoids/ retinol, vitamin C, mulberry extract, licorice, grapeseed extract, salicylic acid, niacinamide, mequinol, and arbutin. Known inhibitors of tyrosinase include hydroquinone, kojic acid, azelaic acid, vitamin C, mulberry extract, licorice, and arbutin. Hydroquinone is the most effective single agent for the treatment of hyperpigmentation disorders. It has more than 40 years of efficacy and safety data. Although there are potential side effects with high concentrations of hydroquinone used for long periods of time, there was not a single documented case of either an internal or cutaneous malignancy. Hydroquinone decreases tyrosinase activity by 90%. It is also cytotoxic to melanocytes. Adverse reactions that are acute include allergic or irritant contact dermatitis, post-inflammatory hyper, or hypopigmentation. Chronic complications include ochronosis, conjunctival melanosis, and nail discoloration. There are less than 25 reported cases of hydroquinones associated ochronosis in the past 25 years. Most humans are exposed to hydroquinone daily. Hydroquinones are found in coffee, tea, rice, onions, wheat, and berries. The standing hypothesis is that the body has gained the capacity to detoxify hydroquinone into inert compounds. Hydroquinones are the cornerstone of proper treatment of hyperpigmentation disorders, especially for skin of color patients. This is a very critical quality of life issue. Tretinoin reduces epidermal pigment in patients with hyperpigmentation when used 0.1% creams. Up to 88% of patients develop irritation from monotherapy. The time to clinical improvement is a greater than 24 weeks. Lumixyl is a synthetic peptide that inhibits tyrosinase was found to provide a 40% improvement in facial pigmentation after nine weeks of use and a 50% improvement after 16 weeks in a small study reported by E-med, the drug developer. Triluma is a triple-combination cream that contains flucinolone acetonide 0.01%, HQ 4%, and tretinoin 0.05%. It is indicated for the short-term intermittent and long-term treatment for more than 12 months for moderate-to-severe melasma. It is FDA approved for this indication. Ambi is a 2% hydroquinone that is sold over the counter. It is used for the treatment of melasma and post-inflammatory hyperpigmentation. Botanical agents show promise in treating skin hyperpigmentation, but additional studies need to be done to prove further efficacy. Table 31.11 reviews pigment lightening ingredients that can improve skin tone in varied cosmeceutical products. MOVE THOSE PRODUCTS

Frankly, once every seven seconds someone in the United States turns fifty. Americans paid over 15 billion dollars for facial skin care Table 31.11 Pigment Lightening Ingredients Hydroquinone Vitamins C+E Kojic acid Azelaic acid Ellagic acid (polyphenol) Niacinamide (B3) Soy Linoleic acid (fatty acids)

Inhibits tyrosinase activity Decreases tyrosinase activity Decreases melanin content in vitro Decreases tyrosinase activity Decreases tyrosinase Inhibits transfer of melanosomes to epidermal keratinocytes Reduces melanin transfer Tyrosine degredation

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products in 2008, according to the ASPS statistics. The growth in demand for cosmetic procedures and cosmeceuticals reflects the aging of America. To start out, consider a preliminary questionnaire to gauge your patients interest in cosmeceuticals. Ask some of your favorite cosmetic patients what products are on their wish list that they would like you to sell. Buy a few cases of products and give some free products to your staff, favorite patients, and your family to see if they like them. Try absolutely all the products that you are going to sell yourself. Use them, touch them, and smell them so you can relate to them when asked questions. Elicit feedback from staff and patients. Does the product have a bad smell, is it irritating or did it cause a breakout? Choosing between cosmeceuticals is also critical. Speak to at least three good cosmetically oriented dermatologists about what products they sell and why they like them. Any time a new drug or cosmeceutical representative enters your office with a new product line that you have interest in review all the new information carefully. Ask to call their three biggest accounts for feedback. Speak to each doctor personally about the pros and cons of the products. Always look at the cost analysis and project in advance what you believe you can make in profits each quarter. In terms of purchasing decisions look at new trends in ingredients and focus on natural ingredients delivery systems and niche products. Both facial and body products should be sold. Do not buy too much inventory at once. Stick to one or two product lines at first, facial cleanser, sunscreen, antioxidants, and antiaging night creams should be your main considerations. Conduct inventories often, return what is not moving, and replace it with more strategic purchases. Always have your office manager order products on a timely basis; if you are always out of products patients will lose interest. If there are expiration dates, have your staff check them every time before they sell the product. All cosmeceuticals should be in a secure closet that can be locked. Do not keep products in an area where patients have access. Train your staff well. Your staff can be your best asset or your weakest link when it comes to marketing and selling cosmeceuticals. Let them use some of the products as samples. Put a responsible staff member in charge of maintaining your product inventory. Product returns are complex, only deal with companies that have an excellent return policy. Have your staff track why products are being returned. Highlight to patients the value in some of the active ingredients and the cost savings in products that are only available from doctors. Explain that we as doctors can sell more concentrated and effective products, so they do not have to shop around. Designing an effective cosmetic antiaging regimen is both simple and important. Primarily you are looking to promote natural skin turnover, which gently exfoliates the skin to improve skin appearance. Additionally, improving the skin barrier helps to restore homeostasis and makes the skin less irritated by other topical products. Moreover, reducing oxidative

Table 31.12 Some Consequences of Photodamage

• • • • • • •

Epidermal thinning Loss of collagen and elastin Melanocytic clumping Photocarcinogenesis Flattening of dermoepidermal junction Immunosurpression Increase in: hyperplastic fiberoblasts, melanocytic clumping, inflammatory infiltrates

Source: From Ref. 30.

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stress by free radicals by using antioxidants will decrease oxidative cell damage of the skin including improving skin texture, tone, and fine lines. Promoting the natural production of both collagen and hyaluronic acid will help to decrease the appearance of wrinkles. Finally, minimizing hyperpigmentation improves skin tone leading to more beautiful skin. Choosing a cosmeceutical protocol is very straightforward. The doctor and patient should identify a need and reasonable treatment goal. Next products are selected that address that problem and also consideration is given to factor in the patients exact skin type (oily, sensitive, prone to hyperpigmentation, etc.). The patients are then educated on using the products and expectations are discussed. Table 31.12 discusses some consequences of photodamage that I review with my patients. Ultimately the results are evaluated after four to six weeks at least. Build reasonable expectations including better texture and more even skin tone, patients should not expect to look 10 years younger. Mail products and utilize charge sends for your patients that cannot make it to the office to purchase products. A key point is when patients have follow-up office visits, always ask them if they need any additional products. Patients should be told that they can stop by the office during regular business hours to purchase products even though they do not have an appointment. Stress the synergy between cosmetic procedures and cosmeceuticals, as this will help build your cosmetic practice. Advertise to your existing patient base in the waiting room and examination rooms, and in your practice marketing brochure. Run a loop on your DVD/VCR showing a patient using one of the products that is part of their treatment regimen and discuss the benefits of each product. The front desk staff must be knowledgeable of the products the doctor recommends and specifically what the doctor personally uses in their own skincare regimen. To seal the cosmeceutical deal, make tester samples available for patients to feel, touch and smell at your check out area. What patients touch and feel in many instances is what they will purchase. CONCLUSION

Americans paid over 15 billion for facial skin care products in 2008, according to the ASDS. Obviously, the growth in demand for cosmeceuticals and cosmetic procedures reflects the aging of America. The development and marketing of cosmeceuticals will continue to increase as the aging population increases. Americans are seeking less expensive, non-invasive alternatives to fight aging. More clinical trials that are well designed are needed to prove efficacy of the all the varied products on the market. As cosmetic dermatologists, we must take the reigns and research, learn and educate our patients, about what the best products are for their individual skin types. Using the products ourselves, promoting skin health before profit, and doing our own individual research before embarking on selling cosmeceuticals are the elements critical to success. BIBLIOGRAPHY

Alam M, et al. Requisites in Dermatology: Cosmetic Dermatology. New York, NY: Elsevier, 2009: 7–34. Badreshia-Bansal S, Draelos Z. Insight into skin lightening cosmeceuticals for women of color. J Drugs Dermatol 2007; 6(1): 32–9. Baumann L. Botanical ingredient in cosmeceuticals. J Drugs Dermatol 2007; 6(11): 1084–8. Baumann L. Cosmeceutical critique: hydroquinone. Skin & Allergy News 2007; 38(2): 28–9.

Baumann L. Less known botanical cosmeceuticals. Dermatol Therap 2007; 20: 330–42. Baumann LS. Active naturals: ancient medicine enters the scientific age. Skin & Allergy News Supplement 2008: 5–7. Ditre C, Wu J, et al. Innovations in natural antioxidants and their role in dermatology. Cutis 2008; 82: 2–16. Ditre CM, et al. Natural approaches to management of photoaging. Skin & Allergy News Supplement 2008: 11–13. Downie JB. Cosmeceuticals. Why They Are Profitable. American Society for Dermatologic Surgery Lecture, October, 2007. Downie JB. Topical Rejuvenation Options for the hyperpigmentation patient. Practical Dermatol 2009; Jun: 31–3. Downie JB, Kircik LH. Inside the science of cosmeceuticals. Practical Dermatol 2008; Jan: 61–5. Draelos ZD. Cosmetics and skin care products. A historical perspective. Dermatol Clin 2000; 18: 557–9. Draelos ZD. Optimal skin care for aesthetic patients: topical products to restore and maintain healthy skin. Cosmetic Dermatol 2009; 22(3 Suppl 1): 2–8. Guttman C. Ideal aging. Dermatol Times 2007; Oct(Suppl): 13–17. Habif TP. Clinical dermatology. In: A Color Guide to Diagnosis and Therapy, 3rd edn. St. Louis: Mosby, 1996; 23–41. Harman D. Aging: a theory based on free radical and radiation chemistry. J Geroritol 1956; 11: 298–300. Lemperle G, Morheen V, et al. Human histology and persistence of various injectable filler substances for soft tissue augmentation. Aesthetic Plastic Surg 2003; 27: 354–66. Leyden J, Baumann L, Downie J, et al. The role of natural ingredients in dermatology. Skin & Allergy News Supplement 2003: 1–4. Lupo M. Cosmeceutical Round Up. Cosmetic Boot Camp Lecture. June, 2009. Lupo M, Draelos ZD, Farris P, et al. Coffeeberry: a new natural antioxidant in professional anti-aging skin care. Cosmet Dermatol 2007; 20(10 Suppl 4): 2–9. Narins RS, Brandt F, et al. A randomized double blind multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg 2006; 20: 588–95. Nordlund JJ, Grimes PE, Ortonne JP. The safety of hydroquinone. J Eur Dermatol Venereol 2006; 20: 781–7. Palmer DM, Silverman Kitchen J. Science of aging Dermatol Times 2008; 30(3): 17. Pinnell S. Cutaneous photodamage, oxidative stress, and topical antioxidant protection. J Amer Acad Dermatol 2003; 48(1): 1. Stallings AF, Lupo MP. Practical uses of botanicals in skin care. Clin Aesthetic Dermatol 2009; 17(2): 36–9. The US Cosmeceuticals Market. [Available from: http://www.mindbranch.com/prod-toc/cosmeceutical-anti-aging-r567-701.] June 2008 (accessed September 3, 2008). Wallo W, Nebus J, Nystrand G. Agents with adjunctive potential in atopic dermatitis. J Amer Acad Dermatol 2007; 56(2 Suppl 2): AB70 Abstract P712. Weinkle S. The Scientific Basis for Cosmeceuticals, Cosmetic Boot Camp Lecture. June, 2009. Wolfender J, Terreau C, et al. The importance of LC-MS and LC-NMR in the discovery of new lead compounds from plants. Pharmaceut Biol 2000; 38(5 Supp1): 41–54. Yaar M, Gilchest BA. Skin aging. Postulated mechanisms and consequent changes in structure and function. Clin Geriatric Med 2001; 17: 617–30.

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Diverse populations in aesthetics: Young patients Ava Shamban

INTRODUCTION

The field of aesthetics has expanded to include a more youthful population, as men and women who are old enough to sign a consent form present not only with the traditional problems of acne and acne scarring but also with the desire to improve their appearance with nonsurgical interventions. Our culture values aesthetic beauty to the point that Americans spent almost $11.8 billion on cosmetic procedures in 2008 (1). Teens and young adults are well aware of the options out there: they are, after all, the children of the baby boomers, who dominate the market for these procedures. Besides watching their mothers refuse to age, these young, mostly female patients are holding themselves to the same high standards of the airbrushed celebrities they see in magazines, on TV, and on their hand-held devices. In addition, some issues may be too embarrassing for young people to bring up to a physician. For that reason it’s imperative to have patients fill out an extensive questionnaire or to be carefully interviewed to identify issues they are too shy to mention but would be relieved to have addressed. These include acne scarring, scars from selfmutilation, pigmentary disorders, excessive hair, early wrinkling, and red and brown birthmarks. Although this population barely has wrinkles to fill, it is concerned at the first sign of a line and wants to prevent aging at its inception. In addition, even if these patients aren’t modeling their features after a specific celebrity, they’re attuned to perfecting their own faces, requesting Botox as a prophylactic to negate future lines of expression, hyaluronic acid to fill in tiny wrinkles, or a collagen stimulator such as poly-L-lactic acid (PLLA) to enhance proportion and contour by augmenting cheekbones or chins. The approach to the youthful patient requires a sense of aesthetic responsibility. Facial features may be enhanced and made symmetrical but not exaggerated. It is important not to pander to body dysmorphic syndrome in utilizing the aesthetic toolbox, since the size and shape of facial features go in and out of style in the same way that hemlines go up and down. Every physician should determine a sense of their own aesthetics and follow the guidelines of aesthetic responsibility to ensure that their patients look like themselves, but better, and have their problems addressed in a meaningful way. This patient population exhibits a keen interest in preventive measures that can be taken to prolong a youthful appearance to the skin. Their healthy vanity allows the practitioner to illustrate the inevitable results of failing to be proactive about smoking, sun exposure, drinking, lack of exercise, and good skin care practices (6). By watching for telltale signs of aging so they can stay ahead of the curve, they grant us an opportunity to discuss maintenance therapies and to offer options to consider on the long road ahead.

on the market because they are non-immunogenic and hydrophilic, maintaining their volume longer than bovine collagen (3). HA fillers also stretch fibroblasts and inhibit collagenase, which stimulates collagen production and prevents its breakdown (4). By plumping these shallow lines and building more collagen to support the tissue, these early wrinkles can be stopped in their tracks, while still allowing for animation of the face. Two of the best-known brands of HA fillers are Restylane (Medicis Pharmaceutical Corporation, Scottsdale, Arizona, USA) and Juvederm Ultra (Allergan, California, USA), both of which are approved to treat wrinkles and folds in patients 18 years or older. Undereye circles are not just a complaint of older individuals with thinning skin; plenty of young patients seek help after hearing that they look tired, even if they’re not. HA fillers can erase those circles caused by a type of bone structure and absence of the orbital fat pad that produces the appearance of deep-set eyes. The shadowy darkness can be due to the fact that the undereye surface is concave, contributing to a canyon effect that traps light. Augmenting these recessed areas with HA fillers makes the surface convex, so that light is reflected back out (Fig. 32.2A and B). Lips that are voluptuous are in vogue, and many young patients are requesting HA fillers to add volume and pout, or to correct genetic asymmetry. These patients, especially young women, possess an aesthetic sophistication that belies their years: If they have thin lips that are too small for their face, they want them augmented to balance out their features (Fig. 32.3A and B). Although HA fillers are used in the United States to treat the border of the upper and lower lips to enhance contour and definition, their use in the lip is off-label (2). Facial geometry : Depressions in the skin from acne excoriee, as well as traumatic scarring from bicycle and car accidents, dog bites, horseback riding, and self-mutilation, can be addressed with HA fillers (Fig. 32.4A and B). They can also fix facial asymmetry. In addition, by smoothing out a bump on a nose the need for a rhinoplasty is often eliminated. The youthful face has an ample amount of volume, which displays a smooth transition from one area to another (5). In patients where more depth and volume is needed, a tissue stimulator such as PLLA (Sculptra®, Dermik, Bridgewater, New Jersey, USA) or calcium hydroxylapatite (Radiesse®) offers longer lasting correction. These subcutaneous fillers can correct weak chins and can soften the skeletonized appearance of a thin face when injected into the temple, the supraorbital rim, the zygoma, the maxilla, and the mandible (5). As clinicians and patients learn more about the volume changes that occur slowly in all tissues of the face as it ages, they are realizing that addressing early volume changes in multiple areas as soon as they start can make a profound difference with very little effort (5). The conservative amounts of product needed in the younger patient make PLLA and calcium hydroxylapatite a cost-effective choice for a generation lacking much in the way of disposable income.

ASTHETIC CONCERNS IN YOUNG POPULATIONS

Soft Tissue Augmentation Early lines and wrinkles can show up in young people who are genetically predisposed, especially if they have incurred sun damage. Though not usually deep at this young age, these lines are either static (present at rest), or dynamic, appearing during muscular contractions such as smiling or frowning. One way to prevent dynamic lines from being etched in is with neurotoxins (discussed below) or with hyaluronic acid (HA) dermal fillers, which elevate lines to the level of the surrounding skin (Fig. 32.1A and B). They have quickly become the most popular fillers

HYPERDYNAMIC MUSCLES

The effectiveness of botulinum toxin A (Botox Cosmetic, BTX) to prevent facial muscles from contracting and thus skin from furrowing has made it the most frequently performed non-surgical cosmetic procedure in the United States in 2008 (6). Its popularity in this country is not confined to the older set: In 2008, 60% of facial plastic surgeons surveyed had injected BTX in women under age 35 years (6). BTX is approved for use in patients 18 to 65 years, and physicians may exercise their judgment in patients under 18 years (with parental

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(A)

(B) Figure 32.1 Filler NLF: (A) before; (B) after.

(A)

(B) Figure 32.2 Filler under eyes: (A) before; (B) after.

(A)

(B) Figure 32.3 Filler lips: (A) before; (B) after.

consent). Dysport (DYS) is approved for use in patients 18 years and older. Scowl lines, horizontal forehead wrinkles, and crow’s feet are being routinely treated with BTX even in 20-year olds, especially those with hyperexpressive faces. The neurotoxin helps them break the habit and may prevent dynamic lines from forming. Lines that are present when the face is in repose often give an erroneous impression of negative

emotions or personality characteristics. In addition, there is growing evidence that BTX improves not just wrinkles but mood, based on the facial feedback hypothesis in the social psychology literature. One study postulated that viewing our own tense and distressed expressions on our faces can lead to internal feelings of distress, and in contrast, viewing the more relaxed and less stressed appearance of the BTX-treated face can elicit more positive internal changes, leading to greater feelings

DIVERSE POPULATIONS IN AESTHETICS: YOUNG PATIENTS

(A)

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(B) Figure 32.4 Filler scar: (A) before; (B) after.

(A)

(B) Figure 32.5 Botox smile: (A) before; (B) after.

of happiness (7). Results of another study found that the emotional and functional changes after treatment of wrinkles with BTX have the potential to improve the intrapsychic world and the “marketability” of the individual in today’s stressful and competitive world (8)—a world in which young people are trying to gain a foothold. Bruxism can be treated with BTX by injection into the masseter muscles. In one study, patients experienced significant improvement, including a relief of tension in their muscles and the headaches that arose from the bruxism (9). A cosmetic side effect of BTX in the masseters is a slimming of the lower face. In the Western population as opposed to East Asian, an accentuation of cheek prominence by creating a highly desirable “blush” appearance can occur (a recontouring effect that most women attempt to create with makeup) (9). And in a study of patients with myofascial pain, BTX was injected into the masseter and anterior temporal muscles, causing decreased muscle action—which resulted in an improvement in pain and psychological status (10). Hyperhydrosis is a condition that can be mortifying to adolescents and young adults and can be treated with BTX. Whether palmar or axillary, excessive sweating can cause stress and a compromised quality of life by limiting activities, physical contact (in the case of palmar hyperhydrosis), and choice of clothing (many who suffer from axillary hyperhydrosis choose to wear only black). A gummy smile (Fig. 32.5A and B) can be lessened by injection of BTX into the lip elevator muscles. And it can alleviate the asymmetry or facial spasms from Bell’s palsy, a condition that causes facial muscles to weaken or become paralyzed.

PREMATURE AGING

Photodamage : Although it is surprising that young people could have sustained enough photodamage to present with skin cancer, recent findings indicate that non-melanoma is increasing in young adults, especially in young women (11). Even more recent data suggest that melanoma as well is increasing in young women, and this may be directly linked to increasing ultraviolet (UV) radiation exposure in this population (12). One reason is that younger skin is particularly sensitive to the detrimental effects of UV light. Suntans are common in this age group due to influence from the celebrity culture and the media, but young people don’t appreciate how injurious this is to their skin. According to one recent study, more than 80% of high school students view movie stars as tan and almost 60% see “tan” people as better looking (13). Although young women realize intellectually that tanning may not be healthy for them, they continue to expose themselves to dangerous UV rays (13). Females between the ages of 20 and 39 years have shown the greatest use of indoor tanning salons, which is problematic because indoor tanning salons and high rates of UV exposures have been linked to higher rates of melanoma and non-melanoma skin cancers (14,15). It is imperative to address this disconnect between knowledge and sun tanning, and to emphasize the importance of reducing the risk of nonmelanoma skin cancer by practicing sun safety (using a full-spectrum sunscreen with an SPF of 15 or higher; covering up with clothing, including a broad-brimmed hat and UV-blocking sunglasses; and seeking shade outdoors especially between the hours of 10:00 AM and 4:00 PM).

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It’s also extremely important to inform patients of the risks of indoor tanning, which not only include premature aging of the skin but the possibility of developing herpetic infections from unsanitary salons. And the last point to impart is that, despite the boast of salon owners that the UV-A they use is not damaging to the skin, there are in fact many studies that have shown the association between UV-A and later development of skin cancer. In this age group a sprinkling of freckles (Fig. 32.6) often is associated with memories of their childhood and summer vacations; however, it quickly progresses to a more mottled appearance, which is unattractive. This photodamage is best treated with non-ablative skin rejuvenation techniques, including the IPL, Nd:YAG LP 532 nm, and LED photomodulation, but may also be approached with topical skin care. Extensive UV exposure in this age group can even lead to the appearance of fine lines and wrinkles. This is visible in young adults in their early twenties who have grown up in Southern and Western regions of the United States with strong levels of UV radiation. Part of the patient education plan is to inform this group about the association between sun exposure and the development of premature aging in the form of lines, wrinkles and discoloration. PIGMENTATION DISORDERS

Melasma is particularly vexing to treat, and can show up in young women using hormonal forms of birth control. Melasma can occur

in all skin types but is most common in deeply pigmented skin, particularly among women of Hispanic, Asian, and East Indian origin (16). Successful melasma treatment (Fig. 32.7A and B) depends on effective topical therapy to lighten the hyperpigmented areas and to prevent the development of new ones, as well as the avoidance of risk factors (including UV exposure and exogenous female hormones). Patient education is the key, as well as adherence to an at-home regimen using a cream that may combine HQ 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% (17). If topical therapy alone does not resolve the condition, other modalities can be added, such as microdermabrasion, peels, higher concentrations of HQ, or combination formulas of HQ with retinoids, and anti-inflammatories. Although traditional lasers have been proposed as a treatment for melasma, ranging from fractional resurfacing to intense pulsed light, there is an increased risk of reoccurrence of the melasma either immediately post-procedure or within a short period of time. For this reason, their use is generally not recommended. There is also the risk of developing hypopigmentation following treatment with a laser (42). Red and brown birthmarks: Youthful patients may not be aware that an effective treatment is available for their birthmarks (Fig. 32.8), but once informed, they want to have treatment. With advanced laser technology, it is now possible to resolve birthmarks that are present on areas of the body that are commonly in view, such as the face, arms, and legs. In one case, a large café au lait macule on the neck of a 21-year-old woman was resolved after six treatments with a 755-nm alexandrite laser [(18), p 98]. Port-wine stain birthmarks can be erased in multiple-treatment sessions with a pulsed-dye laser [(18), pp. 44–5]. Tattoos have become almost de rigueur in this patient group. However, as young people enter the job market, they find that having a tattoo on their hand, wrist, or other visible body part may interfere with a job opportunity and desire its removal. Tattoo removal is frustrating and may necessitate multiple visits. Black-ink tattoos are the easiest to remove, while colored-pigment tattoos are more difficult and may require use of multiple wavelengths. Oddly enough, amateur tattoos can be more challenging to treat than professionally applied tattoos as they typically have more pigment deposited in the skin. The wavelength that is necessary to remove a tattoo is dependent on tattoo color. But in general, Q-switched lasers provide a dramatic improvement over previous modalities, and scarless tattoo removal is the desired outcome. PERSISTENCE OF TEEN ACNE

Figure 32.6 Freckles.

(A)

Acne vulgaris is the most common dermatologic condition in the United States, affecting more than 17 million Americans of all ages (19). It affects nearly 80% of adolescents and young adults aged 11 to 30 years (20,21). Lesions appear primarily on the face, back, chest, and other areas with a high concentration of pilosebaceous glands (20).

(B) Figure 32.7 Melasma: (A) before; (B) after treatment with a chemical peel.

DIVERSE POPULATIONS IN AESTHETICS: YOUNG PATIENTS Severe acne is associated with low self-esteem, poor body image, social withdrawal, and depression (21). Contributing factors to the development of acne may include hormonal changes or the effects of stress, which can release pro-inflammatory stress hormones and chemicals such as neuropeptides. The goals in treating acne are to relieve clinical symptoms and to prevent scarring to which youthful skin is especially prone. Since the extent and type of scarring are associated with the severity and longevity of acne before therapy is initiated (20), it is important for patients to obtain early treatment (22). TOPICAL AND SYSTEMIC TREATMENTS FOR ACNE

Due to an improved understanding of acne pathogenesis, experts recommend a combination of treatments to target the causes of acne. The goals include reducing the production of sebum; reversing hyperproliferation and normalizing keratinization; resolving microcomedones and comedones; reducing colonization of P acnes and inflammation; preventing formation of microcomedones, comedones, and inflammatory lesions; and resolving existing inflammatory lesions (20,44). Combining therapeutic agents to target different pathologic factors in acne results in increased efficacy, more rapid resolution of lesions, and reduced likelihood of antibiotic resistance (23). For example, a topical retinoid in combination with either an antibiotic (oral or topical) or BPO is the standard of care for inflammatory or comedonal acne. The retinoid probably enhances penetration of antimicrobial agents through the skin (24) and the quick and longer lasting effects of the combination products probably improve compliance and psychological well being (20). Topical combination therapy is considered the standard of care. The importance of using a retinoid in this population is to not only address the active acne but to reduce the risk of development of acne scarring. Retinoids are multifunctional: They reduce follicular obstruction, they are important agents in the treatment of comedonal and inflammatory acne; and reduce the incidence of post-inflammatory hyperpigmentation. Skin irritation with current retinoid formulations may require specific modification of cleansers and moisturizers in order to inhibit retinoid dermatitis, and any measures necessary should be taken. Retinoids are still effective when used with a non-detergent cleanser and a moisturizer is applied immediately following the retinoid application. By reducing inflammation with the use of over-the-counter

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anti-inflammatories, such as green tea or calendula, and improving the barrier function of the skin by using prescription moisturizers containing ceramides, such as Epi-Ceram (Promius Pharma, Bridgewater, New Jersey, USA) one reduces the risk of irritation. Benzoyl peroxide (BPO) is effective, but a consensus for relative efficacies of different formulations is not available. Since BPO can prevent or eliminate resistance of P acnes to oral or topical antibiotics, it is often used in combination with these agents. Erythromycin and clindamycin are effective and well tolerated but bacterial resistance may limit their use as monotherapies. Azelaic acid is effective in acne and may reduce the incidence of post-inflammatory hyperpigmenation experienced by Fitzpatrick types III, IV, V, and VI. There are new combination products that have been developed that include a retinoid and topical clindamycin or a BPO, and these are not only more effective but more convenient for application, particularly in this patient population (e.g., EpiDuo [Galderma Laboratories, Texas, USA] and Ziana [Medicis Pharmaceutical Corporation, Scottsdale, Arizona, USA]). For young people, the importance of following a regimen consistently cannot be overemphasized, since they are prone to nonadherence. Patients need to be told in detail to apply the acne medication to the entire face (and not just on lesions) and to avoid the corners of the mouth and around the eyes; to use the medication once or twice a day, as directed; to counter residual irritation by using a nondrying cleanser and a moisturizer; and to wear sunscreen every day, since acne medications make the skin sun-sensitive. In short, the most useful item to give the patient at the time of the visit is a step-by-step instruction plan, listing all of the above (cleanse; medicate; moisturize). Systemic antibiotics may be necessary in order to manage moderate to severe acne refractory to topical treatments. Minocycline and doxycyline are considered more effective than erythromycin (41). Hormonal treatment for acne can be particularly important in this age group, and it includes oral contraceptives, spironolactone, and cyproterone acetate. Some estrogen-containing contraceptives for the treatment of acne in women are FDA approved for this use and supported by clinical trial data. The antiandrogen spironolactone is effective against acne by blocking androgen receptors. There are several combination oral contraceptives that are effective in women, for example Yaz and Yasmine (both of which contain drosperinone and ethinyl estradiol) that are also approved for acne in the United States. Diane35, which contains cyproterone acetate and ethinyl estradiol, is approved for use in Europe. Oral isotretinoin is approved for the treatment of severe recalcitrant nodular acne, and is also considered useful in managing less severe acne that is resistant to other treatments and causes psychological or physical scars. Its vaunted ability to shrink sebaceous glands and create a “poreless looking” complexion makes it very popular among certain cosmetic patients, who may resist going off the drug when their acne resolves. But oral isotretinon’s teratogenicity and other potential side effects mandate that the patient enroll in a federal registry program. LASER AND LIGHT-BASED THERAPIES

Figure 32.8 Birthmark.

Since they do not require ongoing patient compliance as do topical and oral agents, laser and light-based therapies may succeed in patients who have failed conventional therapy (25). These devices target P acnes, the sebaceous gland, or the infundibulum of the hair follicle. A landmark study of the use of phototherapy for the treatment of mild-to-moderate acne was reported by Papageorgiou and colleagues in 2000 (26). Another adjunctive treatment is photodynamic therapy (PDT). PDT involves the application of aminolevulinic acid so that it accumulates in the sebaceous glands, and is activated by blue light or an intense pulsed light device such as the Isolaz. PDT can potentially

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(A)

(B) Figure 32.9 Acne scars: (A) before; (B) after treatment with 1450 nm diode laser.

(A)

(B) Figure 32.10 Acne: (A) before (B) after treatment with the Isolaz system.

eliminate active acne and shrink pore size, but it is particularly effective in difficult-to-treat areas such as the back. A major advantage of laser devices is that wavelength, pulse duration, and fluence can be adjusted to treat specific lesions (27). The 1450 nm laser has been shown to be effective in treatment of mild-tosevere inflammatory facial acne, as well as a 1350-nm laser. These lasers will address both active acne as well as early acne scarring (Fig. 32.9A and B), with good results (28,29). PHOTOPNEUMATIC THERAPY

Photopneumatic therapy (PPx) is the only light-based technology cleared for the treatment of pustular and comedonal acne (30). The device applies gentle suction pressure to elevate the sebaceous target closer to the skin surface, so that its contents can be mechanically removed. Then the broadband blue light (400 nm) destroys bacterial porphyrins and the infrared (1200 nm) light produces an anti-inflammatory tissue effect (31). In a study of 56 patients with mild-to-severe acne, the median physician-rated clearance increased from 50% after a single treatment of PPx to 90% after the fourth treatment (30). By mechanically clearing the sebaceous gland, PPx allows for better delivery of photons to the light-sensitive porphyrins synthesized by P acnes, and also enhances

the ability of a topical skin-care program to reach its target (30). Anesthesia is not required because the treatment is painless (30). STRESS ACNE

The youthful lifestyle of burning the candle at both ends, combined with the chronic stress of finding permanent employment in a tough economy, can worsen acne. The biggest trigger is stress, which floods the body with neuropeptides such as substance P that increase sebum production (32). Substance P can also be ushered in by environmental stress factors such as pollutants, heat, and allergens. In addition, stress signals the body to product corticotropin-releasing hormone (CRH), which fuels inflammation (32) and cortisol, high levels of which can stimulate sebaceous gland activity. Patients under stress also tend to neglect their skin, lacking the energy and motivation to comply with acne treatment regimens. Even worse, tense people often can’t leave pimples alone, picking at them and thus exacerbating the inflammatory response (Fig. 32.10A and B). Treatment : Stress reduction techniques such as yoga, meditation, and daily exercise, along with adequate sleep, can help reduce the release of neuropeptides and cortisol levels (which are lowest in the early stages of deep sleep).

DIVERSE POPULATIONS IN AESTHETICS: YOUNG PATIENTS Diet: Contrary to popular belief, chocolate and oily or fatty foods have not been implicated; rather a high-glycemic index diet and milk intake have been associated (33). There have been recent studies that have shown that consumption of foods with a high glycemic index, through elevation of serum insulin levels, appears to stimulate sebum production (33) suppress SHBG concentrations, and raise androgen concentration (33) thereby contributing to acne. ACNE SCARRING

Patients in this age group may present with a wide range of scarring, from residual scarring from teenage acne to adult active acne. This population is particularly concerned about acne scarring, because it is very difficult to cover with makeup, and men cannot use makeup. Scarring occurs in 95% of patients with acne and in both sexes equally. The other important consideration is the presence of post-inflammatory hyperpigmentation, which many young adults term a scar. In order to address these points, the author has developed an acne typing scale, in order to best classify and determine the best approach to treatment (45). Acne scars vary in their presentation, which determines the approach necessary to achieve an optimal result. Icepick scars have been shown to penetrate all the way into the deep dermis, and therefore cannot be reduced by laser resurfacing. Traditional dermabrasion is not an option here either, because the depth needed to reach an icepick scar would leave the patient with a smooth, shiny face. They may be treated by punch excision, punch elevation, or fractional laser (39,40). Boxcar scars can be treated with punch elevation. Moderate-tosuperficial peels are not effective in treating either of the above types of deep acne scars. Bound-down scars should ideally be treated first with subcision and then a dermal filler (see below). Superficial acne scarring has been shown to improve with fractional resurfacing treatments [(18), p. 259]. A variety of ablative fractional resurfacing lasers are now available and these lasers may be more effective than non-ablative fractional lasers for acne scars, although ablative treatments may have more side effects. Patients should be instructed that results from laser treatment of their scars can take up to 18 months to see a final result (43). But patients and physicians should be encouraged by the fact that acne scars are much easier to treat, for example, than wrinkles. There is more tissue remodeling seen in acne scars treated with laser than in lines and wrinkles. Fillers have become an important addition to the effective treatment of acne scarring. They have a low risk of side effects and involve a short down time, if any. Due to the quick-fix nature of fillers, young people are particularly interested in them. HA fillers (including Restylane) are among the most useful, as is calcium hydroxylapatite (Radiesse), owing to their ability to both fill and stimulate collagen production. The use of PPLA can be indicated in patients who have extensive shallow scars covering the majority of the surface area of their cheeks. SKIN CARE

Patients in this age group have skin-care concerns that fall into at least one of the following categories. Maintaining and Enhancing Results from In-office Procedures Laser and light-source treatments yield better results when coupled with appropriate skin care products. For example, a topical cosmeceutical regimen, such as one containing tretinoin and hydroquinone, can enhance the effects of facial rejuvenation procedures and encourage patients to adopt a daily cleansing and rejuvenation regimen that they can continue afterward to help maintain the aesthetic levels. In one study, a four-step system containing 0.1% tretinoin and

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4% hydroquinone as active ingredients along with a cleanser, toner, exfoliant, sunscreen, and moisturizer was superior to regimens containing tretinoin 0.1% cream plus over-the-counter (OTC) products, hydroquinone plus OTC products, and OTC products alone in terms of improving periocular and perioral fine wrinkles, mottled hyperpigmentation, clarity, sallowness, laxity, and tactile roughness (34). Treating an Underlying Medical Condition Chronic conditions such as acne and melasma can be controlled by diligent use of a topical skin regimen (see “Active Acne” and “Pigmentation Disorders,” respectively). In less severe cases of acne, OTC formulations can be effective and are offered by all the major cosmetic companies: Pro-Activ, Neutrogena, Murad, and Aveeno all offer antiacne programs and systems. Preventing the Aging Process and Supporting the Skin in Preserving its Youthful Appearance Depending on skin type, an individually tailored skin-care regimen can be designed to treat and prevent premature aging. Active ingredients can include alpha hydroxy acids, beta hydroxy acids, anti-inflammatories, antioxidants, a topical retinoid, and ceramidecontaining moisturizers. The ultimate mix of active ingredients should be geared to the patient’s skin type, which can run the spectrum from dry all the way to sebaceous, or confound things by being dry and wrinkly and yet prone to acne. Antioxidants such as vitamins can help protect the skin from oxidative stress in the form of UV exposure, pollution, and smoking. Products containing α-tocopherol (vitamin E), L-ascorbic acid (vitamin C), retinol (vitamin A), and niacinamide (vitamin B3) are effective for the treatment of photoaging (35) and can be effective in treating inflammatory dermatoses, acne, and pigmentation disorders. As long as it is done carefully, exfoliation of the skin can be efficacious in that it will allow better penetration of active ingredients through the epidermis. An at-home exfoliation device such as the Clarisonic brush is especially attractive to the mind-set of this technologically oriented youthful population. This ultrasonic brush can be used not only on the face while showering but on the back of the arms for keratosis pilaris. Other devices on the market that appeal to this generation are the Tanda Skincare System (an at-home light-emitting diode system that uses blue light to treat acne, red light to diminish wrinkles), My-No-No, and MyZenoAcne Treatment. REFERENCES

1. American Society for Aesthetic Plastic Surgery, Cosmetic Surgery National Data Bank Statistics for 1998. [Available from: http://www. surgery.org/download/2008stats.pdf ] (accessed March 12, 2009). 2. Flynn TC, Carruthers J, Carruthers A. Introduction of a validated rating scale for the management of lip fullness and aging options. J Drugs Dermatol. 2009; 8 (4 Suppl): 24S–27S. 3. Matarasso SL, Carruthers JD, Jewell ML. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg 2006; 117(3 Suppl): 3S–34S. 4. Wang F, Garza LA, Kang S, et al. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol 2007; 143: 155–63. 5. Fitzgerald R, Vleggaar D. Using poly-L-lactic acid (PLLA) to mimic volume in multiple tissue layers. J Drugs Derm 2009; 8(10 Supp): S5–13. 6. American Society for Aesthetic Plastic Surgery. Non-invasive cosmetic procedures in greater demand. Aesthetic Practitioner News 2009; 4(2): 16–7.

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7. Alam M, Barrett KC, Hodapp RM, et al. Botulinum toxin and the facial feedback hypothesis: can looking better make you feel happier? J Am Acad Dermatol 2008; 58(6): 1061–72. 8. Fried RG, Werschler P, Floirendo T. The botulinum toxin experience: results of a patient self-report questionnaire. J Clin Aesthetic Dermatol. 2009: 2(11): 37–40. 9. Liew S, Dart A. Non-surgical reshaping of the lower face. Aesthet Surg J 2008; 28(3): 251–7. 10. Kurtoglu C, Gur OH, Kurkcu M, et al. Effect of botulinum toxin-A in myofascial pain patients with or without functional disc displacement. J Oral Maxillofac Surg 2008; 66(8): 1644–51. 11. Borrowman TA, Vachon CM, Tollefson MM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. J Am Med Assoc 2005; 294: 681–90. 12. Purdue MP, Beane LE, Freeman WF, Tucker A. Recent trends in incidence of cutaneous melanoma among US Caucasian young adults. J Invest Dermatol 2008; 1038: 1–4. 13. Ashinoff R, Levine VJ; Steuer AB, Sedwick C. Teens and tanning. J Clin Aesthetic Dermatol 2009; 2(21): 48–50. 14. Bataille V., Winnett A, Sasieni P, et al. Exposure to the sun and sunbeds and the risk of cutaneous melanoma in the UK: a casecontrol study. Eur J Cancer 2004; 40: 429–35. 15. Gallagher RP, Spinelli JJ, Lee TK. Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidermiol Biomarkers Prev 2005; 14: 562–6. 16. Pandya AG, Guevara IL. Disorders in hyperpigmentation. Dermatol Clin 2000. 18: 91–8. 17. Dover JS, Baumann L, Bikowski J, et al. A stepwise approach to melasma management and treatment. J Cosmetic Derm 2009. 22 (2): 81–7. 18. Goldman MP. Cosmetic and Cutaneous Laser Surgery. Orlando, FL: Elsevier, 2006; 98. 19. White GM. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol 1998; 39: S34–S37. 20. Gollnick H. Current concepts of the pathogenesis of acne: implications for drug treatment. Drugs 2003; 63(15): 1579–96. 21. Tan JK, Vasey K, Yung KF. Beliefs and perceptions of patients with acne. J Am Acad Dermatol 2001; 44: 439–45. 22. Thiboutot DM. Overview of acne and its treatment. Cutis 2008; 81(1 Suppl): 3–7. 23. Zaenglein AL, Thiboutot DM. Expert committee recommendations for acne management. Pediatrics 2006; 118(3): 1188–99. 24. Gollnick H, Cunliffe W, Berson D, et al. Global alliance to improve outcomes in acne. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2003: 49 (1 Suppl): S1–S37. 25. Sami NA, Attia AT, Badawi AM. Phototherapy in the treatment of acne vulgaris. J Drugs Dermatol 2008: 7(7): 627–32. 26. Papageorgiou P., Katsambas A, Chu A. Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. Br J Dermatol 2000; 142: 973–8.

27. Patton I, Kress D. Light therapy in the treatment of acne vulgaris. J Cosmet Dermatol 2004; 17(6): 373–8. 28. Friedman P, Jih M, Kimyai-Asadi A, et al. Treatment of inflammatory facial acne vulgaris with the 1450-nm diode laser: a pilot study. Dermatol Surg 2004; 30: 147–51. 29. Glaich A, Friedman P, Jih M, et al. Treatment of inflammatory facial acne vulgaris with combination 595-nm pulsed-dye laser with dynamic-cooling device and 1450- nm diode laser. Lasers Surg Med 2006; 38: 177–80. 30. Shamban AT, Enokibori M, Narurkar V, Wilson D. Photopneumatic technology for the treatment of acne vulgaris. J Drugs Dermatol 2008; 7(2): 139–45. 31. Narurkar V. Novel photopneumatic therapy delivers high-efficiency photons to dermal targets. Cosmet Dermatol 2005; 18: 115–20. 32. Zouboulis CC. Acne and sebaceous gland function. Clin Dermatol 2004; 22(5): 360–6. 33. Spencer EH, Ferdowsian HR, Barnard ND. Diet and acne: a review of the evidence. Int J Dermatol 2009; 48; 339–347. 34. Herndon JH, Stephens TJ, Sigler ML. Efficacy of tretinoin/hydroquinone-based skin health system in the treatment of facial photodamage. Cosmet Dermatol 2006; 19: 255–62. 35. Burgess C. Topical vitamins. J Drugs Dermatol 2008; 7(7 Suppl): S2–6. 36. Kennedy J, Pottier R, Pross D. Photodynamic therapy with endogenous protoporphyrin IX: basic principles and present clinical experience. J Photochem Photobiol B 1990; 6: 143–8. 37. Nestor M, Gold M, Kauvar A, et al. The use of photodynamic therapy in dermatology: results of a consensus conference. J Drugs Dermatol 2006; 5: 140–54. 38. Wanitphakdeedecha R, Tanzi EL, Alster TS. Photopneumatic therapy for the treatment of acne; J Drugs Dermatol 2009; 8 (3): 239–41. 39. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol 1994; 19(4): 303–8. 40. Bayat A, McGrother DA, Ferguson MWJ. Skin scarring. Br Med J 2003; 326: 88–92. 41. Dreno B, Bettoli V, Ochsendorf F, et al. European Expert Group on Oral Antibiotics in Acne. European recommendations on the use of oral antibiotics for acne. Eur J Dermatol 2004; 14(6): 391–9. 42. Joshi SS, Boone, SL, Alam M, et al. Effectiveness, safety, and effect on quality of life of topical salicylic acid peels for treatment of postinflammatory hyperpigmentation in dark skin. Dermatol Surg 2009; 35(4): 638–44. 43. Alster T, Zaulyanov L. Laser scar revision: a review. Dermatol Surg 2007; 33: 131–40. 44. Pochi PE, Shalita AR, Strauss JS, et al. Report of the consensus conference on acne classification, Washington, DC, March 24 and 25, 1990. J Am Acad Dermatol 1991; 24: 495–500. 45. Shamban A, Narurkar V. Multimodal treatment for acne, acne scars, and pigmentation. Dermatol Clin 2009. 27(4): 459–71.

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Diverse populations in aesthetics: Male patients Toral Patel and Murad Alam

INTRODUCTION

Male patients are often overlooked in cosmetic medicine, either because the patient is reluctant to admit interest or because the physician assumes that the patient is not interested in cosmetic treatments. However, while most cosmetic procedures are still performed on women, the proportion of men receiving aesthetic treatments is beginning to increase. According to data from the American Society for Aesthetic Plastic Surgery, Americans spent over $13 billion on cosmetic procedures in 2007. The top three non-surgical cosmetic procedures in men were botulinum toxin, laser hair removal, and microdermabrasion. Men accounted for 9% of total cosmetic procedures, including surgical and non-surgical interventions. And cosmetic procedures in men increased by 17% from the previous year. Overall, since 1997, nonsurgical cosmetic procedures in men have increased by 886% and surgical procedures by only 3% (1). In today’s society, where great value is placed on youthfulness, men may view the appearance of advancing age as a detriment to financial or romantic success (2). Even so, some men may not yet be willing to receive cosmetic procedures due to perceived societal stigmas, and the feeling that such procedures are appropriate for women only. The availability of minimally invasive cosmetic procedures with little to no downtime may increase the likelihood that men ambivalent about cosmetic procedures may in fact decide to obtain them. Short downtime procedures allow the patient to return to work soon afterward, and are not associated with telltale scars or signs which may alert others to the procedure having taken place. For men, this may be critical factor in a patient’s decision to undergo treatment. Cultural background and sexual orientation are additional factors that may influence the overall look a patient desires. These issues should be addressed at the patient’s initial cosmetic consultation. It is imperative that the physician have a clear understanding of the male patient’s cosmetic concerns and desired outcomes, and that, in turn, realistic expectations and probable outcomes are conveyed to the patient at the onset. THE AGING FACE IN MEN

Factors contributing to the aging face include chronic sun damage, volume loss due to decreased subcutaneous fat, loss of elasticity and gravitational effects, bony resorption, and remodeling of cartilage (3). Changes of the aging face become evident in the early twenties, as the supporting structures of the face begin to gradually weaken. This leads to the emergence of rhytides (which are subtle at first and deepen over time), glabellar frown lines, and prominent nasolabial folds. Descent of the malar fat pad causes accentuated jowls, poorly defined cheekbones and exaggeration of the nasojugal folds (4). BOTULINUM TOXIN IN MEN

Deep furrows of the eyebrows, glabella, and forehead can make men appear angry when they are not (Fig. 33.1). Loss of elasticity from sun exposure and the natural aging process can induce further glabellar ptosis and accentuates these lines. For these reasons, botulinum toxin injections are a popular choice for the male patient. Botulinum toxin can soften muscle actuated wrinkles of the upper third of the face. In addition, eyebrow position and shape can be adjusted with toxin injections. Ideal eyebrow position in men is at or just above the supraorbital rim, with an almost horizontal shape. Depression of the brows below the level of the supraorbital rim results in a fatigued appearance, which can be corrected

with botulinum toxin (5). Crow’s feet or laugh lines resulting from repeated contraction of the orbicularis oculi muscle can also be mitigated in a similar manner. In men, the required dose of botulinum toxin is significantly higher than that needed to treat similar lines in women. A 2005 study by Jean and Alastair Carruthers conducted a randomized control trial of the safety, efficacy, and duration of four different doses of botulinum toxin type A for the treatment of glabellar rhytides in men (6). The investigators found that doses of 40, 60, or 80 units were consistently more effective than 20 unit doses. Response rate and duration of treatment both showed a dose-dependent increase. Altering the volume of saline used to reconstitute a vial of botulinum toxin was hypothesized to also affect the final outcome (5). Treatment of the glabellar complex involves injections into the procerus and corrugator supercilii muscles. The corrugator may be broad in some men, with far lateral fibers, and care should be taken to inject botulinum toxin at the edges of the forehead to treat these lateral fibers, or the patient may be able to asymmetrically contract the distal aspect of the muscle (7). While the glabella, periorbital region (crow’s feet), and forehead are the sites most commonly treated with botulinum toxin in men, other areas amenable to treatment include the mid and lower face, including the nasalis muscles, mentalis, perioral region, and platysmal bands. Botulinum toxin is now a well-established effective treatment for axillary and palmoplantar hyperhidrosis. For the treatment of axillary hyperhidrosis, an average of 50 units per axilla is used, with intradermal injections spaced 1.5 to 2 cm apart to account for the diffusion of the toxin (8). Repeat treatments are required at 6 to 12 month intervals. Local nerve blocks may reduce discomfort during injection of palmoplantar surfaces; higher doses of botulinum toxin are required for these sites than those needed to treat the axillae (9). SOFT TISSUE FILLERS IN MEN

Soft tissue fillers are often used in men for wrinkle correction, volume replacement, and treatment of acne scars. Facial sites commonly treated include the nasolabial folds, lips, chin, and cheeks. Various injection techniques are used, including threading, serial puncture, cross-hatching, and fanning. Hyaluronic acid (HA) fillers remain the most popular and versatile. Other FDA-approved fillers include bovine, human, and porcine collagen; poly-L-lactic acid; and calcium hydroxylapatite. HA fillers may be avian or bacterially derived. Naturally occurring HA has a tissue half-life of one to two days. Cross-linking the product provides higher longevity and stability (10). The average duration of effect with HA fillers is 6 months but may be as long as 12 months. NASHA (nonanimal-stabilized HA) fillers currently available in the United States are Juvederm (Ultra and Ultra Plus), Restylane, and Perlane. While all of these fillers contain the same HA polymer as their backbone, they differ in their degree of cross-linking, percent of cross-linked HA, and particle size, as well as in other characteristics. Selection of the correct filler for the problem area to be treated is crucial to achieve naturallooking results. Restylane and Juvederm Ultra are often used effectively for treatment of nasolabial folds and lips. Deeper rhytides and folds may be best treated with a larger particle filler such as Perlane or Juvederm Ultra Plus. Poly-L-lactic acid (Sculptra™, Sanofi-Aventis) is polymerized lactic acid in powdered form, which is resuspended in water prior to injection.

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Figure 33.1 Forehead wrinkling.

Volume replacement is via stimulation of a foreign body response, which results in dermal fibroplasia and new collagen formation. The polymer microspheres are slowly degraded. Three to five treatment sessions, spaced 4 to 6 weeks apart, are required to reach the final clinical endpoint. Results can last for as long as two years. While poly-L-lactic acid is currently FDA approved only for the treatment of HIV lipoatrophy (Fig. 33.2), it has been successfully used off-label for age-related volume loss, both of the mid-face (cheeks, nasolabial folds), and lower face (mandible, chin) (2). Radiesse® (Bioform Medical) is calcium hydroxylapatite (CaHA) microspheres suspended in an aqueous sodium carboxymethylcellulose gel. CaHA is the major mineral component of bone; it is radio-opaque and therefore visible on Xrays. Sites commonly treated with Radiesse® include the nasolabial folds, cheeks, and tear troughs. The filler is injected into the deep dermis; after injection, the gel carrier is slowly absorbed and the microspheres remain as scaffolding for angiogenesis and neocollagenesis. Use of the linear threading or cross-hatching technique of injection with long needles allows for more even distribution of the filler and helps prevent superficial placement (11). Immediate volume correction after injection is due to the filler substance itself; sustained improvement is believed to be associated with the production of new collagen. Duration of effect ranges from six months to as long as two years in some patients. Erythema, edema, and ecchymosis often occur after injection (as with most fillers), but are typically short lived. The most commonly seen adverse effect with Radiesse® is the development of lip nodules, which in some cases may require subcision and drainage or intralesional steroid injection. This complication can be avoided entirely by not injecting the lip, as this use is not indicated and discouraged by the manufacturer (12). Collagen was the first substances to be used as a dermal filler in the United States, with the FDA approval of Zyderm I in 1981 as an agent for soft tissue augmentation. Zyderm® I & II and Zyplast® (Allergan, Inc.) are bovine collagens; hypersensitivity is possible, and double skin testing is recommended prior to their use (13). Cosmoderm® and Cosmoplast® (Allergan, Inc.) are derived from a single human fibroblast cell culture

(unlike other human-derived collagens, which are cadaveric); they do not require skin testing. Patients are often frustrated by the short duration of action of collagen fillers; improvements last on average three to six months. A newer collagen filler, Evolence® (Johnson & Johnson), is porcine collagen that is cross-linked with ribose; duration of effect is longer than that seen with older generation collagens, from 6 to 12 months. Evolence® was FDA approved in 2008 for the correction of moderate-to-deep facial wrinkles and folds, particularly the nasolabial folds. Evolence Breeze® is a finer collagen that can be used for treatment of more superficial lines and for lip enhancement; it can also be layered over Evolence® in cases where there is a fine line overlying a deeper crease (14). HAIR TRANSPLANTATION IN MEN

Androgenetic alopecia is a common condition associated with focal or widespread hair loss that can cause significant psychological distress for men. This form of alopecia is multifactorial but is in large part due to the effect of 5α-reductase, which converts testosterone into dihydrotestosterone (15). The Norwood classification is the standard system for classifying the degree of alopecia, with grades ranging from I to VII; many patients, however, fall outside these standard grades. While hair transplantation is primarily used to treat male pattern baldness, it can also be used for restoration of hair at other sites such as eyebrows and eyelashes, and also for correction of hair loss caused by surgical or accidental scarring. The only medical treatments for hair loss that have proven clinical efficacy are topical minoxidil and oral finasteride. Men may find these therapies to be less than optimal due to difficulties with regular compliance and/or potential side effects; however, many hair transplant surgeons recommend these medical therapies in conjunction with transplantation (16). Follicular unit transplantation (FUT) is now considered the “gold standard” technique for hair transplantation, and has largely replaced older techniques involving larger graft sizes that are derided as “plugs”. In FUT, stereo-microscopic graft dissection is used to transplant hair in naturally occurring groups of one to four follicular units.

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Normal

Grade 3

Grade 1

Grade 4

Grade 2

Grade 5

Figure 33.2 Lipoatrophy.

The process commences after the donor site has been adequately anesthetized and tumescence is performed. Thereafter, the hair is harvested using punch excision, a single blade or a multiblade apparatus. Common donor sites are the occipital scalp, posterior neck, and above the ears. Patients interested in hair transplantation should be advised that hair loss is a progressive condition that may require future transplant sessions. Temporary post-transplant telogen effluvium is commonly observed, and may be controlled with conjunctive medical therapy. Final results are not evident until six months after transplant. TATTOO REMOVAL

A 1996 study reported more men than women requesting tattoo removal (17), but a 2006 study of 196 patients (66 men, 130 women) revealed a significantly larger percentage of women (69%) than men (31%) requesting removal (18). This may mirror a shift in the overall tattoo removal patient population. Motivations for tattoo removal in men include embarrassment or regret, the desire to erase memories of

a previous relationship or experience, and workplace requirements regarding appearance. Q-switched lasers (ruby, alexandrite and Nd:YAG) are typically used for tattoo removal; the 510 nm flashlamppumped PDL may also be useful for some colors. Black tattoos are most amenable to treatment since black pigment absorbs all laser wavelengths. Other colors must be selectively treated with devices that emit the proper light, but some tattoo colors, like sky blue and yellow, are difficult to remove. Older tattoos may be easier to treat than fresh tattoos since the pigment deposits tend to be less dense. Professional tattoos may also be more difficult to remove than amateur tattoos, and multiple treatments (as many as ten) may be required. Even in the best circumstances, patients should be counseled that complete removal may not be possible (13). LASER HAIR REMOVAL

Pseudofolliculitis barbae (PFB) is a chronic inflammatory condition most often involving the beard region of men with pigmented skin. Inflammatory papules and pustules develop in the affected area, often

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Figure 33.3 Pseudofolliculitis.

with resultant hyperpigmentation and scarring (Fig. 33.3). This condition is a serious problem for military personnel, especially African Americans, since their strict grooming regulations require a clean-shaven face (19). Treatments include chemical depilatories, careful shaving technique (including warm compresses and gentle release of ingrown hairs), clipping rather than shaving, and topical medications including retinoids, antibiotics and steroids. Systemic antibiotics may be helpful in treating inflammation. Laser hair removal has been shown to be an effective and safe treatment for PFB. The 1064 nm neodymium: yttrium–aluminum–garnet (Nd:YAG) laser, 810 nm diode laser, 755 nm alexandrite laser, and intense pulsed light device can all be used for hair removal in patients with PFB. For darker skin types, 1064 nm lasers are superior due to the lower risk of post-inflammatory hyperpigmentation, and longer pulse durations can also reduce the risk of skin discoloration. The risk of dyspigmentation is further minimized with adequate but not excessive pre-, parallel, and post-cooling (20). Men may be concerned about excessive hair growth at atypical sites such as the ears, back, and buttocks, and laser hair removal can effectively treat these areas. Informational brochures in the waiting room or exam room or a cosmetic questionnaire in which men may check off their concerns are non-intimidating methods with which to initiate discussion about potentially embarrassing issues such as unwanted hair. LIPOSUCTION

Liposuction was the most common invasive cosmetic surgical procedure in men in 2007. This procedure is indicated not for weight loss, but rather for resolution of focal pockets of subcutaneous fat not amenable to diet and exercise (Fig. 33.4). When performing liposuction, realistic expectations, and likely outcomes should be fully discussed with the patient at the pre-operative consultation. Men should be counseled that striae and cellulite do not improve with liposuction. Furthermore, visceral fat cannot be mobilized by liposuction.

The flanks (“love handles”), abdomen, and chest are common sites for male liposuction. The protruding anterior abdomen is difficult to treat in some patients, as the majority of fat may be located behind the rectus abdominus muscle and cannot be reached by liposuction cannulas (7). Gynecomastia, or protuberant male breasts, can be improved with liposuction, provided the excess breast tissue is primarily adipose in nature and not glandular. As the male breast can be very fibrous, the liposuction procedure can be challenging and results are unpredictable; a 50% improvement can be expected. Further improvement may be achieved by excision of persistent glandular tissue (7). A thorough medical history is typically obtained in patients requesting liposuction. Some practitioners routinely request medical clearance in all patients over the age of 60 years, and in those patients with a history of diabetes or cardiac disease (21). The Klein method of tumescent anesthesia is a safe technique for liposuction under local anesthesia. In the context of normal liver function, total lidocaine doses of up to 55 mg/kg have not been associated with lidocaine toxicity (7). Laser lipolysis is a newer alternative to traditional tumescent liposuction, and may in selected cases cause less bleeding, swelling, and bruising (22). This procedure commonly utilizes a medium-pulsed 1064 Nd:YAG laser that simultaneously targets small areas of excess adipose tissue and tightens the overlying skin. An approximately 300 µm laser fiber is threaded into a 1 mm cannula, which is then inserted into the area to be treated (23). Adipocytes are lysed by the laser pulses, and tissue coagulation by the laser promotes skin tightening and hemostasis. Laser lipolysis has been successfully used to treat the abdomen and submental regions, although in some cases normal tumescent liposuction is performed in combination. The main purported benefits of laser lipolysis are pre-disruption of the fat, which increases the ease of suction, and dermal tightening secondary to heat delivery. COSMECEUTICALS

Men are becoming increasingly interested in skin care products, as evidenced by the fact that many companies now have product lines

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for the development of lipoatrophy are age greater than 40 years, CD4 count <200/µl and higher nadir viral load (29). Lipodystrophy is associated with potentially significant psychological consequences, as it is a telltale marker of HIV status. Facial involvement results in subcutaneous fat loss of the buccal, preauricular, and parotid regions, resulting in a hollowed, cachectic appearance. The use of soft tissue fillers is a mainstay of therapy for HIV lipoatrophy. Poly-L-lactic acid (Sculptra™, Sanofi-Aventis) was first FDA approved for the treatment of this condition. In a 96-week, open-label, uncontrolled single center study of Sculptra™ for the treatment of HIV lipoatrophy (VEGA study), 50 patients were injected at approximately two-week intervals and received four to five injections each. On average, one vial of product was injected intradermally into each cheek at each injection session. Results were assessed at weeks 8, 24, 48, 72, and 96. Statistically significant increases in skin thickness were noted at all time points during the study, and results persisted for up to two years. The most common device-related adverse effect was the delayed appearance of subcutaneous papules, with time to onset on average seven months after injection; subcutaneous papules were noted in 52% (26/50) of patients in the VEGA study, and resolved spontaneously in 26% of them (6/26). Other studies have reported incidences of 6% to 31% (30). Autologous fat transfer is also a potentially effective treatment option for lipoatrophy, but since subcutaneous fat loss can also be seen at other body sites in HIV patients, the amount of available donor fat may be insufficient or too abnormal for transplant. CONCLUSIONS

Figure 33.4 Fatty deposits.

specifically for men. Men may seek product advice to decrease the visible manifestations of aging, or to improve conditions such as acne, rosacea, and PFB. Sun protection should be emphasized as an important cornerstone of their anti-aging regimen, as men tend to use sunscreen less regularly than women. Specifically, male patients should be reminded to protect the scalp, ears, periorbital regions, and lips when outdoors (24). Alphahydroxy acid products, such as those that contain glycolic acid, improve the appearance of skin texture through their epidermal effects of corneocyte disadhesion, resulting in exfoliation and improvement of fine rhytides (25). These products may also be helpful for men with PFB due to their exfoliative effect. Salicylic acid is an oil-soluble betahydroxy acid, and may be beneficial for acne patients due to its ability to penetrate the pilosebaceous unit (26). Topical antioxidants have been shown to counteract the effects of free radicals on the skin. Vitamin C is perhaps the best-known antioxidant in skin care, but other agents on the market include idebenone, green tea extract, ferulic acid, and Coffeeberry® extract (27). Male patients seeking antiaging skincare products may be interested in an antioxidant serum; a few drops are applied to the skin once daily, either alone or mixed with moisturizer/ sunscreen. Marketing cosmeceuticals to the male patient should focus on efficacy and ease of use. In general, men are likely to prefer a one- or two-step regimen as opposed to a more elaborate one. TREATMENT OF LIPOATROPHY

Drug-induced lipodystrophy syndrome (HIV/HAART LDS) is a wellrecognized fat wasting condition that is an adverse effect of certain HAART medications, especially thymidine analog nucleoside reverse transcriptase inhibitors (NRTIs), such as stavudine. The loss of subcutaneous fat may be accelerated when medications are used in conjunction with certain protease inhibitors such as indinavir (28). Other risk factors

While the majority of patients seeking cosmetic procedures and products are women, men represent a growing demographic in aesthetic medicine. The availability of minimally invasive procedures with little to no downtime and proven efficacy is an attractive option for patients who do not want to miss much or any time from work. As with any patient seeking cosmetic rejuvenation, male patients should be assessed thoroughly at an initial consultation prior to proceeding with treatment. This discussion should pinpoint desired goals, and the patient should be advised frankly about potential downtime, realistic results, and the need to continue a post-procedure skincare regimen at home to maintain effects of treatment. Before and after photos of the specific treatments being considered are very helpful during such a consultation. Men may be just as motivated to maintain a youthful appearance as some women. An honest and comfortable relationship with their cosmetic physician, in which men are comfortable discussing their aesthetic concerns, is the first step in translating this motivation into action. Positive results will likely encourage the patient to continue with future treatments. REFERENCES

1. American Society of Plastic Surgeons Website: www.plasticsurgery. org, 2008. 2. Fried, R. Esthetic treatment modalities in men: psychologic aspects of male cosmetic patients. Dermatol Therap 2007; 20: 379–84. 3. Carruthers A, Carruthers J. Soft Tissue Augmentation. Philadelphia, PA: Elsevier, Inc., 2008: 11–12. 4. Dhaliwal J, Friedman O. Injectables and fillers in male patients. Facial Plast Surg Clin N Am 2008; 16: 345–55. 5. Carruthers A, Carruthers J. Botulinum Toxin. Philadelphia, PA: Elsevier Inc., 2008. 6. Carruthers A, Carruthers J. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg 2005; 31: 1297–303. 7. Flynn T. Botox in men. Dermatol Therap 2007; 20: 407–13.

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8. Naumann M, et al. Botulinum toxin type A is a safe and effective treatment for axillary hyperhidrosis over 16 months: a prospective study. Arch Dermatol 2003; 139: 731–6. 9. Lowe N, et al. Efficacy and safety of botulinum toxin type A in the treatment of palmar hyperhidrosis: a double-blind, randomized, placebo-controlled study. Dermatol Surg 2002; 28: 822–7. 10. Monheit G, Prather C. Hyaluronic acid fillers for the male patient. Dermatol Therap 2007; 20: 394–406. 11. Alam M, Yoo S. Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions. J Am Acad Dermatol 2007; 56: 285–9. 12. Sklar J, White S, Radiance FN. A new soft tissue filler. Dermatol Surg 2004; 30: 764–8. 13. Darke L, et al. Guidelines of care for soft tissue augmentation. J Am Acad Dermatol 1996; 34: 695–7. 14. Smith K. New fillers for the new man. Dermatol Therap 2007; 20: 388–93. 15. Bolognia J, et al. Dermatology. Philadelphia, PA: Elsevier, Inc., 2008. 16. Avram M, et al. The potential role of minoxidil in the hair transplantation setting. Dermatol Surg 2002; 28: 894–900. 17. Armstron M, et al. Motivation for tattoo removal. Arch Dermatol 1996; 132(4): 412–16. 18. Armstrong M, et al. Motivation for contemporary tattoo removal. Arch Dermatol 2008; 144(7): 879–84.

19. Alexander A, Delph W. Pseudofolliculitis barbae in the military. J Natl Med Assoc 1974; 66(6): 459–79. 20. Smith E, et al. Modified superlong pulse 810 nm diode laser in the treatment of pseudofolliculitis barbae in skin types V and VI. Dermatol Surg 2005; 31: 297–301. 21. Robinson J, et al. Surgery of the Skin. Philadelphia, PA: Elsevier, Inc., 2005. 22. Badin A, et al. Laser lipolysis: flaccidity under control. Aesthet Plast Surg 2002; 26: 335–9. 23. Kim K, Geronemus R. Laser lipolysis using a novel 1,064 nm Nd:YAG laser. Dermatol Surg 2006; 32(2): 241–8. 24. Berwick M, et al. Sun exposure and sunscreen use following a community skin cancer screening. Prev Med 1992; 21(3): 302–10. 25. Dietre C, et al. Effects of alpha-hydroxy acids on photoaged skin. J Am Acad Dermatol 1996; 34: 187–95. 26. Davies M. Studies on the effect of salicylic acid on the normal stratum corneum. Br J Dermatol 1980; 103: 191–6. 27. Farris P. Idebenone, green tea and Coffeeberry® extract: new and innovative antioxidants. Dermatol Therap 2007; 20(5): 322–9. 28. Moyle G. Expert Column- Cosmetic Interventions for HIV-associated Lipoatrophy. Medscape.com, 2006. 29. Lichtenstein K. Redefining lipodystrophy syndrome. J Acquir Immune Defic Syndr 2005; 39: 395–400. 30. Sculptra™ package insert. Sanofi-Aventis, 2006.

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Diverse populations in aesthetics: Ethnic patients Ava Shamban

INTRODUCTION

The shift in the U.S. demographic, predicted by Time magazine in 1993, where a female computer-generated composite of several ethnic types graced the cover, has arrived (1). The United States is more diverse than ever before, with respect to both ethnic background and heterogeneity of skin pigmentation. The increase in population of Asians and Hispanic groups are expected to render Caucasians a minority by 2050 (2). As of 2010, one in about every five office visits to a dermatology practice was by a patient of color (3). Some dermatologists report that a third of their patient population is comprised of Asians, African Americans, and Hispanics (4). The continuing crossover between populations also means there is more diversity than ever before. Increasing interest in cosmetic procedures in ethnic populations is being met by improved techniques and technology to match the needs and special considerations across different skin types and ethnic groups. These considerations include unique aspects of the anatomy of different ethnic groups as well as specifics of skin color and type. The desired pale white appearance with pink undertone, sometimes referred to as “cherry blossom,” has been prized as a sign of freshness and youth in Japanese skin. All these factors are relevant to the choice of procedure and inform the approach to the problem as well as indicate specific measures needed to prevent side effects. The use of pigmentation to determine skin type or ethnicity can be extremely misleading. Documenting ancestry offers a more accurate background than does self-identified ethnicity (5). The 35-year-old Fitzpatrick scale—a scale that ranges from a very fair skinned type 1 to a dark-skinned Type VI (Fig. 34.1)—only describes a phenotype. However, a type I may have in her genotype a much darker skin tone which will affect her response to a laser treatment (6,7). In addition, the type IV classification may include Asian, African American, and Hispanic skin types, all of which may require slightly different or specially tailored approaches, both medically and cosmetically due to biological differences between skin of each ethnicity independent of skin color. Some specialists in the field of genetic medicine have advocated for DNA sampling to improve capture of the genetic profile of patients, particularly since in the future it may improve the choice of medical intervention and therefore patient care (8). STRUCTURE OF SKIN ACROSS ETHNICITIES

There are structural variations in the facial skin of different ethnic groups both in composition and structure (9). The stratum corneum in very dark skin appears to be more easily replenished (10) and has more epidermal shedding. Studies of scans using optical-coherence tomography show that dark skin is thicker where the dermis and epidermis join, and that this relative difference persists even as the thickness of the epidermis–dermis juncture decreases with age (11). Such striking structural differences extend to the epidermis itself—regeneration apparently is more efficient in darker skin, too (12). One of the contributing reasons is better barrier function, and faster turnover of cells in the stratum corneum, as well as a different distribution of melanin (13). In general, skin of color is exquisitely sensitive. Light skin, particularly of Asian origin, typically shows more vascular responsiveness. Even mild skin irritation in darker skin tones can produce postinflammatory pigmentation due to its higher melanin content. In addition, both Asian and African American skin are more prone to

developing keloids, particularly on the jawline, chest, and back typically following trauma but may occur spontaneously (Fig. 34.2). African Americans tend to manifest signs of aging 10 to 20 years later than age-matched lighter counterparts and develop muscle-related or expressive “smile” lines over time more predominantly than suninduced wrinkles over the face (13). Their faces present the signs of aging differently, as well, with more sagging of the malar fat pads and in the mid-face (22). In contrast, linear wrinkling along the forehead, corners of the eyes and mouth, is seen more commonly in Caucasians. In a study comparing Chinese and European women, Chinese women exhibited a pattern more like African Americans (14). They showed fewer fine wrinkles and more folds and fat pad re-distribution than age-matched Caucasians. AESTHETIC CONCERNS IN ETHNIC POPULATIONS

Photoaging Skin: The Influence of Ethnicity and Race There are distinct differences in the effect of photo damage on light skin in contrast to darker skin types. In Caucasians, about half of the UV energy absorbed penetrates the dermis, causing substantial changes in dermal nuclei and cytoplasm, including inhibition of DNA and RNA expression and protein synthesis (15). Darker skin is protective in two ways: It has a more effective barrier mechanism, a thicker dermis, and the distribution pattern and activity of melanocytes may actually inhibit the potential for solar injury (16). However, the widespread assumption that dark skin is relatively immune to photodamage is erroneous. Dermal penetration by UV light is lower in dark skin, so although these alterations are reduced, they do exist. It is a myth that darker skin does not experience UV damage in the same fashion as that experienced by lighter skin types: diminished collagen and deposits of elastotic material occur in all skin types exposed to UV light. Although the tools used to approach age-related changes among ethnicities are the same, the approaches need to take into account differences in signs of aging among different ethnicities and skin types. Melasma Approximately five to six million people in the United States have melasma, although comparisons among ethnic groups are elusive. It is far more common in dark skin, especially Hispanics and Asians, in women and may be inherited (17). The disorder has been correlated with pregnancy, the use of birth control pills, estrogen replacement therapy, and ovary or thyroid dysfunction. Onset usually occurs in the twenties and thirties, with the appearance of symmetric light-gray to dark-brown macules and patches, most often on sun-exposed areas. Treatment of melasma targets removal of existing pigments and prevention of new formation (Fig. 34.3). A number of topical agents have been shown to work in a variety of combinations. The most common one is hydroquinone 5%, tretinoin 0.1%, and dexamethasone 0.1%. In some patients, topical therapy alone is insufficient. In these cases, a topical combined with chemical peels has been found to achieve generally good results. Light-based treatment with fractionated lasers and intensive-pulse light therapy has shown mixed results. Frequently the melasma recurs and can be worse than before laser treatment. It is imperative to emphasize to the patient the importance of ongoing treatment with a retinoid and complete UV protection, sunscreen and hat (18). As UVA, UVB, and visible radiation stimulate melanocytes to produce melanin, either directly or through the production of

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Figure 34.1 (A) Skin type III: Middle Eastern; (B) skin type IV: African Am Ind; (C) skin type IV: Asian; (D) skin type V: African American.

free radicals, it is imperative to use a sunscreen that blocks the full range of light. Because of the risk of ochronosis with long-term use of hydroquinone, long-term treatment with a retinoid can be effective at preventing recurrence (19). There is no “cure” for this disorder: it requires lifelong treatment and sun vigilance. Dermatosis Papulosa Nigra These brown papules typically occur on the face and neck, and affect about 50% of African Americans. Treatments include laser surgery, simple excision, and electrodessication. The first two approaches may result in scarring or post-inflammatory hyperpigmentation (PIH). In general, simple electrodessication gives the best result. However, it is best to perform a test spot before beginning treatment.

Figure 34.2 Keloid scars caused by acne in a Hispanic woman.

Keloids Keloids, which form in response to skin wounds or arise spontaneously, consist of dense collagen, extend beyond the borders of the original

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(B) Figure 34.3 Melasma (A) before and (B) after treatment by a chemical peel.

Acne Keloidalis Nuchae Acne Keloidalis Nuchae is a chronic inflammatory disease commonly seen in African Americans resulting in papules, pustules, and keloidal scarring, usually in the back of the neck and scalp region. Chronic folliculitis usually is concurrent. Topical and oral antibiotics, retinoids, intralesional steroid injections and surgical and laser hair removal all are treatment modalities to reduce scarring.

Figure 34.4 Pseudofolliculitis barbae.

Figure 34.5 Acne affecting the forehead in an African American woman.

wound and do not regress (20). They are far more common in African Americans, Hispanics, and Asians, with an incidence rate of up to 16%. Common sites include ears, shoulder blades, chest, and abdomen. Treatment options include excision combined with intralesional therapy that may consist of corticosteroids mixed with 5-flurouracil and most recently interferon necessary because of the high recurrence rate (21). Pairing intralesional treatment with a vascular laser can be the most effective option.

Pseudofolliculitis Barbae Pseudofolliculitis barbae are red papules, nodules and pustules along the jaw and neck that are commonly seen in African American males and females due to the etiology: Their curly hair becomes ingrown hair creating the inflamed papule (Fig. 34.4). Although this condition is most frequently seen in darker skin, it can occur in any ethnicity, and is seen also in Mediterranean groups and Caucasians. This condition is best treated by laser hair removal but a topical regimen that takes into account the sensitivity of the neck area can be effective too. Using special razors, low strength alpha hydroxyl acid, possibly a retinoid along with an anti-inflammatory or ceramide containing cream can be effective. Lentigines These hyperpigmented macules occur on sun-exposed areas of skin and are due to UV damage. Lentigines are most common in Asian and Hispanic groups; less so in African Americans. Topical bleaching agents can be used at home, such as hydroquinone, tretinoin, adapalene, and mequinol/tretinoin combination but are rarely effective. Cryotherapy can be attempted but complications of hyper- or hypo-pigmentation or scarring can occur, so a test patch is needed. Glycolic acid, TCA, Jessner’s solution, and salicylic acid have also been shown to be effective. Advances in laser technology have resulted in safer and more effective treatments of lentigines in darker skin types with wavelengths appropriate to the skin type. Pre- and post-treatment use of bleaching agents can reduce the chance of laserrelated PIH complications, but individuals with darker skin are at more risk for pigmentary discoloration, and the importance of a test patch cannot be over-emphasized. Prevention is essential and entails complete UV protection in the form of sunscreen, hats, clothing, and shade. Acne in Ethnic Skin Acne occurs in all racial groups (23). Currently, acne is found in 40% to 54% of those older than 25 years—and in 12% of women and 3% of men in middle age, as well as in the overwhelming majority of high school-aged youth (24). Acne inflicts a negative body image and interferes with quality of life among Japanese youth (25), Latino men and

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women (26), African American adolescents and adults, and those of mid-Eastern descent (27) as well as Caucasians. Acne is frequently underdiagnosed in ethnic or more pigmented skin (Fig. 34.5). It is the experienced practitioner who can appreciate comedones in darker skin with underlying inflammation. In addition, other conditions often misdiagnosed as acne are folliculitis, pseudofolliculitis barbae, rosacea, and acne cosmetica, from hair products. Common complications from acne in ethnic skin are the development of keloids, PIH, inflammation, and textural changes (Fig. 34.6). Rosacea Despite the widespread assumption that rosacea affects only Caucasians it can occur in patients of color due to the fact that many affected patients have genes from a relative of Caucasian heritage. It can be difficult to diagnose because characteristic flushing or redness may be masked by the pigmentation of skin types in African American, Asian, and Hispanic skin (28). Nearly half experience flushing as the single most common initial symptom, and a quarter identify persistent redness as the second most common sign (29). The disease typically is chronic, usually persisting over decades. It primarily is seen on the cheeks, nose, chin, or forehead. Pustules usually develop after an initial period in which the only symptom may be intermittent facial redness or flushing. Blood vessels may become visible (telangiectasia). Eye irritation, burning, or stinging may later arise, signaling ocular involvement. The goals of therapy include reduction of papules, pustules, erythema, physical discomfort, and improvement in quality of life (30). Standard topical agents include metronidazole, azelaic acid, and sodium sulfacetamide–sulfur. Topical retinoids have also been reported to be effective, though careful patient selection and addition of a prescription ceramide cream is necessary to avoid excessive irritation and dryness in skin types typically associated with the disease. Vascular lasers can be used as well in addition to the treatments previously described.

activity of muscles through inhibition of the neurotransmitter acetylcholine. However, technique plays a critical role in successful use of it. The toxin works most effectively when delivered in a way that adjusts the movement between the facial muscle elevators and depressors, a method aimed at achieving relaxation of the muscles that contribute to dynamic lines, while yielding a result that creates a pleasing countenance (31). Best results are obtained by knowledge, experience, and skill in treating the face as one entire cosmetic unit. Special technique is required when using neurotoxins for age-related changes in specific ethnicities. For example, in the Asian face, the female brow may be flat, lacking a well-defined arch, which can give the face a masculine look. The goal is to attain a pleasing arched brow—without too much brow elevation and without the excessive lateral wing—avoiding the so-called “Spock” look. Also, the jaw line may be overly broad, and by reducing the size of the masseter muscle through botulinum toxin injections, a softer more feminine look can be achieved (32). Historically, the brow was so important to Chinese women that, in ancient times they would shave off their eyebrows, then paint on a new pair, to create a “proper arch” (33). Generally, the ideal female face, across cultures, is heart shaped. The characteristics include a prominent upperand mid-face with arched eyebrows and a well-defined chin (34). Every face must be approached with a fresh eye in order to ensure appropriate treatment. The African-American face may show the influence of many different ethnicities with wrinkle patterns that may be include those associated with Asian, American Indian, or Caucasian skin and musculature. For example, if the brow is already at the appropriate place, then only the procerus may need to be treated to eliminate a frown line. However, there may be dramatic marionette lines—the lines that run from the corner of the mouth to the jawline—in which case the depressor anguli oris muscle must be treated. If there are no frown lines, but instead deep lines in the forehead, then only the frontalis muscle needs to be treated. No “cookie-cutter recipe” exists, especially in ethnic populations. Training in the use of the neurotoxins is essential for appropriate dosing for muscle mass, and anatomy across the ethnic spectrum.

COSMETIC TREATMENTS IN ETHNIC SKIN TYPES

Neurotoxin Use Botulinum neurotoxin A (BoNT-A) is now the most popular minimally-invasive procedure in cosmetic surgery (7). This method uses very dilute amounts of the neurotoxin to decrease the contractile

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Use of Facial Fillers in an Ethnically Diverse Population The safety, tolerability, and efficacy of fillers such as hyaluronic acids, different types of collagen, and hydroxylapatite have been demonstrated in different skin colors and types. Restylane, a hyaluronic acid filler, has been

(B)

Figure 34.6 Acne with PIH in an African American woman (A) before and (B) after treatment by glycolic acid peel followed by topical retinoid.

DIVERSE POPULATIONS IN AESTHETICS: ETHNIC PATIENTS shown to stimulate collagen production (35). It is important to understand that beauty ideals may differ cross-culturally, and also be cognizant of possible side effects of fillers that may be unique to these groups. Concerns of complications such as PIH, hemosiderin deposition from purpura due to traumatic injection, or appearance of the filler in the skin, can be addressed by using linear threading as opposed to serial puncture and placement of these products in the hypodermis (36,37). Careful, gentle injections prevent bruising, therefore avoiding hemosiderin deposition. Also, when the face is injected slowly there is less risk of PIH or scar formation. Studies have shown that there is no significant increase in keloid formation, hypertrophic scarring, or hyperpigmentation with the use of hyaluronic acids in skin of color (38). In well-trained hands, all of these fillers can soften lines or wrinkles, as well as re-contour the face to a more youthful appearance, while making it look “refreshed.” Re-volumizing to erase the “deflated” appearance gives the face a softer look. It is worth stressing that the flip side is also true: too much can mean an abnormal-looking change. This is an extremely important consideration in the approach to the lips (39). The size and shape of the lips are specific to different ethnicities, and it can be impossible to create a change in the actual shape of the lip with a filler.

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The more challenging task is to understand how to re-volumize the individual face in an aesthetically pleasing fashion. For example, the Asian face may develop a deep nasolabial fold that is often best addressed by injecting from an inferior point at the top of the nasolabial fold toward the malar eminence to attain a “liquid lift” as well as an effacement of the nasolabial crease (Fig. 34.7). Another approach is to use a mattress or “fern” technique—to fill from the lateral to medial areas, rather than going under the fold, which can create a “shelf effect” (40). As long as the product is placed on the periosteum, any of the long-lasting hyaluronins or hydroxlyapatite can be used. The Hispanic face may have more folds and fat pad redistribution than fine lines and wrinkles and can be approached in a similar fashion to the Asian face. The African-American face can have both folds and lines and wrinkles. The folds must be treated from a deeper plane but the wrinkles can be treated in a more superficial, although still hypodermal location. The periorbital area is an ideal place for fillers (Fig. 34.8), but only for the most experienced injector (41). The hyaluronic acid must be injected in small amounts gently outside the orbit on the periostium just below the orbital rim. “Dark circles” are often due to an optical illusion: The

(B) Figure 34.7 Asian female (A) before and (B) after combination therapy with fillers and botulinum toxin.

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Figure 34.8 African American woman (A) before and (B) after injection of her NLF and undereye area with hyaluronic acid filler.

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concave surface serves as a light trap and until it is made convex the area will never lighten, regardless of the amount of skin lightener that is applied. Often, by stretching the skin, the physician can see how much actual hyperpigmentation of the skin contributes to the raccoon look. Nonsurgical rhinoplasty, in which implants of this dermal filler are injected at specific sites on the nose, has been found to provide a noninvasive method for creating a more aquiline nasal profile, as well as enhancing the nasal ridge. However, it is extremely important to be aware of the vasculature in the nose anatomy before attempting this technique. This approach has been used in all ethnicities with success by experienced practitioners (42). In sum, there is increasing demand for aesthetic use of fillers across ethnicities and skin types. The establishment of safety and tolerability affirm the feasibility of their use in all ethnicities. COSMETIC TREATMENTS USING RADIOFREQUENCY AND LIGHT BASED DEVICES

Radiofrequency Devices Radiofrequency devices can help to resolve skin laxity by stimulating tissue tightening through delivery of energy to deeper planes of the skin. They can be monopolar, bipolar, or a hybrid of both. Because the process heats the skin as a result of tissue resistance to electron movement rather than selective photothermolysis, it can be used safely in ethnic skin as long as the settings are adjusted to a level where the patient is comfortable and the multiple pass, vector and low energy approach is used (43). Side effects such as scars, pigmentation, indentation, and burns can occur in any skin type if the settings are too high. It is crucial to select patients without a history of vitiligo or other pigmentary disorders that could in theory be worsened by a treatment.

(A)

Fractionated Laser Therapy Fractionated lasers are a resurfacing technology that stimulates collagen production, by damaging microscopic areas of the epidermis and dermis through a patterned delivery of energy (44). Because of the risk of difficult to treat, long-term PIH, the risk benefit ratio must be clearly discussed with the patient. Even though the thermal injury is reduced the depth of penetration is such that PIH is a known side effect. As the fractionated lasers have been shown to be effective in difficult to treat acne scars the patients may be willing to undergo the series of treatments necessary to attain a result. In general these lasers may be useful in different skin types and colors to improve traumatic scars, or certain types of lines and wrinkles, but test patches are essential to ascertain the likelihood of complications. Pre-treatment with a retinoid and hydroquinone may speed healing and reduce the incidence of pigmentary changes. Maximum improvement is seen 6 to 12 months posttreatment; and at least four to six treatments are needed three to four weeks apart. Short-term swelling, redness, and crusting often occur, but resolve after 3 to 14 days depending on settings used. Laser and Intense Pulsed Light Sources These devices work on the principle of selective photothermolysis where the target chromophore is matched to the appropriate wavelength (45). In darker skin types and ethnic skin, this principle is extremely important in order to choose a device with the appropriate wavelength to treat the problem while simultaneously avoiding the potential complication of post-treatment pigmentary change. Common issues experienced by all ethnicities include telangiectasia on the face, red birthmarks, brown birthmarks, scars, and lentigines (Figs. 34.9 and 34.10).

(B) Figure 34.9 Hispanic woman (A) before and (B) after treatment of nevus of Ota by QSRL.

(A)

(B)

Figure 34.10 Asian woman with post-surgical scar (A) before and (B) after multiple treatments with a 595 pulsed dye laser and a nonablative fractionated laser.

DIVERSE POPULATIONS IN AESTHETICS: ETHNIC PATIENTS Telangiectasia, scars, and red birthmarks such as port wine stains are treated typically with a 595-nm wavelength in darker skin types rather than a 532-nm wavelength, at longer pulse widths and with a cooling device. Test patches, lower energies, and multiple treatments are recommended to prevent any PIH (46,47). If PIH occurs, it is almost always transient. Lentigines and brown birth marks such as nevus of Ota can be successfully treated with longer wavelength lasers such as a Q-switched ruby (694 nm) or the Q-switched Nd:YAG (1064 nm). Occasionally an intense pulsed light (IPL), or broadband light-based device, can be used for lentigines but only with a low-energy setting. Once again, test patches are required and pre- and post-treatment skin care must be provided to prevent PIH. Nevus of Ota is identifiable by the blue–brown or gray patches that appear over areas of the face, along the track for the trigeminal nerve. It is most common in Asians, who express it unilaterally in about 90% of the cases (48). Q-switched laser therapy is the current treatment of choice, but pre- and post-treatment skin cooling is advised. Treatments are done at intervals that range from 2 to 4 months to allow the pigment to clear. Laser Hair Removal Darker-skinned ethnic patients often have darker, coarser and thus more noticeable hair than lighter skinned patients, which can lead to increased cosmetic concern over unwanted hair (49). But only within the last decade has it been safe to perform laser-assisted hair removal in patients with darker skin types (Fitzpatrick IV–VI). This is due to the advent of lasers with longer wavelengths, longer pulse durations, and improved cooling mechanisms, all of which can significantly reduce the number of hairs (and fineness, darkness, and rate of growth) while maintaining a low incidence of side effects such as hypo- and hyperpigmentation from thermal damage. The long-pulse Nd:YAG has proven to be the best laser choice for darker pigmented skins (50,51). Other devices, including the diode laser using long-pulse durations and long-pulsed alexandrite (51), have also been effective. The increased wavelength allows for decreased epidermal melanin absorption and increased penetration depth, and the long pulse duration causes slower heating and results in a lower incidence of dyspigmentation. Between the diode and the Nd:YAG, the latter is generally safer, particularly for very dark skin types; however, the diode laser may be more effective because of greater melanin absorption (52). For example, a mean hair reduction ranging from 58% to 62% on facial sites and 66% to 69% on nonfacial sites has been reported after three treatments with the long-pulsed Nd:YAG compared with 74% to 84% hair reduction with the diode laser 6 months after the final laser treatment (53). Both the long-pulsed Nd:YAG and diode devices are FDA-approved for laser hair removal in darker skin types. Cooling devices provide added benefit for laser hair removal, especially in ethnic skin (49). They not only cool the epidermis to prevent laser-induced hyperthermia with subsequent PIH, but decrease the pain associated with the procedure. Laser units equipped with cooling tip devices are often best, especially those with embedded sapphire cooling plates, because they lead to dermal compression, which brings follicular structures closer to the area of maximal dermal laser penetration and also compresses blood vessels, thereby decreasing the concentration of the hemoglobin (54). Other laser units deliver a cooling cryogen spray. However, this may lead to further dyschromia in darker skinned patients it should be used cautiously (55). With or without a cooling device, a thick layer of cooled aloe gel should be applied after laser treatment. When treating darker skinned patients, performing test sites at inconspicuous areas is crucial. The maximum fluence tolerated is determined by the epidermal pigmentation, and the fluence is carefully increased while the skin is observed for signs of acute epidermal injury,

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such as whitening, blistering, or erythema. The ideal immediate response is vaporization of the hair shaft, with no other apparent effect. The average number of laser sessions needed to achieve a significant reduction of excess hair is between five and six treatments performed in 1 to 3 month intervals. The number of treatments needed to obtain the best results for different anatomic sites is unknown, although anecdotal evidence reveals that certain areas such as the axilla, bikini area, and beard area in men may require more treatments (56). 1450 Diode Laser for Acne Treatment While the 1450-nm diode laser has been shown to be effective in the treatment of mild-to-severe inflammatory facial acne, its suspected mechanism of action has only recently been studied. The laser acts through bulk heating of the dermis, which appears to damage the sebaceous glands and inhibit their output. One study found a significant reduction in sebum output of 18% after three treatments with the 1450 nm diode laser (57). This laser provides a satisfactory alternative for patients with mild-to-moderate acne and those with adult-onset acne, who can’t take or haven’t responded to systemic treatment. It can also be effective for enlarged pores or excessive oiliness. Improvement from the laser treatment can be maintained and enhanced by a topical regimen that includes a retinoid. CHEMICAL PEELS

Peeling agents induce a controlled wounding of the skin in order to generate a new epidermis and dermal collagen remodeling. Used primarily for treating pigment dyschromias in ethnic skin, superficial, and medium-depth chemical peels can also improve a number of other conditions, including acne vulgaris, PIH, melasma, scarring, photodamage, and pseudofolliculitis barbae. But it is critical to identify the patient’s Fitzpatrick skin type as well as ethnicity before selecting a peeling agent (58). Each peeling agent has different properties that make it more or less suited for a specific patient. Three of the most useful agents include the following. Glycolic acid peels, which range in concentration from 20% to 70%, and pH from 3 to 7, are performed monthly for a total of four to six treatments. They are indicated for melasma, PIH, mild photoaging, and acne, and are usually well tolerated in all skin types and colors. Salicylic acid peels range in concentration from 20% to 30% and are performed every 3 to 4 weeks for a total of three to five treatments. They are indicated for acne vulgaris, melasma, PIH, rough, and oily skin with enlarged pores, and mild-to-moderate photodamaged skin. They are also available in at home preparations. TCA PEELS in general use range in strength from 10% to 35%. They are indicated for the treatment of acne scarring, fine rhytids, actinic damage, mild epidermal dyschromia, reduction of superficial keratoses, and comedone formation. Treatment intervals between applications are generally within 7 to 28 days. TCA peels at low concentrations of 10% to 25% also work well to treat acne scarring in skin of color and, when used in combination with 70% glycolic acid gel, can also rejuvenate uneven mottled skin pigmentation. Regardless of the peeling agent chosen, caution needs to be exercised in darker skinned patients. Treatments should first be attempted at low concentrations and short contact times to decrease the risk of adverse side effects. A general rule of thumb is that multiple treatments of low strength may outweigh the benefits of higher concentrations and deeper peels. THERAPY FOR ACNE IN SKIN OF COLOR

Treatment of acne in ethnic and pigmented skin must have a comprehensive approach in order to address the common sequelae; PIH and scarring. By using a new acne scale to determine the presence of concomitant complications, an effective treatment program can be designed (59).

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Monotherapy is generally not as effective as combination approach for acne, but use of benzoyl peroxide and retinoids must be combined with moisturizers in darker skinned patients to avoid any drying effect, which could incite pigment change (60). Topical therapy should always include a retinoid as they have become the standard of treatment across all race and ethnic groups. Not only do they reduce active lesions but they combat PIH in African Americans (61). The retinoids are particularly useful in darker skin because benzoyl peroxide can cause irritation, resulting in PIH. Hispanic skin tends to respond to retinoids as well. In Asian skin, which can be especially hyper sensitivite, persistent erythema may occur. Azelaic acid has been shown to be effective in treating acne in darker skin, and the risk of hyperpigmentation has also been shown to be low (62). Azelaic acid also can be used in light Asian skin—it does not appear to have the drying effects of other therapies. Laser and light therapy can also be used to treat acne in ethnic and deeper tone skin. IsolazTM—a combination of pneumatic energy and broadband light—has been used to treat inflammatory acne, comedonal acne, and pustular acne. It is efficacious and safe to use on darker skin and can improve PIH (59). Diode lasers have also been shown to be effective and safe in this patient population as well as photodynamic therapy. Once again, lower settings and precautions need to be taken to prevent pigmentary complications. SKIN CARE

The unique melanin distribution of ethnic skin poses a challenge for intensive skin care, since irritation can result in an undesirable darkening of the skin color called PIH. Although mild skin irritation may be tolerable in minimally pigmented skin, since the resulting erythema is short lived and not accompanied by hyperpigmentation, any productinduced inflammation in ethnic skin may cause prolonged pigmentary change (63). Thus, cleansers designed to produce mild exfoliation and improve skin surface texture in Caucasian skin may produce PIH in African-American skin. Similarly, antiaging moisturizers with hydroxy acids designed to stimulate epidermal turnover and collagen formation in Caucasian skin may also produce pigmentary changes in AfricanAmerican skin. All these factors need to be taken into account to effectively design regimens for photoprotection and skin lightening. Skin care products with active ingredients, which fall into the broad category of cosmeceuticals, are of particular interest to the ethnic population, since skin ashiness, facial skin shine, antiaging photoprotection, and irregular pigmentation are of key importance . Cleansing and Moisturizing Pigmented skin appears much shinier than Caucasian skin with a minimal amount of sebum, owing to the way light is reflected both from and within the skin. Shiny skin is considered to be oily and unattractive skin by many ethnic individuals. Although current studies show no significant differences between African Americans and Caucasians in instrumental measurements of sebum (64), there is a positive correlation in Asian women between darker pigmentation and the amount of skin surface lipids (65). Oily Skin A good cleanser must remove enough sebum from the skin to appear clean but not too much sebum to create ashy skin scale. While a high pH bar soap (Ivory) is excellent at sebum removal, it may be too irritating for ethnic skin, so a better choice would be a neutral-pH synthetic detergent bar (Dove, Oil of Olay, Cetaphil), which eliminates less sebum but is not likely to damage intercellular lipids (63). Dry Skin Lipid-free cleansers are ideal for dry ethnic skin, because they leave behind a thin moisturizing film (examples include Cetaphil Cleanser,

Galderma, and CeraVe Cleanser). Cleansing creams and cold creams will efficiently remove makeup from extremely dry ethnic skin. But their high oil, petrolatum, and wax content precludes their use in patients with acne or oily skin. Removing Ashiness Moisturizers are designed to improve the texture, feel, and appearance of the skin. To do this they should increase the water content of the skin, make it feel smooth and soft, and protect injured or exposed skin from harmful stimuli. This is accomplished through use of occlusive ingredients, which are found in popular ethnic moisturizers and include cocoa butter, lanolin, shea butter, and mineral oil. Emollient oils in moisturizers create a smooth skin surface by temporarily filling the spaces between desquamating skin scales. Examples include jojoba oil, propylene glycol, and nongreasy silicone oils such as dimethicone and cyclomethicone. Antioxidants and anti-inflammatories are also useful. These include vitamins A, D, and E (for emolliency), aloe, and allantoin (an antiinflammatory to prevent PIH). Photoprotection Irregular pigmentation from the sun is an enormous concern for ethnic patients. UVA as well as UVB protection is extremely important to prevent unwanted tanning and decrease the incidence of photoinduced PIH, and UVB protection is important to prevent sunburn. Because the inorganic sunscreens, zinc oxide, and titanium dioxide, even when micronized can leave a white sheen on the skin, organic sunscreens containg UVA absorbers such as mexoryl, avobenzone, ecamsule, and oxybenzone are preferable. Pigment Lightening Whether present in the form of solar lentigenes across the cheeks, periorbital pigmentation in persons of Indian descent, or dark spots from acne lesions, treating hyperpigmentation with cosmeceuticals is problematic. A successful treatment must remove existing pigment from the skin, shut down the manufacture of melanin, and prevent the transfer of existing melanin to the melanosomes. Hydroquinone is the gold standard of pigment-lightening ingredients, and is found in many OTC, physician-dispensed, and prescription preparations. Proprietary hydroquinone-containing drugs, which have undergone FDA scrutiny, have well established safety and efficacy profiles. Some formulations include penetration enhancers such as glycolic acid or tretinoin, or contain microsponges to create timed delivery of hydroquinone to the skin, while others add sunscreen ingredients to prevent UV-induced pigment darkening. A patch test for several weeks on a limited hyperpigmented site may be valuable. It is a balancing act to choose the most potent topical cocktail for lightening while avoiding irritation, as the irritation will create PIH. The primary prescription lightening alternative to hydroquinone is mequinol, packaged in a sponge-tipped applicator for spot treatments. The prescription retinoids tretinoin and tazarotene have also been used, indirectly as penetration enhancers and directly to help fade freckles and lentigenes. Preparations that contain both hydroquinone and a retinoid must also incorporate a topical corticosteroid to prevent the excess irritation that could cause PIH. A less irritating ingredient is azelaic acid, available by prescription in a 15% gel. Although its lightening effects are mild, several large studies done with a diverse ethnic background population have compared its efficacy to that of hydroquinone (66,67). The strongest botanical pigment-lightening ingredients have a chemical structure similar to hydroquinone, such as arbutin. The synthetic form of deoxyarbutin is probably the most effective pigment-lightening agent in the OTC realm. Kojic acid comes in second but is a known sensitizer.

DIVERSE POPULATIONS IN AESTHETICS: ETHNIC PATIENTS Other botanical ingredients that lighten with some efficacy are aleosin, licorice extract, ascorbic acid, soy proteins, and N-acetyl glucosamine. REFERENCES

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26. Quandt SA, et al. The association of dermatologist-diagnosed and self-reported skin diseases with skin-related quality of life in Latino migrant farm workers. Int J Dermatol 2008; 47(3): 236–1. 27. El-Essawi D, et al. A survey of skin disease and skin-related issues in Arab Americans. J Am Acad Dermatol 2007; 56(6): 933–8. 28. Rosacea Review. ROSACEA.ORG. www.rosacea.org/rr/2008/summer/qa.php#2 29. National Rosacea Society. http://www.rosacea.org/index.php 30. Blount BW, Pelletier AL. Rosacea: a common, yet commonly overlooked, condition. Am Fam Physician 2002; 66(3): 435–40. 31. Klein AW. The clinical use of botulinum toxin. Dermatol Clin 2004; 22: 197–205. 32. Liew S, Dart A. Nonsurgical reshaping of the lower face. Aesthet Surg J 2008; 28(3): 251–7. 33. Bangkok Post. The art of oriental beauty. [Available from: http:// www.Bangkokpost/leisure/women/10357/theart-of-orientalbeauty]. 34. Sundaram H. A practical primer for Dysport part 3: putting it all together—strategies for success with integrative rejuvenation of the upper face. Practical Dermatol N 2009, 47–52. 35. Wang F, et al. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol. 2007; 143(2): 155–63. 36. Kamer FM, Churukian MM. Clinical use of injectable collagen: a three-year retrospective review. Arch Otolaryngol 1984; 110(2): 93–8. 37. Alam M, Yoo S. Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions. J Am Acad Dermatol 2007; 56(2): 285–9. 38. Pigeon T. Evaluating hyaluronic acids in patients with skin of color. Practical Dermatol 2009, 11–13. 39. Fitzgerald F, Vleggaar D, Burgess. Facial dermal fillers. Aesthet Surg J 2008; 28(6): 699–701. 40. Eijk T, Braun M. A novel method to inject hyaluronic acid: the Fern Pattern Technique. J Drugs Dermatol 2007; 6(8): 805–8. 41. Goldberg RA. Technique issues in nonsurgical filling of the periorbital hollows reply. Aesthetic Surg J 2007; 27(3): 296. 42. Rivkin A, Soliemanzadeh P. Nonsurgical injection rhinoplasty with calcium hydroxylapatite in a carrier gel (Radiesse): a 4 year, retrospective, clinical review. Cosmet Dermatol 2009; 22: 619–24. 43. Bogle MA, Dover JS. Tissue Tightening Technologies. In Narukar VA, Thiers BH, eds. Cosmetic Dermatology: Dermatol Clin 2009; 27: 491–9. 44. Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med 2006; 38: 169–76. 45. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220: 524–7. 46. Sommer S, Sheehan-Dare RA. Pulsed dye laser treatment of port-wine stains in pigmented skin. J Am Acad Dermatol 2000; 42(4): 667–1. 47. Chang CJ, Nelson JS. Cryogen spray cooling and higher fluence pulsed dye laser treatment improve port-wine stain clearance while minimizing epidermal damage. Dermatol Surg 199; 25(1): 767–72. 48. Lui H, Zhou Y. Nevi of Ota and Ito. eMedicine, July 14, 2008. 49. Soriano T, Beynet D, Carranza DC. Laser hair removal in darker racial ethnic groups (Chapter 32). In: P Grimes, ed. Aesthetics and Cosmetic Surgery for Darker Skin Types. Philadelphia, PA: Lippincott Williams & Wilkins, 2008. 50. Lanigan SW. Incidence of side effects after laser hair removal. J Am Acad Dermatol 2003; 49–882. 51. Garcia C, Alamoudi H, Nakib M, et al. Alexandrite laser hair removal is safe for Fitzpatrick skin types IV–VI. Dermatol Surg 2000; 26: 130.

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60. Halder RM, Brooks HL, Callender VD. Acne in ethnic skin. Dermatol Clin 2003; 21: 609–15. 61. Halder RM. The role of retinoids in management of cutaneous conditions in blacks. J Am Acad Dermatol 1998; 39: S98–S103. 62. Fitton A, Goa KL. Azelaic acid: a review of its pharmacological properties and therapeutic efficacy in acne and hyperpigmentary skin disorders. Drugs 1991; 41: 780–98. 63. Draelos ZD. Cosmeceuticals in ethnic skin (Chapter 14). In: Alam M, et al., eds. Cosmetic Dermatology for Skin of Color. New York, NY: McGraw-Hill Companies, 2009. 64. Grimes PE, Edison BL, Green BA, et al. Evaluation of inherent difference between African American and white skin surface properties using subjective and objective measures. Cutis 2004; 73(6): 392–6. 65. Abe T, Arai S, Mimura K, et al. Studies of physiological factors affecting skin susceptibility to ultraviolet light irradiation and irritants. J Dermatol 1983; 10: 531–7. 66. Fitton A, Goa KL. Azelaic acid: a review of its pharmacological properties and therapeutic efficacy in acne and hyperpigmentary skin disorders. Drugs 1991; 5: 780–98. 67. Balina LM, Graupe K. The treatment of melasma. 20% azelaic acid versus 4% hydroquinone cream. Int J Dermatol 1991; 30(12): 893–5.

Index

AAMC. See American Association of Medical Colleges Abdominoplasty, 11–12 Ablative fractional laser resurfacing clinical indications, 238–239 clinical results, 238, 240 complications, 240 healing of, 239 patient preparation, 238 patient selection, 238 post-treatment care, 238 wavelengths for, 239 Ablative resurfacing, 14 AbobotulinumtoxinA, 119 Accessibility, 36 Accreditation Council for Graduate Medical Education (ACGME), 39 ACGME. See Accreditation Council for Graduate Medical Education Acne in ethnic patients, 267–268 ethnic skin, 267–268 persistence of teen, 254–255 scarring, 257 stress, 256–257 therapy, 271–272 topical and systemic treatments, 255 Acne keloidalis nuchae, in ethnic patients, 267 Acne vulgaris, 254 ADA. See Americans with Disabilities Act (ADA) ADG® needle, 121 Aesthetic marketplace, 5 contractions in, 14 Aesthetic medical procedure non-surgical procedures Botox, 12 chemical peels, 14 injectible hyaluronic acid, 14 laser hair removal, 14 laser skin resurfacing, 12, 14 surgical procedures abdominoplasty, 11–12 breast augmentation, 9–10 breast reduction, 12 facelift, 10–11 lipoplasty, 10 Aesthetic medicine aging, 85 blepharoplasty, 87–88 brow lifting, 88–89 combined procedures, 91–92 deep peeling, 85–87 face and neck lifting, 89–90

laser skin resurfacing, 85–87 long-term results, 93–95 Aesthetic neck composition of, 215 criteria for, 216 Aesthetic office cabinetry, 38 casework, 38 chair, 37–38 entrance, 36–37 exam and procedure rooms, 37 lighting, 37 lobby, 36–37 monitors, 38 physician stool, 37 procedure table, 37–38 staff awareness, 38 training, 38 Aesthetic specialist, role of, 1 African American patients acne keloidalis nuchae, 267 keloid formation, 204 pseudofolliculitis barbae, 267 skin color, 265 Aging face, in male patients, 259 lipoatrophy atrophy/hypertrophy model, 155 injection steps, 155–156 injection technique, 155 patient selection, 155 PLLA-injection preparation, 155 safety and efficacy history, 155 mechanisms and classifications of, 85 ALA. See 5-aminolevulinic acid Alexandrite laser, 5 Alphahydroxy acids (AHAs), 172, 174–175, 248 Ambi, 249 American Association of Medical Colleges (AAMC), 39 American Society for Aesthetic Plastic Surgery (ASAPS), 209, 232, 259 market overview and assessment, 9 methodology, 9 American Society for Dermatologic Surgery (ASDS), 130 Americans with Disabilities Act (ADA), 37 5-Aminolevulinic acid (ALA), 228–229 Androgenetic alopecia, 260 Anesthesia pretreatment, 142 tumescent, 238 Anesthesia, vibratory, 120 Antiviral prophylaxis, 172–173

Aperture, 18 Aperture priority mode, 19 Aquamid, 163 Artefill. See Polymethylmethacrylate (PMMA) ASAPS. See American Society for Aesthetic Plastic Surgery ASDS. See American Society for Dermatologic Surgery Ashiness, 272 Asian eyelids, 191 Atrophy model, 155 Augmentation mammaplasty, 209–213 mentoplasty, 221 soft tissue, 251 Autologous fat transfer, 263 Axillary hyperhidrosis, 118–119 Azelaic acid, 272 Barbed sutures, 221–222 Bargain hunters, 43 Benzoyl peroxide (BPO), 255 Beta hydroxy acids (BHAs), 248 Betadine™ solution, 115 Bio-Alcamid, 163–164 Birthmarks, 254 Black tattoos, 261 Black-ink tattoos, 254 Blepharoplasty canthal angle distortion, 205 diplopia, 204 dry eye, 204 incision irregularities, 204–205 infection, 205 lacrimal gland prolapse, 204 lagophthalmos, 204 lower, 199–202 lower eyelid, 88 lower lid malposition, 205 ptosis, 204 sulcus and nasojugal deformities, 205 undercorrection, 205 upper, 197–199 upper eyelid, 87–88 vision loss, 203–204 Blogs, 48 Bony prominence, 158 Botanical agents, 249 BOTOX®, 12, 106 Botulinum neurotoxin A (BoNTA), 268 Botulinum toxin, 3–4 complications crow’s feet, 99 forehead, 98 glabella, 98–99

275

276 Botulinum toxin (Continued) infraorbital region, 99 lower face treatment, 99–100 neck treatment, 100 non-specific complications, 98 safety considerations, 100 consent forms, 74–75 in male patients, 259 medication guide, 71–74 post-operative forms, 77 Botulinum toxin type A (BTX-A), 222 clinical usage lower face, 111–113 midface, 110–111 upper face, 107–110 contraindications and precautions, 106–107 dosing, 106 immunology, 106 pharmacology, 106 preparations of, 106 toxicity, 106 Botulinum neurotoxin type B, 125–126 Bovine collagen, 135 Boxcar scars, 257 BPO. See Benzoyl peroxide Breast augmentation, 9–10 anatomy, 209 historical evolution, 209 implant position, 210–211 post-operative care, 213 pre-operative evaluation implant shape and texture, 210 implant size, 209 saline vs. silicone implants, 209–210 surgical approach, 211 surgical techniques inframammary technique, 211–212 periareolar technique, 212 transaxillary technique, 213 Breast reduction, 12 Brow lifting, 88–89 Brow ptosis, 99 Bruising, 104, 120–121 hyaluronic acid fillers, 138 Bruxism, 253 BTX-A. See Botulinum toxin type A Cabinetry, 38 Calcium hydroxylapatite (CaHA) dermal filler cheeks, 144–145 chin recession, 147–148 collagen, 141 composition, 141 cutaneous lip lines, 148 hands, 148–150 hyaluronic acids, 141 indications, 142 injection techniques, 142 marionette lines, 145–146 mechanism of action, 141 midface, 144–145

INDEX nasal sculpting, 145 nasolabial fold, 143 oral commissure, 145–146 patient counseling and evaluation, 142 person color, 141–142 post-operative treatment, 150 pre-jowl sulcus, 147 pretreatment anesthesia, 142 submalar cheek hollows, 145 treatment tips, 142 Camera lenses, 18 Canthal angle distortion, 205 Canthal tendons, 192 Canthoplasty, 202 Captique, 135 Carrier proteins, 248 Cellulite creams, 246 Cellulite lighting, 31 Cellulite reduction, 5–6 Cervical suspension, 222 Cheap patient, 43 Chemical peel forms, 67 Chemical peeling aesthetic medical procedure, 14 alphahydroxy acids, 172 antiviral prophylaxis, 172–173 complications infection, 180 milia, 180 pigmentation, 179–180 prolonged erythema, 180 scarring, 180–181 systemic, 181–182 consent, 173 consultation, 173 in ethnic patients, 271 history, 172 hydroquinone, 172 medical spa, 3 photography, 173 pre-operative preparation, 172 pre-treatment with tretinoin, 172 sunscreens, 172 superficial, 173–174 Chinese women, skin color, 265 Chin recession, 147–148 Chromhidrosis, 124 Chromophore, 225 Clay-based mask, 246 Clinical cosmetic photography, 21 Cobra deformity, 224 Coffeeberry, 247 Cold lasers, 233–234 Collagen, 260 Comfort, 36 Compensatory sweating, 124 Consent forms, 67, 70 botulinum toxin treatment, 74–75 injectable tissue augmentation procedure, 76 pigmented lesion laser treatment, 66 Consultation chemical peeling, 173

cosmetic interviewing, 39 medical history, 39–40 medical interview, 39 offerings of practice, 47–48 patient education, 39 liposuction, 165 Continuous laser, 233 Corset platysmaplasty, 219–220 Cosmeceuticals cellulite creams, 246 eye creams, 245–246 facial cleansers, 245 facial moisturizers, 245 ingredients coffeeberry, 247 green tea, 247 growth factors, 248 hydroxyacids, 248 peptides, 247–248 soy, 247 male patients, 262–263 masks, 246 night creams, 246 serums, 246 sunscreen, 246–247 therapies for hyperpigmentation, 249 toners, 246 Cosmetic brand definition, 46 delivery explicit brand building, 46 implicit brand building, 46–47 Cosmetic consultation interviewing, 39 medical history, 39–40 medical interview, 39 offerings of practice, 47–48 patient education, 39 Cosmetic dermatologists, 39 Cosmetic facial rejuvenation, 40–41 Cosmetic Medicine Task Force, 2 Cosmetic patients cosmetic facial rejuvenation, 40–41 first time vs. experienced, 40 interview, 39 Cosmoderm®, 260 Cosmoplast®, 260 Cranio-facial hyperhidrosis, 123 Cross-hatching, 147 Crow’s feet, 99, 252 Cyanosis, 224 Cytokines, 248 Dedo classification of neck aging, 85 Deep chemical peeling, 178 Deep peeling, 85–87 Deep plane facelift, 218–219 Demographics, 79 Depressor anguli oris (DAO), 99 Depth of field, 18 Dermal fillers, 135 Dermatosis papulosa nigra, 266

INDEX Diabolical brow, 99 Diet, 257 Digital camera, optical viewfinder aperture priority mode, 19 electronic viewfinder, 19 flash options, 19 focal length, 34–35 lighting, 22–23 cellulite, 31 facial, 26, 31 generalized, 24 manual mode, 19 patient preparation attention to detail, 20–21 photographic consent, 20 standardized views, 21 positioning and alignment Frankfort plane vs. natural horizontal facial line, 21–22, 33 lateral face alignment, 22, 33 program mode, 19 shutter priority mode, 19 video capability, 19 Digital compact camera electronic viewfinder, 19 LCD, 19 optical viewfinder, 19 Digital Marketing, 48–49 email, 48–49 Digital single lens reflex (DSLR), 18 Digital zoom, 19 Diode lasers, 5, 272 1450-nm Diode laser, 271 Diplopia, 204 Drug-induced lipodystrophy syndrome, 263 Dry eye, 204 Dry skin, 272 DSLR. See Digital single lens reflex Dyschromia, 227–228 Dysphagia, 100 Dyspigmentation periprocedural intervention, 82–83 prevention of, 80–81 DYSPORT®, 106 Edema, 103 Electronic viewfinder (EVF), 19 Endoscopic brow lifting, 89 Endoscopic thoracic sympathectomy (ETS), 117 EPAT. See Extra corporeal pulse activation therapy Ergonomics accessibility, 36 aesthetic office, 36–38 comfort, 36 efficiency of procedures, 36 perception, 36 principles of, 36 quality of care, 36 reputation, 36 safety, 36 Erythema, 82–83, 103 prolonged, 180

Ethnic patients aesthetic issues acne, 267–268 acne keloidalis nuchae, 267 dermatosis papulosa nigra, 266 keloids, 266–267 lentigines, 267 melasma, 265–266 photoaging skin, 265 pseudofolliculitis barbae, 267 rosacea, 268 chemical peels, 271 cosmetic treatment facial fillers, 268–269 neurotoxin, 268 1450-nm diode laser, 271 fractionated laser therapy, 270 laser and intense pulsed light sources, 270–271 laser hair removal, 271 radiofrequency devices, 270 skin care dry skin, 272 oily skin, 272 photoprotection, 272 pigment lightening, 272–273 removing ashiness, 272 skin color, 265 ETS. See Endoscopic thoracic sympathectomy EVF. See Electronic viewfinder Evolence®, 260 Evolence Breeze®, 260 Excessive lacrimation, 99 Excessively complimentary patient, 44 Excessive scleral show, 99 Explicit brand building, 46 Extra corporeal pulse activation therapy (EPAT), 5 Eyebrows, 99 Eye creams, 245–246 Eyelids Asian, 191 lower, 194 margin, 192–193 ptosis, 98 upper, 193–194 Face and neck lifting, 89–90 Facelift, 10–11 Facial aging, 188 Facial cleansers, 245 Facial enhancement aesthetic surgery, 187–188 dark skin patients, 186–187 periorbital area, 184–185 rejuvenation, 184 Facial fillers, 268–269 Facial geometry, 251 Facial hyperhidrosis, 121–122 Facial lighting, 26, 31 Facial lipoatrophy, 151 Facial lipoatrophy grading scale, 152 Facial moisturizers, 245 Fanning, 147

277 Fat melting devices cold lasers, 233–234 heat-producing lasers, 234–235 laser-assisted liposuction, 235 ultrasound energy, 232 water-assisted liposuction, 235–236 FDA. See Food and Drug Administration Festoons, 99 Filler consent forms, 67 Fillers, 88 in dark skin patients, 186–187 facial, 268–269 Financial health of practice budget creation, 58–59 expense control, 58 external professionals, 58 inspection, 50 internal assessment, 50 marketing expense, 56–57 non-provider payroll ratio, 55–56 operating expense ratio, 55 rent expense ratio, 56 retail product sales, 54–55 supplemental information, 59 tactical opportunities, 57–58 Fitzpatrick scale, 80 Focal hyperhidrosis, 115 Focal length, 18 Follicular unit transplantation (FUT), 260 Food and Drug Administration (FDA), 2, 41, 67, 106 Forehead anatomy, 107 complications, 108–109 injection technique, 107–108 physiology, 107 Forms consent forms, 67, 70 examination/progress notes, 60, 67 financial agreements, 60 post-operative care sheets, 70, 78 pre-operative checklists, 60–61 Fractional ablative laser resurfacing clinical indications, 238–239 clinical results, 238, 240 complications, 240 healing of, 239 patient preparation, 238 patient selection, 238 post-treatment care, 238 wavelengths for, 239 Fractional photothermolysis, 241 Fractionated laser therapy, 270 Free fat grafts, 205 Frey’s syndrome, 122–123 Fried & Werchler screening tool, 41 Full time equivalent (FTE) physician aesthetician, 52, 54 net collected revenue, 50, 52 vs. non-physician, 52 revenue rate per hour, 52 Fungal infections, 104 FUT. See Follicular unit transplantation

278 Generalized hyperhidrosis, 115 Generalized lighting, 24 Genistein, 247 GF. See Growth factor Glabella, 107 botulinum toxin complications, 98–99 Glogau scale, 80 Glycolic acid peels, 271 Glycolic moisturizers, 246 GPO. See group purchasing organization (GPO) Gravimetric testing, 115 Green tea, 247 Group purchasing organization (GPO), 58 Group seminars, 48 Growth factor (GF), 248 Gummy smile, 253 Gustatory sweating, 122–123 Gynecomastia, 262 HAART. See Highly active antiretroviral therapy Hair removal, 5 intense pulsed light, 227 Hair transplantation, in male patients, 260–261 Harmonic scalpel, 184 Health Insurance Portability and Accountability Act (HIPAA) Heat-producing lasers, 234–235 Hemostasis, 199 HH. See Hyperhidrosis Highly active antiretroviral therapy (HAART), 151 HIPAA. See Health Insurance Portability and Accountability Act (HIPAA) Hispanic face, 269 Hispanic patients keloid formation, 204 lentigines, 267 HIV patients injection technique, 152–153 operative steps, 153–154 patient selection, 152 PLLA-injection preparation, 152 treatment plan, 152 Hyaluronic acid (HA) fillers complications, 136, 138, 140 injectible, 14 in men, 259 one syringe, 130 options, 135 practical applications, 135–136 Hyaluronidase, 101, 198 Hydrogel polymers efficacy and safety, 163–164 indications, 163 mechanism of action, 163 technique, 164 Hydroquinone, 172, 249, 272 Hydroxyacids, 248 Hylaform, 135 Hylaform Plus, 135 Hyperdynamic muscles, 251–253

INDEX Hyperhidrosis (HH) axillary, 118–119 botulinum toxin therapy, 118 facial, 121–122 focal, 115 forms of, 116 Frey’s syndrome, 122–123 generalized, 115 impact of, 115 localized, 115 localized unilateral, 125 measuring, 115–116 palmar, 119–121 plantar, 121 Ross syndrome, 125 therapy, 116–118 Hyperhidrosis disease severity scale, 117 Hyperhydrosis, 253 Hyperpigmentation, 103, 179–180 therapies for, 249 Hypertrophic scarring, 204–205 Hypertrophy model, 155 Hypopigmentation, 103–104, 179–180 Icepick scars, 257 Imiquimod, 83 Implants position, 210–211 saline, 9 saline vs. silicone, 209–210 shape and texture, 210 silicone gel, 9 size, 209 Implicit brand building, 46–47 Incision irregularities, 204–205 Incision line suture tracts, 204 Indecisive patients, 44 Infection blepharoplasty, 205 chemical peeling complications, 180 fungal, 104 injectable filler complications, 101 laser complications, 104 Inflammatory reactions, 101–102 Informed consent, 142 Inframammary technique, 211–212 Injectable endoprosthesis agents, 163 Injectable filler complications infection, 101 inflammatory reactions, 101–102 injector-dependent adverse outcomes, 101 neovascularization, 103 nodules, 101 non-specific complications, 100–101 product migration, 102 Tyndall effect, 101 vascular compromise, 102–103 Injectable fillers, 4 Injectable forms, 60, 64 Injectable PMMA. See Polymethylmethacrylate Injectable soft tissue fillers, 222

Injectible hyaluronic acid, 14 Injection lipolysis, 6 Integrative non-ablative devices, 243–244 Intense pulsed light (IPL), 5 in dermatology, 225 dyschromia, 227–228 in ethnic patients, 270–271 hair removal, 227 medico legal issues, 230 photodynamic therapy, 228–229 pigmented lesions, 227–228 rhytids, 229–230 skin tightening, 229–230 sources, 226 vascular lesions, 225–226 Intense pulsed lights and laser forms, 67 Internal marketing advantages of, 46 capturing patients for treatment, 47 cosmetic brand setup, 46–47 offerings of practice, 47–48 relationship with patients, 48–49 Interview, cosmetic patients, 39 Investigational permanent agents. See Hydrogel polymers Iodine/starch test, 115 Iontophoresis, 116 IPL. See Intense pulsed light Jessner’s solution, 174 Keloids in ethnic patients, 266–267 Lacrimal gland prolapse, 204 Lagophthalmos, 204 Laser in ethnic patients, 270–271 Laser-assisted liposuction, 165, 170 advantages and disadvantages, 235 Laser complications blistering and crusting, 103 edema, 103 erythema, 103 fungal infections, 104 hypopigmentation, 103–104 infection, 104 paradoxical hypertrichosis, 104 purpura, 104 scarring, 104–105 Laser energy cold lasers, 233–234 heat-producing lasers, 234–235 liposuction, 232–233 Laser hair removal, 14 in ethnic patients, 271 male patients, 261–262 LASER. See Light amplification by the stimulated emission of radiation Laser lipolysis, 262 Laser resurfacing, 6 Laser skin resurfacing, 12, 14, 85–87

279

INDEX Lateral ocular canthi anatomy, 109 complications, 109–110 injection technique, 109 physiology, 109 Lentigines, in ethnic patients, 267 Light amplification by the stimulated emission of radiation (LASER), 232 Lipid-free cleansers, 272 Lipoatrophy aging process, 152–153 localized facial, 156–157 male patients, 263 patients with HIV injection technique, 152–153 operative steps, 153–154 patient selection, 152 PLLA-injection preparation, 152 treatment plan, 152 Lipodystrophy, 263 Lipoplasty suction-assisted, 10 ultrasound-assisted, 10 Liposuction case studies, 166–170 consultation, 165 lasers in, 232–233 male patients, 262 pre-operative phase, 165 Liposuction operative notes, 67 Lips, 251 Liquid injectable silicone, 161 Liquid silicone (LIS) efficacy and safety, 161 indications, 161 mechanism of action, 161 technique, 161 Litigious patient, 45 Localized facial lipoatrophy, 156–157 Localized hyperhidrosis, 115 Localized unilateral hyperhidrosis (LUH), 125 Loquacious patient, 44 Lower blepharoplasty subciliary approach, 201–202 subciliary fat transposition, 202 transconjunctival approach, 199–200 transconjunctival fat transposition, 200–201 Lower lid malposition, 205 LUH. See Localized unilateral hyperhidrosis Lumixyl, 249 MA. See Medical assistant Malar fold, 192 Male patients aging face, 259 botulinum toxin, 259 cosmeceuticals, 262–263 hair transplantation, 260–261 laser hair removal, 261–262 lipoatrophy, 263 liposuction, 262

soft tissue fillers, 259–260 tattoo removal, 261 Mammaplasty, augmentation. See Breast augmentation Manipulator, 43–44 Manual mode, 19 Margin-to-reflex distance (MRD), 193 Marionette lines, 145–146 Marketing expense, 56–57 Marketing, internal advantages of, 46 capturing patients for treatment, 47 cosmetic brand setup, 46–47 offerings of practice, 47–48 relationship with patients, 48–49 Masks, 246 Medical assistant (MA), 56 Medical facials, 3 Medical interview, 39 Medical photography, 20 Medical spa, 2 botulinum toxin, 3–4 cellulite reduction, 5–6 chemical peels, 3 hair removal, 5 injectable fillers, 4 injection lipolysis, 6 intense pulsed light, 5 laser resurfacing, 6 medical facials, 3 microdermabrasion, 2 photorejuvenation, 5 tissue tightening, 6 Medication guide, 71–74 Medium depth peeling, 175–177 Melasma, 254 in ethnic patients, 265–266 Microdermabrasion, 2 Milia, 180 Minor’s iodine-starch test, 115, 118, 123 Müller’s muscle, 191 Moisturizer, 272 Monopolar RF devices, 6 Monotherapy, 272 MRD. See Margin-to-reflex distance Narcissist patient, 44–45 Nasal sculpting, 145 Nasojugal fold, 192 Nasolabial fold anatomy, 110 complications, 111 injection technique, 110–111 physiology, 110 National Institute for Occupational Safety and Health (NIOSH), 36 Natural ingredients, 248 Nd:YAG laser, 5 Neck deformity, 216 Neck, surgical rejunevation anatomy, 215 complications, 222–224 composition of aesthetic neck, 215

nonoperative strategies botulinum toxin A, 222 injectable soft tissue fillers, 222 operative strategies augmentation mentoplasty, 221 barbed sutures, 221–222 cervical suspension, 222 corset platysmaplasty, 219–220 deep plane facelift, 218–219 rhytidectomy with lateral SMASectomy, 217–218 SMAS facelift, 216–217 submental liposuction, 216 submental W-plasty, 220–221 patient evaluation, 215 Necrosis, 102 Neovascularization, 103 Nerve blocks, 120, 148 Net collected revenue FTE aesthetician, 52, 54 FTE non-physician, 52 FTE physician, 50, 52 Neurotoxins, 88, 268 Newsletter, 48 NFR. See Non-ablative fractional laser resurfacing Night creams, 246 NIOSH. See National Institute for Occupational Safety and Health Nipple areolar asymmetry, 213 Nodules, 101 Non-ablative devices fractional laser resurfacing, 241–242 integrative, 243–244 photorejuvenation, 241 skin tightening, 242–243 Non-ablative fractional laser resurfacing (NFR), 241–242 Non-ablative resurfacing, 14 Nonanimal-stabilized hyaluronic acid (NASHA) fillers, 259 Non-facial peels, 178–179 Nonsurgical rhinoplasty, 270 Normal lens, 18 Office, aesthetic cabinetry, 38 casework, 38 chair, 37–38 entrance, 36–37 exam and procedure rooms, 37 lighting, 37 lobby, 36–37 monitors, 38 physician stool, 37 procedure table, 37–38 staff awareness, 38 training, 38 Oily skin, 272 OnabotulinumtoxinA, 119 One syringe product selection, 130 stretching, 130, 133

280 Operating expense ratio, 55 Optical reflective pigments, 245 Optical viewfinder digital compact camera, 19 digital SLR camera, 19 Optical zoom, 19 ORAC. See Oxygen radical absorbance capacity Oral antibiotics, 203 Oral commissure, 145–146 Oral isotretinoin, 255 Orbicularis excision, 202 Orbicularis plication, 202 Orbital hemorrhage, 204 Oxygen radical absorbance capacity (ORAC), 245 Pain management, 140 Palmar hyperhidrosis, 119–121 Paradoxical hypertrichosis, 104 Patient appreciation, 49 Patient relationship digital marketing, 48–49 group seminars, 48 newsletter, 48 patient appreciation, 49 Patients aesthetic surgery, 187–188 dark skin, 186–187 narcissist, 44–45 Peptides, 247–248 Perception, 36 Perfectionist, 44 Periareolar technique, 212 Periorbital hyperpigmentation, 194 Periorbital rejuvenation blepharoplasty complications of, 203–205 lower, 199–202 upper, 197–199 canthoplasty, 202 clinical anatomy lower eyelid, 194 periorbital regions, 194–195 upper eyelid, 193–194 orbicularis excision, 202 orbicularis plication, 202 post-operative instructions, 203 skin excision, 202–203 surgical anatomy Asian eyelids, 191 canthal tendons, 192 eyelid margin, 192–193 eyelids, 189–191 malar fold, 192 nasojugal fold, 192 retro-orbicularis oculi fat, 191 skin, 189 suborbicularis oculi fat, 191–192 superficial musculoaponeurotic system, 192 surgical management patient evaluation, 195–196

INDEX pre-operative considerations, 195 surgical planning, 196–197 Periorbital rhytids, 195 Periprocedural intervention dyspigmentation, 82–83 erythema, 82–83 scarring, 82–83 Perlane, 135 Permanent fillers hydrogel polymers efficacy and safety, 163–164 indications, 163 mechanism of action, 163 technique, 164 liquid silicone efficacy and safety, 161 indications, 161 mechanism of action, 161 technique, 161 polymethylmethacrylate efficacy and safety, 162–163 indications, 162 mechanism of action, 161–162 technique, 163 PFB. See Pseudofolliculitis barbae Photoaging skin, in ethnic patients, 265 Photodamage, 249 Photodynamic therapy (PDT) intense pulsed light, 228–229 photorejuvenation, 5 Photofacials, 241 Photography aperture, 18 chemical peeling, 173 depth of field, 18 focal length, 18 medical, 20 for non-treatment purposes consent, 20 principles of, 18 shutter speed, 18 Photopneumatic therapy (PPx), 256 Photoprotection, 272 Photorejuvenation, 5, 241 Photothermolysis, fractional, 241 Physician full time equivalent aesthetician, 52, 54 net collected revenue, 50, 52 vs. non-physician, 52 revenue rate per hour, 52 goal of, 1 Pigmentation disorders, 254 Pigmented lesions, 227–228 Pigment lightening, 272–273 Pigment lightening ingredients, 249 Plantar hyperhidrosis, 121 Plastic surgery. See Facial enhancement Platysmaplasty, 219–220 PLLA. See Poly-L-lactic acid PMMA. See Polymethylmethacrylate Polyhydroxyacids (PHAs), 248 Poly-L-lactic acid (PLLA), 259 duration of effect, 151–152

lipoatrophy caused by aging process, 155–156 lipoatrophy in patients with HIV injection technique, 152–153 operative steps, 153–154 patient selection, 152 PLLA-injection preparation, 152 treatment plan, 152 localized facial lipoatrophy, 156–157 mechanism of action, 151 off-label use injection technique, 159 legal and ethical considerations, 158 patient selection, 158 safety history, 151 Polymethylmethacrylate (PMMA) efficacy and safety, 162–163 indications, 162 mechanism of action, 161–162 technique, 163 Port-wine stain birthmarks, 254 Post-operative forms botulinum toxin, 77 fillers, 77 liposuction procedure, 69 PPx. See Photopneumatic therapy Premature aging, 253–254 Pre-operative forms breast augmentation, 62–63 liposuction procedure, 69 sample form, 61 Preseptal cellulitis, 205 Prevelle, 135 Primary focal hyperhidrosis. See Hyperhidrosis Product migration, 102 Professional tattoos, 261 Program mode, 19 Prolapsed lacrimal gland, 204 Prolonged erythema, 180 Prophylactic antibiotics, 104 Protuberant male breasts, 262 Pseudofolliculitis barbae (PFB) in ethnic patients, 267 laser hair removal, 261–262 Pseudomonas, 180 Pseudoptosis, 210 Ptosis, 204 Pulsed laser, 233 Purpura, 104 Quality of care, 36 Quizzical brow, 99 Radiesse®, 141, 260 Radiofrequency devices, in ethnic patients, 270 Red flag patients bargain hunters, 43 cheap, 43 excessively complimentary, 44 indecisive, 44 litigious, 45

281

INDEX loquacious, 44 manipulator, 43–44 narcissistic, 44–45 perfectionistic, 44 with poor hygiene, 44 seductive, 44 surgiholic, 45 with unrealistic expectations, 43 VIP patient, 44 Rent expense ratio, 56 Reputation, 36 Reputation of practice, 47 Restylane, 135 Retail product sales, 54–55 Retinoids, 83, 255 Retrobulbar hemorrhage, 204 Retro-orbicularis oculi fat (ROOF), 191 Rhytidectomy, 184 Rhytidectomy with lateral SMASectomy, 217–218 Rhytids, 229–230 RimabotulinumtoxinB, 125, 126 Roberts hyperpigmentation scale, 80 Roberts scarring scale, 80 Roberts skin type classification system clinical patient example 1, 79–80 clinical patient examples 2 and 3, 80 Fitzpatrick scale, 80 Glogau scale, 80 Roberts hyperpigmentation, 80 Roberts scarring scale, 80 Rosacea, in ethnic patients, 268 Ross syndrome, 125 Ruby laser, 5 Safety, 36 Salicyclic acid, 175 Salicylic acid peels, 271 Saline implants, 9, 209–210 Scarring chemical peeling complications, 180–181 evaluation, 82 hypertrophic, 204 laser complications, 104–105 periprocedural intervention, 82–83 prevention of, 80–81 Sclerotherapy forms, 67 Scowl lines, 252 Seductive patient, 44 Selective serotonin reuptake inhibitor (SSRI), 45 Serums, 246 Shadowing effect, 194 Shutter priority mode, 19 Shutter speed, 18 Silicone implants, 209–210 sheeting, 83 Silicone gel, 83 Silicone gel implants, 9 Single lens reflex (SLR), 18 Skin, 189

Skin Cancer Foundation, 247 Skin care, 257 Skin color African Americans, 265 Chinese women, 265 ethnic patients, 265 Skin cooling, 82 Skin excision, 202–203 Skin excision markings, 197 Skin irritation, 255 Skin laxity, 85 Skin-muscle flap, 202 Skin tightening intense pulsed light, 229–230 non-ablative, 242–243 Skin type dyspigmentation periprocedural intervention, 82–83 prevention of, 80–81 global demographics, 79 imiquimod, 83 onion extract, 83 periprocedural intervention dyspigmentation, 82–83 erythema, 82–83 scarring, 82–83 retinoids, 83 Roberts skin type classification system clinical patient example 1, 79–80 clinical patient example 2, 80 clinical patient example 3, 80 Fitzpatrick scale, 80 Glogau scale, 80 Roberts hyperpigmentation scale, 80 Roberts scarring scale, 80 silicone gel, 83 silicone sheeting, 83 vitamin E, 83 SLR. See Single lens reflex SMAS. See Superficial musculoaponeurotic system SMAS facelift, 216–217 Society of Trust and Estate Practitioners (STEP), 41 Soft tissue fillers, 259–260 Solar lentigines, 228 Soy, 247 SPF. See Sun protection factor SSRI. See Selernalctive serotonin reuptake inhibitor Staff salary survey, 56 STEP. See Society of Trust and Estate Practitioners Stress acne, 256–257 Subciliary fat transposition, 202 Submental liposuction, 216 Submental W-plasty, 220–221 Suborbicularis oculi fat (SOOF), 191–192 Suction-assisted lipoplasty, 10 Sulcus and nasojugal deformities, 205 Sulcus fullness, 194 Sun protection factor (SPF), 172 Sunscreen, 246–247

Suntans, 253 Superficial acne scarring, 257 Superficial chemical peeling post-operative care, 174 pre-operative considerations, 173–174 Superficial musculoaponeurotic system (SMAS), 192 Superficial peeling agents alphahydroxy acids, 174–175 Jessner’s solution, 174 salicyclic acid, 175 trichloroacetic acid, 174 Surgical rejuvenation of neck anatomy, 215 complications, 222–224 composition of aesthetic neck, 215 nonoperative strategies botulinum toxin A, 222 injectable soft tissue fillers, 222 operative strategies augmentation mentoplasty, 221 barbed sutures, 221–222 cervical suspension, 222 corset platysmaplasty, 219–220 deep plane facelift, 218–219 rhytidectomy with lateral SMASectomy, 217–218 SMAS facelift, 216–217 submental liposuction, 216 submental W-plasty, 220–221 patient evaluation, 215 Surgiholic patients, 45 Suture milia, 205 Sweating, 115 Systemic anticholinergic drugs, 116 Tattoos, 254 professional, 261 removal, in male patients, 261 TCA. See Trichloroacetic acid TCA peels, 271 Teen acne, 254–255 Telephoto lens, 18 Temporary mechanical ptosis, 204 Through the lens (TTL), 18 Tissue tightening, 6 Toners, 246 Topical bleaching agents, 267 Toxic shock syndrome, 180 Transaxillary technique, 213 Transconjunctival fat transposition, 200–201 Tretinoin, 172, 249 Trichloroacetic acid (TCA), 174 Triluma, 249 TTL. See Through the lens Tumescent anesthesia, 238 Tweaking, 186 Tyndall effect, 101 Ultrasound, 6 Ultrasound-assisted lipoplasty, 10 Ultrasound energy, 232

282 Undercorrection, 205 Undereye circles, 251 Unrealistic expectations, 43 Upper blepharoplasty, 197–199 Vascular lesions, 225–226 Vertical palpebral fissure (VPF), 193 Vibration amplification of sound energy at resonance (VASER) advantages and disadvantages of, 233 vs. ultrasound technologies, 232 Vibratory anesthesia, 120 Video capability, 19 VIP patient, 44

INDEX Vision loss, 203–204 Vitamin E, 83 VPF. See Vertical palpebral fissure Water-assisted liposuction (WAL), 235–236 Web-based marketing, 48 White-coat syndrome, 36 Whitnall’s ligament, 191 Wide angle lens, 18 Wound closure, 199 Wrinkles, 251 XYZ Dermatology, 46

Young patients acne scarring, 257 aesthetic issues, 251 hyperdynamic muscles, 251–253 laser and light-based therapies, 255–256 persistence of teen acne, 254–255 photopneumatic therapy, 256 pigmentation disorders, 254 premature aging, 253–254 skin care, 257 soft tissue augmentation, 251 stress acne, 256–257 topical and systemic treatments for acne, 255