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Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery is a practical how-to guide that focuses on the latest techniques used to perform cosmetic plastic surgery procedures in an office or outpatient setting. The procedures covered range from chemical peels to short-incision face and neck lift, and much more!

Key Features:

  • Online access to over three hours of video in which experts demonstrate the surgical techniques presented in the book
  • Chapters are written so that both novice and more experienced practitioners can become proficient at performing new techniques
  • More than 500 detailed color illustrations, presented in a step-by-step format, clarify the procedures
  • Written by experts in the fields of facial plastic surgery, dermatology and plastic surgery

Facial plastic surgeons, otolaryngologists, dermatologists, and plastic surgeons will repeatedly consult this book to review specific techniques in detail before performing a procedure in cosmetic facial surgery.

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Minimally Invasive and Office-Based
Procedures in Facial Plastic Surgery

Minimally Invasive and Office-Based
Procedures in Facial Plastic Surgery

Fred G. Fedok, MD, FACS

Professor and Chief
Facial Plastic and Reconstructive Surgery
Otolaryngology–Head and Neck Surgery
Department of Surgery
The Hershey Medical Center
The Pennsylvania State University
Hershey, Pennsylvania

Paul J. Carniol, MD, FACS

Clinical Professor
Department of Otolaryngology–Head and Neck Surgery
Rutgers University Medical School
Newark, New Jersey

New York · Stuttgart

Thieme Medical Publishers, Inc.
333 Seventh Ave.
New York, NY 10001
Executive Editor: Tim Hiscock
Managing Editor: J. Owen Zurhellen
Editorial Assistant: Elizabeth Berg
Senior Vice President, Editorial and E-Product Development: Cornelia Schulze
Production Editor: Kenneth L. Chumbley
Medical Illustrator: Birck Cox
International Production Director: Andreas Schabert
Vice President, Finance and Accounts: Sarah Vanderbilt
President: Brian D. Scanlan
Compositor: Prairie Papers Inc.
Cover Illustration: Taken from The Birth of Venus (1486) by Sandro Botticelli. Image courtesy of the Uffizi Gallery, Florence,
Italy, whose collection includes this painting.
Printer: Everbest Printing Co.
Library of Congress Cataloging-in-Publication Data
Minimally invasive and office-based procedures in facial plastic surgery / [edited by] Fred G. Fedok, Paul J. Carniol.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-60406-567-1 (alk. paper)—ISBN 978-1-60406-568-8 (eISBN)
I. Fedok, Fred G. II. Carniol, Paul J.
[DNLM: 1. Cosmetic Techniques. 2. Face—surgery. 3. Ambulatory Surgical Procedures—methods. 4. Reconstructive
Surgical Procedures—methods. 5. Surgical Procedures, Minimally Invasive—methods. WE 705]


Copyright © 2014 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright.
Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation wi; thout the publisher’s
consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or
duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.
Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge,
changes in treatment and drug therapy may be required. The authors and editors of the material herein have consulted
sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of
the work herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other party who has
been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or
complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information.
Readers are encouraged to confirm the information contained herein with other sources. For example, readers are advised
to check the product information sheet included in the package of each drug they plan to administer to be certain that the
information contained in this publication is accurate and that changes have not been made in the recommended dose or
in the contraindications for administration. This recommendation is of particular importance in connection with new or
infrequently used drugs.
Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or
proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a
name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public
Printed in China
ISBN 978-1-60406-567-1
Also available as an e-book:
eISBN 978-1-60406-568-8

To Adrienne Zoe and Eric Marshall, my children, who as infants and young children spent many hours sitting on
my lap or next to me on the couch as I studied descriptions of procedures and surgical-technique videos during
my years in training. They, in countless ways, made all the hours much more memorable.
Fred G. Fedok
To my sons, Michael, Alan, and Eric, and my wife, Renie. Thank you all for your thoughtful input and ongoing
support in the completion of this book and my other endeavors. Your confident encouragements have made all
things attainable and possible.
Paul J. Carniol

To access additional material or resources available with this e-book, please visit After completing a short form to verify your e-book
purchase, you will be provided with the instructions and access codes necessary to retrieve
any bonus content.


Video Contents.........................................................................................................................................................................ix
Foreword.................................................................................................................................................................................. xii
Preface...................................................................................................................................................................................... xiii

Facial Aging, Cosmetic Concerns, and Facial Cosmetic Procedures...................................................................1
Fred G. Fedok and Paul J. Carniol


Basic and Advanced Skin Care.....................................................................................................................................8
Lisa D. Grunebaum, Ilanit S. Samuels, and Leslie Baumann


Anesthesia and Analgesia for Facial Cosmetic Procedures................................................................................ 20
Sadeq A. Quraishi


Techniques for Office Anesthesia: Local Anesthesia and Regional Block Techniques................................ 28
David A. F. Ellis and YuShan Lisa Wilson


Superficial Chemical Peels......................................................................................................................................... 42
Phillip R. Langsdon, David W. Rodwell III, Parker A. Velargo, Carol H. Langsdon, and Amanda Guydon


Medium-Depth Chemical Peels................................................................................................................................ 47
Fred G. Fedok and Dhave Setabutr


Hetter Chemical Peels................................................................................................................................................. 57
Devinder S. Mangat


Deep Chemical Peels.................................................................................................................................................... 68
E. Gaylon McCollough


Skin Rejuvenation for Patients with Fitzpatrick Skin Types IV, V, and VI..................................................... 80
Jennifer Parker Porter


Intense Pulsed Light (with and without Photodynamic Therapy)................................................................. 91
J. Randall Jordan


Laser Resurfacing with an Emphasis on Fractionated Technologies.............................................................. 98
Louis M. DeJoseph and Paul J. Carniol


Treatment of Vascular Lesions................................................................................................................................ 107
William Russell Ries and Joseph E. Hall


Hair Removal............................................................................................................................................................... 117
Mark Hamilton and Jaimie DeRosa

viii Contents

Laser Treatment of Facial Scars.............................................................................................................................. 124
Arden Edwards, Jennifer L. MacGregor, and Tina S. Alster


Surgical Treatment of Facial Scars......................................................................................................................... 138
Maurice Khosh


Treatment of Facial Imperfections with Dermal Fillers................................................................................... 147
Georgann A. Poulos and Suzan Obagi


Treatment of Nasal Defects and Acne Scars with Microdroplet Silicone.................................................... 158
Jay G. Barnett and Channing R. Barnett


Soft Tissue Fillers for Facial Augmentation......................................................................................................... 166
Thomas L. Tzikas


Facial Liposculpture and Fat Transfer................................................................................................................... 175
Stephen E. Metzinger, James N. Parrish Jr., and Aldo B. Guerra


Neuromodulators....................................................................................................................................................... 189
Kartik Nettar, Jason P. Champagne, and Corey S. Maas


Endonasal Rhinoplasty............................................................................................................................................. 197
Paul J. Carniol, Dhave Setabutr, and Fred G. Fedok


Office Rhinoplasty Techniques................................................................................................................................ 209
Ira D. Papel and Theda C. Kontis


Brow Rejuvenation..................................................................................................................................................... 216
Donn R. Chatham


Upper Eyelid Blepharoplasty................................................................................................................................... 233
Fred G. Fedok and Paul J. Carniol


Lower Blepharoplasty and Midface Rejuvenation............................................................................................. 247
Christina K. Magill and Jonathan M. Sykes


Avoidance and Management of Complications Following Lower Eyelid Surgery.................................... 257
Farzad R. Nahai


Lip Rejuvenation......................................................................................................................................................... 267
Brian P. Maloney


Otoplasty and Earlobe Rejuvenation.................................................................................................................... 277
Edward H. Farrior


Short-Incision Facelift and Necklift...................................................................................................................... 285
Gregory J. Vipond and Harry Mittelman


Liposuction and Minimally Invasive Fat Reduction.......................................................................................... 300
T. Gerald O’Daniel and Ron Hazani


Hair Transplantation................................................................................................................................................. 314
Agata K. Brys and Daniel E. Rousso

Index........................................................................................................................................................................................ 331

Video Contents


Advanced Skin Care: Superficial Chemical Peel, by Lisa D. Grunebaum
Dr. Grunebaum demonstrates a superficial chemical peel. This particular superficial peel may be used
on a variety of skin types (it is very superficial). It contains hydroquinone, lactic acid, salicylic acid, and
Kojic acid.


Supraorbital, Lacrimal, and Supratrochlear Nerve Blocks, by David A. F. Ellis
Dr. Ellis demonstrates nerve blocks of the supraorbital, lacrimal, and supratrochlear nerves.


Mental, Infratrochlear, and External Nasal Nerve Blocks, by David A. F. Ellis
Dr. Ellis demonstrates nerve blocks of the mental, infratrochlear, and external nasal nerves.


Infraorbital, Zygomatic-Facial, and Buccal Nerve Blocks, by David A. F. Ellis
Dr. Ellis demonstrates nerve blocks of the infraorbital, zygomatic-facial, and buccal nerves.


Zygomatic-Temporal Nerve Block, by David A. F. Ellis
Dr. Ellis demonstrates a nerve block of the zygomatic-temporal nerve.


Auriculo-Temporal Nerve Blocks, by David A. F. Ellis
Dr. Ellis demonstrates a nerve block of the auriculo-temporal nerve.


Enhanced Superficial Chemical Peel, by Dr. Phillip R. Langsdon and Carol H. Langsdon
Dr. Philip Langsdon and Carol Langsdon demonstrate the technique for a series of three progressive TCA
peels. They use these progressive peels to optimize the results.


The 35% TCA/Jessner’s Peel, by Fred G. Fedok
In this video, Dr. Fedok presents the science, technique, and the results of the 35% TCA peel/Jessner’s.


Full-Face Hetter Peel, by Devinder S. Mangat
In this video, Dr. Mangat presents a detailed demonstration of the technique for the Hetter peel. This is
an important for review prior to performing a Hetter peel.


The Baker-Gordon Peel, by E. Gaylon McCollough
Dr. McCollough demonstrates a Baker-Gordon Formula chemical peel of the upper eyelids and immediately adjacent regions.


Intense Pulsed Light with and without Photodynamic Therapy, by J. Randall Jordan
Dr. Jordan demonstrates the techniques for IPL and IPL with photodynamic therapy.


Fractionated CO2 Laser Resurfacing, by Louis M. DeJoseph
Dr. DeJoseph demonstrates fractionated CO2 laser resurfacing.


x Video Contents

Laser Treatment of a Facial Port Wine Stain, by William Russell Ries
Dr. Ries demonstrates flashlamp pumped dye laser treatment of a port wine stain involving the left side
of the face and lower eyelid region, as well as eye safety precautions for treating a lesion involving the


Laser Hair Removal–Upper Lip, by Michele Gillen
Michelle Gillen of Hamilton Facial Plastic Surgery demonstrates laser hair removal of the upper lip with
a 755 nm laser.


Laser Treatment of Scars, by Tina S. Alster
Dr. Alster demonstrates laser treatment of acne scars using a fractionated CO2 laser and laser treatment
of traumatic scars using a pulsed dye laser.


Filler Injection Techniques, by Suzan Obagi
At the start of this video, Dr. Obagi shows how she marks areas that will be treated with fillers. She then
demonstrates her techniques for injecting three different facial fillers.


Tear Trough Correction with Diluted Restylane, by Thomas L. Tzikas
Dr. Tzikas demonstrates the injection of adiluted hyaluronic acid filler into a tear trough deformity.


Temporal Augmentation with CaHA, by Thomas L. Tzikas
Dr. Tzikas demonstrates the injection of calcium hydroxylapatite into the temporal region.


Intraoral Midface Augmentation with CaHA, by Thomas L. Tzikas
Dr. Tzikas demonstrates calcium hydroxylapatite injection of the midface using an intraoral approach.


Submalar PLLA, by Thomas L. Tzikas
Dr. Tzikas demonstrates the injection of poly-L-lactic acid filler into the submalar region.


Silikon 1000 Injection in the Perioral Region, by Thomas L. Tzikas
Dr. Tzikas demonstrates the injection of Silikon 1000 into the perioral region.


Facial Fat Grafting, by Drs. Metzinger, Guerra, and Parrish
Dr. Guerra gives a detailed demonstration of facial fat grafting. This includes harvesting of the fat as well
as injection into several areas of the face.


Botulinum and Hyaluronic Acid Filler Enhancement of the Periorbital Area, by Corey S. Maas
Dr. Maas demonstrates the injection of botulinum toxin into the glabella and crow’s feet regions. He also
demonstrates the injection of a hyaluronic into the tear trough region.


Fundamental Aspects of the Endonasal Approach, by Fred G. Fedok
Dr. Fedok demonstrates various incisions and techniques used in endonasal rhinoplasty.


Needle Shave of a Nasal Dorsal Irregularity, by Ira D. Papel
Dr. Papel demonstrates the needle shave of a nasal dorsal irregularity. In this video, using this minimally
invasive technique, Dr Papel reduces a limited dorsal imperfection.


Concepts in Brow Rejuvenation, by Donn R. Chatham
Dr. Chatham demonstrates several concepts in brow rejuvenation, which can be used on men or women.


Upper Blepharoplasty, by Fred G. Fedok
Dr. Fedok demonstrates upper blepharoplasty.


Midface Lift (Lower Eyelid Approach), by Jonathan M. Sykes
Dr. Sykes demonstrates a midface lift through a lower eyelid approach. This includes a detailed demonstration of the procedure.


Ectropion Repair: Lower Lid Reconstruction with Enduragen, by Farzad R. Nahai
Dr. Nahai demonstrates lower eyelid ectropion repair using a dermal collagen implant. This is one of the
techniques that can be used for treatment of ectropion.


Video Contents xi


Hyaluronic Acid Injection for Lip Augmentation, by Brian P. Maloney
Dr. Maloney demonstrates lip augmentation with hyaluronic acid filler and the details of his technique.


Dermal Matrix Lip Augmentation and Vermillion Advancement, by Brian P. Maloney
Dr. Maloney demonstrates dermal matrix lip augmentation and vermillion advancement.


Upper Lip Enhancement with Nasal Base Resection, Hyaluronic Acid Filler, and Botulinum Toxin, by
Brian P. Maloney
Dr. Maloney demonstrates upper lip enhancement with nasal base resection, hyaluronic acid filler, and
botulinum toxin.


Otoplasty, by Edward H. Farrior
Dr. Farrior gives a precise demonstration of his technique for correcting prominent ears.


Short Incision Facelift: Multi-Vector SMAS Plication, by Harry Mittelman
Dr. Mittelman demonstrates the use of a multi-vector SMAS plication in conjunction with a short incision rhytidectomy.


Laser-Assisted Lipolysis, by T. Gerald O’Daniel
Dr. O’Daniel starts this with a demonstration of the issues being considered in one patient for whom he
is planning facial rejuvenation surgery. As part of this rejuvenation procedure, he demonstrates laserassisted lipolysis.


Follicular Unit Transplantation Surgery, by Daniel E. Rousso
Dr. Rousso gives a comprehensive presentation of his technique for hair transplantation. This starts with
a presentation of the technique for harvesting the grafts and then preparing the grafts. It continues with
a demonstration of follicular unit transplantation surgery.


The most striking initial impression on picking up
Minimally Invasive and Office-Based Procedures in
Facial Plastic Surgery is its elegant simplicity. It immediately reflects the beauty and value of a superbly
written book.
Dr. Fedok and Dr. Carniol, both experienced and respected practitioners and educators in facial plastic
surgery, highlight the expanding role of minimally
invasive procedures in aesthetic facial surgery. They
have collected a coterie of leading experts who have
reflected on their experience and relate their wisdom in a text that is both extensive and incisive at
the same time. It paints the broad strokes and fills in
the details.
Minimally Invasive and Office-Based Procedures in
Facial Plastic Surgery begins with chapters on the
aging process, skin care, and anaesthesia. It then discusses the various chemical peels and lasers for skin
resurfacing before reviewing their application, along
with surgical techniques, for treatment of scars. Subsequent chapters emphasize the importance of tissue volume management through various fillers, fat,
and liposuction techniques. Neuromodulators are
reviewed before the final chapters outline the extensive scope of more minimally invasive surgical procedures. These include the full gamut of techniques
available today, beginning with endonasal and office
rhinoplasty procedures. A variety of brow, blepharoplasty, mid face, and lower face rejuvenation procedures are detailed. Final specialty chapters describe
lip rejuvenation, otoplasty, fat reduction, and hair
transplantation procedures.
This book will be a highly treasured and very functional reference for the novice and experienced facial
plastic surgeon, plastic surgeon, or dermatologist.
Each chapter begins with key concepts that highlight
the essence of the topic. An introduction, followed by


relevant basic science or anatomical information and
patient selection, provide valuable background prior
to the concise description of technical components
of the procedure. Chapters conclude with postoperative care, expected results, and complications.
For the nascent practitioner, this consistent organization provides a simple, memorable, and useful
paradigm to grasp the topic. For the experienced
practitioner, the experience and wisdom of the authors is apparent, the state of the art is defined, and
its application to one’s own specific patients can be
ascertained. The chapters are all beautifully illustrated and have a large number of excellent tables that
engage the reader and enhance the textual message.
Postoperative photographs confirm the efficacy of
the techniques described. References, often extensive, provide the immediate opportunity to obtain
more specific or broader information if so desired. A
number of chapters have supplementary video clips
to enhance the educational experience.
Minimally Invasive and Office-Based Procedures in
Facial Plastic Surgery is a collaborative, comprehensive, and concise presentation of important innovations and the state of the art as it is practiced today.
Its information provides the basis for essential understanding and reflective contemplation of technical advances yet to be discovered. It is a convenient
text that will prove to be a valuable and definitive resource for those seeking superior results in aesthetic
facial surgery.
Peter A. Adamson, MD, FRCSC, FACS
Professor and Head
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
University of Toronto
Toronto, Ontario, Canada


Facial cosmetic surgery arose from many beginnings,
with many practitioners and disciplines contributing
to surgical techniques that aim to correct congenital
and acquired facial imperfections and the unrelenting deleterious impact of aging. Over relatively few
decades, the biology of many of these maladies has
become better understood, surgical techniques have
evolved, and technologies have been created. Along
with the rapid expanse of general information and
knowledge that characterizes our modern era, there
has been a similar explosion in the knowledge surrounding cosmetic concerns. This collection of knowledge is at once a science, a discipline, and a craft.
In recognizing this rapidly advancing collection of
knowledge and the accompanying desire to create
a credible teaching vehicle, we conceptualized this
book. Our first goal was to have experts from a variety of specialties and practice settings teach areas
important to the practice of cosmetic surgery. Thus,
all of the authors assembled are recognized experts
in the practice of facial cosmetic procedures. Our
second goal was to provide a “how-to” orientation
within the book to propel the less experienced surgeon, as well as the more experienced surgeon, to
new skill levels through the presentation of these expert methods. Finally, while this book does not cover
all facial plastic procedures, it does address the ones
that are most commonly performed. Specifically, the
focus is on procedures that are generally of relatively
short duration and that can be performed in an office
or outpatient surgery center setting.
We invite you to read on, enjoying the graphics, the
well-structured text, and the technique-laden videos. It has been a great privilege to work with all our
contributors and to further our own knowledge as
we reviewed their submitted chapters. We are confi-

dent you will find the information within to be valuable to your practice and to enhance your concepts
of cosmetic surgery. In keeping with the essence of
medical training and practice: we teach, we learn,
and patients benefit. Enjoy!

Drs. Fedok and Carniol would like to give special
thanks to the following individuals:
A most special thanks to Kim Gordon who had the
nearly impossible task of keeping us moving ahead
in this project, guiding the contributing authors, and
using a finely sharpened editing scalpel to form the
chapters into a consistent presentation for the editors at Thieme. We are indebted to her work in the
creation of this book. (I, of course, am personally indebted to her also for all of her loving support and
partnership in our life together. FGF)
To Beth Shultz who tirelessly worked to coordinate
the communications and numerous electronic files
between Drs. Fedok and Carniol, the numerous authors, and Thieme.
To Tim Hiscock, Owen Zurhellen, Elizabeth Berg,
and the Thieme staff who stood by prodding, waiting, and doing everything else that superb editors
and publishers do in the production of this new and
innovative book.
To Birck Cox who artistically interpreted the concepts and images presented by the authors to create
the exceedingly lucid artwork for this book.
Fred G. Fedok
Paul J. Carniol



Tina S. Alster, MD
Washington Institute of Dermatologic Laser Surgery
Clinical Professor of Dermatology
Georgetown University
Washington, DC
Channing R. Barnett, MD
Private Practice
Barnett Dermatology
Assistant Clinical Professor
Department of Dermatology
Columbia Presbyterian Medical Center
New York, New York
Attending Physician
James J. Peters VA Medical Center
Bronx, New York
Jay G. Barnett, MD
Private Practice
Barnett Dermatology
New York, New York
Leslie Baumann, MD
Baumann Cosmetic and Research Institute
Miami, Florida
Agata K. Brys, MD
Center for Facial Plastic and Hair Restoration Surgery
Hawthorn Medical
North Dartmouth, Massachusetts
Paul J. Carniol, MD, FACS
Clinical Professor
Department of Otolaryngology–Head and Neck
Rutgers University Medical School
Newark, New Jersey
Jason P. Champagne, MD
The Champagne Center
Baton Rouge, Louisiana

Donn R. Chatham, MD
Chatham Facial Plastic Surgery
Louisville, Kentucky
Louis M. DeJoseph, MD
Facial Plastic Surgeon
Premier Image Cosmetic and Laser Surgery
Clinical Instructor
Department of Otolaryngology–Head and Neck
Emory University School of Medicine
Atlanta, Georgia
Jaimie DeRosa, MD, MS
Assistant Professor
Harvard Medical School
Department of Otolaryngology–Head and Neck
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Arden Edwards, MD
PGY-5 Internal Medicine/Dermatology Resident
Georgetown University–Washington Hospital Center
Department of Dermatology
Washington, DC
David A. F. Ellis, MD, FRCSC
Professor, Division of Facial Plastic Surgery
Department of Otolaryngology–Head and Neck
University of Toronto
Toronto, Canada
Edward H. Farrior, MD
Medical Director
Farrior Facial Plastic Surgery Center
Associate Clinical Professor of Otolaryngology
University of South Florida
Tampa, Florida
Visiting Associate Professor of Otolaryngology
University of Virginia
Charlottesville, Virginia


xvi Contributors
Fred G. Fedok, MD, FACS
Professor and Chief
Facial Plastic and Reconstructive Surgery
Otolaryngology–Head and Neck Surgery
Department of Surgery
The Hershey Medical Center
The Pennsylvania State University
Hershey, Pennsylvania
Lisa D. Grunebaum, MD
Assistant Professor of Facial Plastics and
Reconstructive Surgery and Clinical Dermatology
Departments of Otolaryngology and Dermatology
University of Miami Miller School of Medicine
Miami, Florida
Aldo B. Guerra, MD, FACS
Guerra Plastic Surgery Center
Scottsdale, Arizona
Amanda Guydon, BA
The Langsdon Clinic
Germantown, Tennessee
Joseph E. Hall, MD
Resident Physician
Department of Otolaryngology–Head and Neck
Vanderbilt University Medical Center
Nashville, Tennessee
Mark Hamilton, MD
Clinical Assistant Professor
Department of Otolaryngology–Head and Neck
Indiana University School of Medicine
Indianapolis, Indiana
Ron Hazani, MD, FACS
Craniofacial Fellow
Division of Plastic and Reconstructive Surgery
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
J. Randall Jordan, MD, FACS
Professor and Vice Chair
Department of Otolaryngology–Head and Neck
Surgery and Communicative Sciences
University of Mississippi Medical Center
Jackson, Mississippi

Maurice Khosh, MD, FACS
Assistant Clinical Professor
Department of Otolaryngology–Head and Neck
Columbia University
New York, New York
Theda C. Kontis, MD, FACS
Assistant Professor
Department of Otolaryngology–Head and Neck
Johns Hopkins Hospital
Facial Plastic Surgicenter, Ltd.
Baltimore, Maryland
Carol H. Langsdon, RNP, BSN
The Langsdon Clinic
Germantown, Tennessee
Phillip R. Langsdon, MD, FACS
Chief, Division of Facial Plastic Surgery
Department of Otolaryngology–Head and Neck
University of Tennessee Health Science Center
Memphis, Tennessee
The Langsdon Clinic
Germantown, Tennessee
Jennifer L. MacGregor, MD
Columbia University Medical Center
Union Square Laser Dermatology
New York, New York
Corey S. Maas, MD, FACS
The Maas Clinics for Aesthetic and Facial Plastic
Associate Clinical Professor
University of California–San Francisco
San Francisco, California
Christina K. Magill, MD
Clinical Fellow, Facial Plastic and Reconstructive
Department of Otolaryngology–Head and Neck
University of California–Davis
Davis, California
Brian P. Maloney, MD, FACS
The Maloney Center PC
Atlanta, Georgia

Devinder S. Mangat, MD, FACS
Professor for Facial Plastic Surgery
Department of Otolaryngology–Head and Neck
University of Cincinnati
Cincinnati, Ohio
Private Practice
Cincinnati, Ohio
Vail, Colorado
E. Gaylon McCollough, MD, FACS
McCollough Plastic Surgery Clinic
Professor, Facial Plastic Surgery
Department of Surgery
University of South Alabama
Gulf Shores, Alabama
Stephen E. Metzinger, MD, MSPH, FACS
Aesthetic Surgical Associates
Clinical Associate Professor
Department of Surgery
Division of Plastic and Reconstructive Surgery
Tulane University Health Sciences Center
New Orleans, Louisiana
Harry Mittelman, MD
Fellowship Director
American Academy of Facial Plastic and
Reconstructive Surgery
Los Altos, California
Farzad R. Nahai, MD
Rhinoplasty by Nahai
Atlanta, Georgia
Kartik Nettar, MD
Department of Head and Neck Surgery–Facial
Plastic and Reconstructive Surgery
Kaiser Permanente
Woodland Hills Medical Center
Woodland Hills, California
Suzan Obagi, MD
Associate Professor of Dermatology
Associate Professor of Plastic Surgery
University of Pittsburgh Medical Center
The Cosmetic Surgery and Skin Health Center
Pittsburgh, Pennsylvania
T. Gerald O’Daniel, MD, FACS
Private Practice
Clinical Assistant Professor, Surgery
University of Louisville Department of Plastic Surgery
Louisville, Kentucky

Contributors xvii

Ira D. Papel, MD, FACS
Associate Professor
Department of Otolaryngology–Head and Neck
Johns Hopkins University
Facial Plastic Surgicenter
Baltimore, Maryland
James N. Parrish Jr., MD, FACS
Mid-Louisiana Surgical Specialists
Alexandria, Louisiana
Jennifer Parker Porter, MD, FACS
Chevy Chase Facial Plastic Surgery, LLC
Chevy Chase, Maryland
Clinical Associate Professor
Department of Otolaryngology–Head and Neck
Georgetown University Medical Center
Washington, DC
Georgann A. Poulos, MD
Cosmetic Dermatology Fellow
The Cosmetic Surgery and Skin Health Center
Department of Dermatology
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Sadeq A. Quraishi, MD, MHA
Assistant Professor
Department of Anesthesia, Critical Care and Pain
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
William Russell Ries
Associate Professor
Department of Otolaryngology–Head and Neck
Vanderbilt University Bill Wilkerson Center
Nashville, Tennessee
David W. Rodwell III, MD
Department of Otolaryngology–Head and Neck
University of Tennessee Health Science Center
Memphis, Tennessee
Daniel E. Rousso, MD, FACS
Private Practice
Rousso Facial Plastic Surgery Clinic
Birmingham, Alabama

xviii Contributors
Ilanit S. Samuels, PA-C, MCMS
Cosmetic Dermatology
Baumann Cosmetic and Research Institute
Miami, Florida
Dhave Setabutr, MD
Division of Otolaryngology
The Hershey Medical Center
Pennsylvania State University
Hershey, Pennsylvania
Jonathan M. Sykes, MD, FACS
Department of Otolaryngology–Head and Neck
Director, Facial Plastic and Reconstructive Surgery
University of California–Davis Medical Center
Sacramento, California
Thomas L. Tzikas, MD
Private Practice
Facial Plastic Surgery
Delray Beach, Florida

Parker A. Velargo, MD
Chief Resident
Department of Otorhinolaryngology–Head and Neck
University of Tennessee Health Science Center
Memphis, Tennessee
Gregory J. Vipond, MD, FRCSC
Gregory J. Vipond, MD, Inc.
Otolaryngology Section
Methodist Hospital of Southern California
Arcadia, California
YuShan Lisa Wilson, MD
Associates in Otolaryngology–Head and Neck
Division of Facial Plastics
Worcester, Massachusetts


Facial Aging, Cosmetic Concerns, and
Facial Cosmetic Procedures
Fred G. Fedok and Paul J. Carniol

Key Concepts

■■ Facial Aging-Related Problems

• Facial aging results from both intrinsic and extrinsic factors.

Facial aging can result from a variety of causes. Some
factors are intrinsic and uncontrollable; others are
extrinsic and controllable to a certain degree. All human beings appear to age along a common progression; however, differences related to lifestyle, gender,
and ethnicity can be seen. For example, it is noted
that the Asian face ages with certain characteristics
that are different from the Caucasian face.1 Similar comparisons can be noted among other ethnic
groups. Furthermore, different ethnic groups may
express cultural differences in their goals for aesthetic facial surgery, and these should be considered
when planning procedures.
The apparent rate of biological aging varies among
individuals. Intrinsic aspects of aging appear to be
highly controlled by heredity and are not largely
influenced by the individual. In contrast, extrinsic
factors are heavily determined by a person’s habits,
nutrition, and exposure to deleterious factors, such
as ultraviolet light and cigarette smoking. Facial aging, for the individual, occurs with various accelerations and decelerations and does not appear to
proceed at an even rate. What is apparent, however,
is the commonality of progression across various
ethnicities that enables certain generalities to be observed (Fig. 1.1).
People either consciously or unconsciously assign
an apparent age to themselves and others based on
facial appearance. A person’s facial appearance is the
visible declaration of the biological changes in the
individual’s basic facial structures. Aging leads to
sagging, alterations in texture, and changes in facial
volume and the underlying skeleton, which affect
the perception of age. Once these age-related chang-

• Sunlight is the most significant external influence for aging of the skin.
• Volume loss occurs at both the skeletal and soft
tissue levels of the face.
• Reversal of many of the signs of facial aging can
be accomplished with the selection of appropriate techniques and technologies.

■■ Introduction
This book presents and graphically illustrates frequently used surgical and minimally invasive techniques to correct many common facial cosmetic
concerns. Cosmetic problems arise from aging, trauma, hereditary conditions, and exposure to powerful extrinsic factors, such as cigarette smoking and
ultraviolet radiation. Changes occur superficially in
both the epidermal and dermal skin components, as
well as in the deeper aspects of the facial anatomy.
Numerous methods and technologies are available to
treat facial cosmetic problems. These “tools” can be
categorized in many ways; however, most fall within
the bounds of surgical procedures, light and laser
technologies, chemical peels, and the use of injectable implants and fillers. A description of the aging
process will help set the stage for discussion of the
various technologies.


2 Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery

Fig. 1.1 Artist’s representation of the progression of facial aging as depicted at consecutive decades during adulthood.

es have occurred, very few are reversible. However,
they can be improved through makeup, cosmetic
skin care, and cosmetic rejuvenative surgical and
minimally invasive techniques.2

Changes in the Skin
The facial skin is continually exposed to a variety of
external conditions, such as wind, cold, heat, and
ultraviolet radiation. The last factor is the principal
agent causing extrinsic aging of the skin, with effects that are significant enough to warrant the term
“photoaging.” This exposure extends throughout an
individual’s life, although it is postulated that the ultraviolet exposure occurring early in one’s life is responsible for most of the changes in the skin decades
later. Some authors have speculated that ~50 to 75%
of a person’s total lifetime ultraviolet radiation exposure occurs before 20 years of age.3 People with fairer
complexions are most susceptible to the harmful effects of ultraviolet radiation.
Sun-damaged epidermis is histologically disorganized and thickened compared with nonexposed
skin. Keratinocytes lose their distinctive alignment,
and a progressive flattening of the cellular architecture occurs. Dyskaryotic changes are seen in the
superficial layers of the epidermis. In response to
long-term exposure to sunlight, epidermal melanocytes enlarge, proliferate, and migrate to higher
levels of the epidermis. This chronic stimulation of

melanocytes leads to dyschromias, spotty hyperpigmentation, and the proliferation of pigmented
keratoses. These changes are reflected in the dull
uneven texture and pigmentation of adult sun-exposed skin.
In the deeper layers of the skin, ultraviolet radiation causes different long-term changes in addition
to those seen in the epidermis. In sun-damaged skin,
the region immediately beneath the epidermis develops a band of densely packed collagen with little
or no elastic content.3 Beneath this region is a broad
zone of electron-dense, elastotic material. Here,
curled entangled masses of the elastin-staining material are found among degenerated collagen fibrils.
Elastotic degeneration of dermal architecture is a
consistent histologic feature of cutaneous photodamage. These occurrences are responsible for many
of the changes seen as wrinkling.4
Part of the aging of the skin is an inevitable degenerative process with changes that are superimposed
on the external aging factors in each individual, thus
producing the endless variety of problems that present. As part of the intrinsic skin-aging process, the
skin varies in thickness. Skin thickness in women
reaches a maximum at ~ 35 years of age and decreases gradually thereafter. In men, the curve is different,
with the peak thickness occurring at 45 years of age.5
There is a diversity of cell size and shape. The dermatoepithelial abutment is flattened with the loss of
rete ridges, rendering skin fragile and susceptible to
injury from shearing forces. The dermis of senescent


Facial Aging, Cosmetic Concerns, and Facial Cosmetic Procedures 3

skin is characterized by marked cellular atrophy and
a corresponding reduction in metabolic activity. The
percentage of newly synthesized collagen in the dermis decreases.6 As a result, the skin is less distensible,
poorly resilient, and prone to fine wrinkling.7 As the
dermis thins, there is a decrease in collagen content,
degeneration of elastic fibrils, decreased water content, and the gradual addition of stable cross-links
between collagen fibrils.8

Changes in Fat and Volume
Changes in the deeper soft tissue structures of the
face complete the picture of the aging face. The face
loses volume through several mechanisms. There appears to be actual fat atrophy, as well as a redistribution of fat. These alterations in the fat distribution are
secondary to changes in the suspensory apparatus
of the facial tissue. Principal among these suspensory mechanisms are the facial ligaments (Fig. 1.2):
(1) zygomatic ligament, (2) mandibular ligament, (3)
masseteric-cutaneous ligament, and (4) platysmaauricular ligament.9
In addition to the exaggeration of age-related
changes from subcutaneous fat atrophy, further malposition of fibrofatty tissues and muscles and atrophy of the facial skeleton create a relative excess of
skin. Absorption of the skull and facial bones occurs
with advancing age. This is most prominent in the areas of the maxilla, the mandible, and the anterior nasal spine, for example, in the widening of the width
of the orbital aperture.

Changes in the Brow
The procerus muscle creates transverse wrinkles at
the nasal root. Descent of the lateral portion of the
eyebrows may produce characteristic “hooding” of
the eyes. Also, during the thirties, deeper wrinkles
across the forehead begin to develop because of the
action of the frontalis muscle. There is a gradual
ptosis of the forehead soft tissue caused by gravity.
Frequently, patients unconsciously maintain a continuously contracted frontalis to overcome this, producing deep and permanent forehead furrows.

Changes in the Periorbital Region
The changes around the eyes are closely linked to
those in the forehead. Excess skin of the upper eyelids frequently appears in the late thirties because of
the ptosis of the brows, as well as the developing laxity of the skin of the upper eyelid. Characteristic agerelated “bags” of the lower eyelid are caused by loss
of midface volume and descent of the midface, as
well as weakening of the orbital septum. Photodamage, with resultant dermatochalasis, further accentuates the undesirable changes in the lower eyelid,
thus producing rhytids and skin redundancy.
Fine wrinkles generally begin to appear in individuals during their twenties, deepening as they approach
their thirties. “Crow’s feet” may occur around the
eyes in the late twenties, or earlier in persons prone
to squinting. These are secondary to the contraction
of the orbital portion of the orbicularis oculi muscle

Fig. 1.2 Graphic depiction of the approximate
anatomic locations of the facial ligaments: (1) zygomatic ligament, (2) mandibular ligament, (3)
masseteric-cutaneous ligament, and (4) platysmaauricular ligament.

4 Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery
and are accentuated by elevation of the upper cheek
by the zygomatic head of the quadratus labii superioris muscles. Vertical glabellar lines resulting from
the contraction of the bilateral corrugator supercilii
muscles frequently develop during the thirties.

Changes in the Nasolabial Region
With the attenuation of the suspensory structures in
aging, several developments occur. In the lower face,
many of these changes are seen to create deepening
of the nasolabial fold. The nasolabial fold represents
the point at which the fibers of the quadratus labii
superioris, zygomaticus, and risorius muscles interdigitate and insert into the dermis.10 Beyond the age
20 group, the groove created by these attachments
grows longer and apparently deeper, eventually becoming a prominent feature of the face.
This apparent deepening in the nasolabial fold is
largely caused by the more anteromedial and inferior
projection of the cheek mass in older individuals and
is not secondary to retrusion of the nasolabial fold itself. Sagging of the cheek soft tissue mass may form a
prominence over relatively deeply creased nasolabial
grooves, producing a more pronounced deformity.
The descent of the midfacial structures is reflected
not only in changes in the nasolabial fold, but also
in more superiorly age-related changes. As the cheek
mass descends, its superior projection becomes significantly lower in the older individual, leaving a
paucity of soft tissues in its place.11–13 This creates the
obvious hollowing over the inferior orbital rim causing the characteristic biconvexity of midfacial aging.
In all, these midface changes are multifactorial, with
the common denominator of volume loss.

Changes in the Superficial Muscular
Aponeurotic System (SMAS)
There is a gradual ptosis of the superficial muscular
aponeurotic system (SMAS) with its overlying soft
tissues in the lateral cheek and parotid region. SMAS



ptosis plays a role in the development of jowling,
which disturbs the smooth, youthful contours of the
mandibular line. Sagging of the SMAS and platysma
extends to the neck platysma, with relaxation and
lengthening of the suspensory ligaments. This gradually opens the cervicomental angle, eliminating its
youthful contour. Diastasis and hypertrophy of the
leading edge of the platysma muscles bilaterally produce vertical bands that bowstring across the cervicomental angle, during the fifties and later (Fig. 1.3).

Changes in the Nose
The most significant alterations associated with nasal aging occur in the suspension of the cartilages.
The relationship between the upper and lower lateral cartilages slowly dehisces, and the support mechanisms of the tip and interdomal ligaments gradually
weaken.11 There are also changes in the medial crura.
There is a downward rotation of the lobule and absorption of the fat pad in front of the anterior nasal
spine, causing the feet of the medial crura to diverge
and move posteriorly to produce a shortening and
retraction of the columella and further downward
rotation of lobule (Fig. 1.4). As a result, the nose is
actually longer. It also appears relatively longer secondary to the vertical shortening of the lower third
of the face from absorption of components of the
maxilla and the mandible.

Changes in the Lips
The lips are a key feature of the central lower face.
Along with the eyes and the nose, the lips and their
intricate contours comprise some the integral details
of the face. Fine vertical and radial wrinkling begins
to appear and to increase over time during the forties. This is secondary to the underlying action of the
orbicularis oris muscle. Fine vertical wrinkles perpendicular to the fibers of the orbicularis oris muscle
appear on the upper lip during the late forties or
early fifties. These wrinkles will appear earlier in in-


Fig. 1.3 (a) This patient illustrates many desirable features of the youthful neck and jaw line. (b) Changes associated with aging,
with the relaxation and attenuation of the support of the superficial muscular aponeurotic system (SMAS)/platysma and obliteration of the cervicomental angle. (c) Jowling and platysmal bands secondary to the relaxation of the SMAS and platysma.



Facial Aging, Cosmetic Concerns, and Facial Cosmetic Procedures 5


dividuals who use tobacco. A horizontal mentolabial
crease occurs after age 40, secondary to contraction
of the underlying mentalis muscle. In youth, the lips
are round and full with sharply detailed anatomy in
the “Cupid’s bow” and a sharp demarcation of the
vermilion. With aging, the upper lip lengthens and
descends vertically. There is a loss of the underlying tone and bulk of the orbicularis oris muscle. The
projection of the vermilion slowly loses its firm support and descends, causing a loss of fullness in the
exposed red lip (Fig. 1.5).

■■ Facial Rejuvenation
Over time, various technologies and techniques have
evolved to reverse, camouflage, and correct the multitude of cosmetic problems and blemishes. Many of
these technologies and techniques are highly reliable,
safe, and aimed at specific targets, given advances in
science and anatomy. This book addresses these cosmetic issues, focusing on the following areas.
Methods to correct sagging and laxity of the skin
have been largely surgical in nature, to date. These
techniques remain “tried-and-true”; and although
they are among the more invasive of cosmetic procedures, they generally produce the most dramatic results. For the purposes of this presentation―whereas
there are promising, less-invasive skin-tightening
technologies on the horizon―the surgical approaches appear to be the most reliable.
Improving the character of the skin by correcting
dyschromias, fine wrinkling, and skin laxity through
resurfacing continues to evolve. Traditionally, chemi-

Fig. 1.4 Artist’s depiction of the aging-associated changes of the nose with progressive loss
of tip support, tip ptosis, and elongation. (a) A
youthful nose, and (b) an aging nose.

cal peeling provided the mechanism to create a semicontrolled injury to the skin. The skin can be injured
to several different levels, depending on the agent
and how it is utilized. This selective variability allows
for variation in patient selection as to skin type, the
degree of cosmetic problem, the length of time to obtain healing, and the minimization of complications.
Similar to dermabrasion, the deeper the injury, the
more dramatic the result. However, the deeper the
injury, the greater the likelihood of an undesirable
result. In all cases, the final benefit to the patient’s
skin is largely secondary to the natural healing properties of the skin, not the depth of injury. This healing involves the reepithelialization of the skin, with
improvement in texture and pigmentation. Tightening of the skin and the effacement of wrinkles are the
result of the synthesis of new collagen bundles and
the deposition of elastin.
Various chromophores are targeted with the application of laser technologies of different wavelengths.
These technologies more selectively target undesirable aspects of the skin anatomy, including vascular
lesions, dyschromias, unwanted hair, and water. A
variety of ablative and nonablative laser technologies
have allowed resurfacing to be applied to an even
greater cross-section of patient skin types. Improved
safety has allowed resurfacing to be performed by
a greater selection of facial plastic, plastic surgical,
ocular plastic, and dermatologic colleagues.
In the late 1970s and early 1980s, liposuction was
popularized as a method to recontour the soft tissue in the facial area and the neck. Suction-assisted
lipectomy can be performed independently or as
an adjunctive procedure with facelifting, and it can
involve laser-assistive technologies. In the 1980s,

6 Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery





Fig. 1.5 (a,c) A patient in her twenties, and (b,d) another patient in her forties. With aging there is a draping or lengthening of the
upper lip, thinning of the bulk of the red lip, and the appearance of radial rhytids that are accentuated with muscle activity.

the transfer of fat became more popular and has
achieved a present peak of popularity as a means
to use the patient’s own fat to correct other contour
deformities (i.e., volume depletion and depressions).
The management of volume in the face now has bimodal attention. In areas of excess, fat removal is performed; in areas of volume depletion, fat is injected.
Over all, this has allowed the practitioner to improve
the areas of the face that were never adequately addressed with either resurfacing or facelifting alone.
There is a wealth of nonautogenous fillers becoming available. It is outside the scope of this particular
chapter to elaborate on them. These fillers are commercially obtainable with several different underlying chemistries and physical characteristics. The
duration of effect is also variable. At this time, they
are safe and popular.
Finally, onabotulinum’s popularity is based on its
sizable safety margin, its availability, and its efficacy

for the treatment of some of the more vexing cosmetic facial problems. The use of onabotulinum toxin
affords a very safe, reliable, and reproducible method
to temporarily correct rhytids and hyperfunctioning
lines, and to actually stabilize or lift the brows.

■■ Conclusion
Over the past several decades, detailed study of the face
has increased our knowledge of the cellular and structural changes that occur with aging. Additionally, there
have been significant advancements in the development of new technologies, products, and surgical techniques. This current understanding of aging, coupled
with these tools, has improved the ability of surgeons
to reverse many of the cosmetic problems associated
with aging and acquired and inherited deformities.


Facial Aging, Cosmetic Concerns, and Facial Cosmetic Procedures 7


7. Daly CH, Odland GF. Age-related changes in the mechani-

1. Shirakabe Y. The Oriental aging face: an evaluation of





a decade of experience with the triangular SMAS flap
technique in facelifting. Aesthetic Plast Surg 1988;12(1):
25–32 PubMed
Fedok FG. The aging face. Facial Plast Surg 1996;12(2):
107–115 PubMed
Consensus Development Panel. National Institutes of
Health summary of the Consensus Development Conference on Sunlight, Ultraviolet Radiation, and the Skin.
Bethesda, Maryland, May 8-10, 1989. [Review] J Am Acad
Dermatol 1991;24(4):608–612 PubMed
Kligman AM, Baker TJ, Gordon HL. Long-term histologic
follow-up of phenol face peels. Plast Reconstr Surg 1985;
75(5):652–659 PubMed
Leveque JL, Corcuff P, de Rigal J, Agache P. In vivo studies
of the evolution of physical properties of the human skin
with age. Int J Dermatol 1984;23(5):322–329 PubMed
Bailey AJ, Robins SP, Balian G. Biological significance of
the intermolecular crosslinks of collagen. Nature 1974;
251(5471):105–109 PubMed





cal properties of human skin. J Invest Dermatol 1979;
73(1):84–87 PubMed
Miyahara T, Murai A, Tanaka T, Shiozawa S, Kameyama M.
Age-related differences in human skin collagen: solubility in solvent, susceptibility to pepsin digestion, and the
spectrum of the solubilized polymeric collagen molecules.
J Gerontol 1982;37(6):651–655 PubMed
Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989;83(1):11–16 PubMed
Ellis DA, Ward DK. The aging face. J Otolaryngol 1986;
15(4):217–223 PubMed
Rubin LR, Mishriki Y, Lee G. Anatomy of the nasolabial
fold: the keystone of the smiling mechanism. Plast Reconstr Surg 1989;83(1):1–10 PubMed
Hamra ST. Repositioning the orbicularis oculi muscle in
the composite rhytidectomy. Plast Reconstr Surg 1992;
90(1):14–22 PubMed
Yousif NJ. Changes of the midface with age. Clin Plast Surg
1995;22(2):213–226 PubMed


Basic and Advanced Skin Care
Lisa D. Grunebaum, Ilanit S. Samuels, and Leslie Baumann

Key Concepts
• Skin typing with the Baumann Skin Typing
System (BSTS) allows for effective skin care by
accounting for important variations in each individual patient.
• Specific cosmeceutical ingredients are useful for each skin type; practitioners and patients alike should be familiar with the myriad
• Retinoids, antioxidants, and sunscreens are
keystones to any good skin-care regimen.
• Minimally invasive procedures, such as superficial peels, microdermabrasion, and intense
pulsed light (IPL), are helpful adjuncts for improving skin appearance―particularly unwanted pigment and redness.

■■ Introduction
The traditional skin-type designations (i.e., dry, oily,
combination, and sensitive) are insufficient in terms
of directing physicians and consumers to proper
product selection because these labels do not address
various cutaneous characteristics, including the tendency to develop wrinkling or pigmentation. In the
opinion of the authors, the BSTS is a better option
for identifying skin type using a wider range of cutaneous factors based on four main skin parameters:
oily versus dry; sensitive versus resistant; pigmented
versus nonpigmented; and wrinkled versus tight (unwrinkled). Evaluating the skin using all four parameters results in 16 potential skin-type permutations,
because these dichotomies are not mutually exclusive
(Table 2.1). The BSTS can guide both physicians and

patients/consumers in finding the most appropriate
skin products. The Baumann Skin Type (BST) acts as a
standardized forum in which to informatively discuss
skin care. The BST is derived from a scientifically validated questionnaire, the Baumann Skin Type Indicator (BSTI), intended to ascertain baseline skin type.1
The resulting data can be used to help identify the
most suitable products and procedures for patients.
This chapter briefly touches on skin-care science according to the format of the BSTS, before discussing
selected minimally invasive techniques.

■■ Background: Basic Science of

Dry skin is characterized by an impaired barrier, lack
of natural moisturizing factor (NMF), or decreased
sebum production; whereas oily skin is characterized by increased sebum production. A higher BSTI
score indicates increased sebum production (oily
skin); a lower score indicates reduced skin hydration
(dry skin); and a score in the middle of this parameter indicates “normal” skin. Changes in climate, or
traveling from one climate to another, can result in
fluctuations between oily and dry skin.
Sensitive skin is characterized by inflammation
and presents as acne, rosacea, burning and stinging
sensations, or skin rashes. Individuals who receive
a high score in the “S” portion of the BSTI are more
likely to have more than one type of sensitive skin.
Resistant skin is typified by a strong stratum corneum (SC) that confers cutaneous protection from allergens, other environmental factors, and water loss.
Although resistant skin―as compared with sensitive
skin―is less prone to acne, it is also less amenable to
topical treatments, thus requiring stronger skin-care
products and in-office procedures.
Pigmented skin within the BSTS framework refers
not to skin color, but to the tendency to develop hyperpigmentation―particularly preventable or treat-


Basic and Advanced Skin Care 9

Table 2.1 Baumann Skin Type determined by the Baumann Skin Type Indicator
Oily, pigmented

Oily, nonpigmented

Dry, pigmented

Dry, nonpigmented

Wrinkled, sensitive





Tight, sensitive





Wrinkled, resistant





Tight, resistant





Abbreviations: DRNT, dry, resistant, nonpigmented, tight; DRNW, dry, resistant, nonpigmented, wrinkled; DRPT, dry, resistant, pigmented,
tight; DRPW, dry, resistant, pigmented, wrinkled; DSNT, dry, sensitive, nonpigmented, tight; DSNW, dry, sensitive, nonpigmented,
wrinkled; DSPT, dry, sensitive, pigmented, tight; DSPW, dry, sensitive, pigmented, wrinkled; ORNT, oily, resistant, nonpigmented, tight;
ORNW, oily, resistant, nonpigmented, wrinkled; ORPT, oily, resistant, pigmented, tight; ORPW, oily, resistant, pigmented, wrinkled; OSNT,
oily, sensitive, nonpigmented, tight; OSNW, oily, sensitive, nonpigmented, wrinkled; OSPT, oily, sensitive, pigmented, tight; OSPW, oily,
sensitive, pigmented, wrinkled.

able with skin-care products and/or procedures (i.e.,
ephelides, melasma, postinflammatory hyperpigmentation, and solar lentigines). Nonpigmented skin
is often seen in people with light skin who do not tan
easily. Knowing a patient’s “P” score can guide practitioners in adjusting chemical-peel strengths and
laser settings to prevent the development of postinflammatory hyperpigmentation.
The fourth parameter (wrinkled versus unwrinkled skin) is inextricably linked to aging. Cutaneous aging results from the complex intersection of
intrinsic and extrinsic factors. Intrinsic aging derives from individual heredity and the natural effects of the passage of time. Extrinsic aging results
from exogenous insults and manifests in premature
skin aging, especially in the face. Rhytid formation,
engendered by changes in the dermal layer of skin,
is the primary manifestation of skin aging. Importantly, despite myriad false claims to the contrary,
few skin care products are proven to adequately penetrate the dermis to improve deep wrinkles; therefore, preventing rhytids is the goal of dermatologic
antiaging skin care.2 Unwrinkled skin is skin that has
been largely protected from exogenous aging factors.
The remainder of this chapter focuses on specific aspects of the four BSTS parameters, as well as selected
facial cosmetic procedures.

sives coat the SC and decelerate transepidermal water loss (TEWL); humectants attract water from the
atmosphere and the epidermis; emollients soften
and smooth the skin. Cleansing agents are used by
people of all skin types. Surfactants are the primary
active ingredients in cleansers. Cleansing products
include bar surfactants, superfatted soaps, transparent soaps, combination bars, synthetic detergent
bars, and liquid surfactants. Patients with dry skin
should be advised to select nonfoaming agents, such
as a cleansing milk, oil, or cream.

■■ Technical Aspects of Procedure


Dry Skin
Basic Skin Care Formulations
Dry skin can be treated by augmenting SC hydration with occlusive or humectant ingredients and
smoothing rough surfaces with an emollient. Occlu-

Moisturizers raise water content in the SC by inhibiting TEWL through occlusive ingredients or by
enhancing the integrity of the skin barrier. This is
achieved via delivery of fatty acids, ceramides, and
cholesterol to the skin, and controlling the calcium
gradient. Moisturization is also achieved by augmenting NMF levels, glycerol (glycerin), and other
humectants (e.g., hyaluronic acid). In addition, skin
hydration is improved by fostering epidermal capacity to absorb important circulatory components, such
as glycerol and water through aquaporin channels.
Most moisturizers, which are designed to improve
skin hydration, are oil-in-water emulsions (e.g.,
creams and lotions) or water-in-oil emulsions (e.g.,
hand creams).

Widely used in skin-care cosmetics, occlusives are
oily substances that can dissolve fats and coat the
SC to inhibit TEWL, resulting in an emollient effect.
Petrolatum and mineral oil are among the most effective occlusives. A purified mixture of hydrocarbons derived from petroleum (crude oil) and used
as a skin-care product since 1872, petrolatum, the
gold standard of occlusives, displays a water vapor

10 Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery
loss resistance 170 times that of olive oil.3 The hydrocarbon molecules present in petrolatum prevent
oxidation, giving it a long shelf life.4 However, petrolatum has a greasy texture that many patients find
unappealing. Cosmetic-grade mineral oil, a noncomedogenic agent derived from the distillation of petroleum in gasoline production, has been available
for more than 100 years and is one of the more commonly used oils in skin products.5 It is important to
note that occlusives are effective only while on the
skin; TEWL returns to prior levels upon removal of
the agent. In moisturizers, occlusives are often combined with humectants. Lanolin, paraffin, squalene,
dimethicone, propylene glycol, beeswax, soybean
oil, grapeseed oil,6 and other “natural” oils (e.g., sunflower seed, evening primrose, olive oil, and jojoba
oils) are also among typically used occlusive ingredients.7–11 Linoleic acid, an omega-6 fatty acid present
in sunflower, safflower, and other oils, is an essential
fatty acid, obtained from the diet or through topical application, necessary for the production of ceramide in the skin’s barrier.

Humectants are water-soluble substances with high
water-absorption capacity. These compounds can attract water from the deeper epidermis and dermis
in low-humidity conditions, which can aggravate dry
skin.8 Consequently, humectants are combined with
occlusive ingredients to achieve the desired effect.
In cosmetic moisturizers, humectant ingredients
protect against evaporation and thickening of the
product, thus extending the shelf life. Humectants
can also change skin appearance by drawing water
into the skin, causing mild SC swelling that makes
the skin look smoother and less wrinkled. Manufacturers often capitalize on this phenomenon in touting some moisturizers as “antiwrinkle creams” even
though no long-term antiwrinkling effects are imparted. Glycerin, urea, sorbitol, sodium hyaluronate,
propylene glycol, alpha hydroxy acids (AHAs), and
sugars are among the normally used humectant ingredients. Glycerin (glycerol) is a potent humectant
with hygroscopic ability comparable to NMF,9 paving
the way for the SC to retain a significant amount of
water even in a dry environment. Urea, included in
hand creams since the 1940s,10 is a constituent of the
NMF and displays mild antipruritic activity.11 Notably, the humectant hyaluronic acid does not penetrate into the dermis when applied topically.

Emollients render a smooth appearance by filling
the spaces between desquamating corneocytes and
increasing cohesion, resulting in a flattening of the
curled edges of the individual corneocytes. In ad-

dition, several emollients exhibit humectant and
occlusive qualities. Occlusives that also confer an
emollient effect include lanolin, mineral oil, and
petrolatum. Several natural ingredients also impart
such benefits. These include oatmeal, shea butter,
vitamins C and E, coffeeberry, green tea, coenzyme
Q10, niacinamide, soy, and glycyl-l-histidyl-l-lysineCu2+ (GHK-Cu), a copper tripeptide complex used for
many years to enhance wound healing and more recently shown to augment collagen synthesis.12,13
Ideal moisturizers contain both humectant and
occlusive ingredients. Glycerin is one of the better
humectants because it can cross aquaporin channels
and penetrate into the dermis. The best occlusive
ingredients are oils that contain antioxidants and/
or linoleic acid, including safflower, sunflower, olive,
walnut, peanut, and grapeseed oils.

Sensitive Skin
Sensitive skin has defied easy characterization. Two
classification systems have been proffered in the last
10 years, but a definitive typing system for sensitive skin remains elusive.24,25 Nevertheless, sensitive
skin is classified in the BSTS based on clinical manifestations: Type 1 (open and closed comedones and
pimples; the acne or S1 type); Type 2 (facial flushing
due to heat, spicy food, emotion, or vasodilation; the
flushing rosacea or S2 type); Type 3 (burning, itching, or stinging; the S3 type); and Type 4 (developing
contact dermatitis and irritant dermatitis and often
associated with an impaired SC; the S4 type) (Table
2.2). Individuals can suffer from combinations of sensitive skin subtypes. The following discussion focuses
on the primary topical treatments for sensitive skin.

Topical Treatments for Sensitive Skin
Corticosteroids block proinflammatory genes that
encode cytokines, cell adhesion molecules, and other
mediators, thus inhibiting the inflammatory process.26 In particular, corticosteroids selectively induce
anti-inflammatory proteins such as MAPK phospha-

Table 2.2 Types of sensitive skin
S3―Burning and stinging
S4―Susceptibility to contact and irritant dermatitis

tase and annexin I, which physically interact with and
suppress cytosolic phospholipase A2a (cPLA2a).27 Consequently, corticosteroids inhibit arachidonic acid release and a subsequent conversion to eicosanoids.28
The use of topical corticosteroids is generally safe for
short-term treatment of inflammatory skin diseases.
However, long-term use can produce adverse cutaneous effects (e.g., acne, folliculitis, hirsutism, purpura,
pigmentary changes, skin atrophy, striae, and telangiectasia).29,30 Chronic topical corticosteroid use has
also led to more serious systemic side effects, such
as avascular osteonecrosis, glaucoma, hyperglycemia,
hypothalamic-pituitary axis (HPA) suppression, and
posterior subcapsular cataracts.31–39 Although corticosteroids can effectively treat rosacea, they should
be avoided for this indication because their use engenders compensatory redness upon discontinuation
and their protracted use can thin the skin.

Cyclooxygenase Inhibitors
Several nonsteroidal anti-inflammatory drugs
(NSAIDs) specifically target the bioactive lipids produced by arachidonic acid. For example, ibuprofen
has shown success in treating acne because inflammatory acne lesions are infiltrated with neutrophils,
and ibuprofen inhibits leukocyte chemotaxis.32 Sunburn can also be treated with NSAIDs. In a randomized double-blind crossover study of 19 psoriatic
patients receiving ultraviolet B (UVB) phototherapy
conducted more than 30 years ago, researchers compared ibuprofen with placebo and evaluated signs
and symptoms of UVB-induced inflammation. A
statistically significant difference was found only in
the technician’s assessment of erythema; however,
findings suggested that ibuprofen was more effective than placebo in delivering symptomatic relief
of UVB-induced inflammation following high doses
of UVB-phototherapy for psoriasis. Based on the observation that dermal prostaglandins are increased
after UVB irradiation, it is thought that an NSAID that
interrupts prostaglandin synthesis may attenuate
UVB-induced inflammation.33

Salicylic Acid
Salicylates have demonstrated anti-inflammatory
and antimicrobial activity in experimental as well
as clinical settings.34 Salicylic acid, a member of the
aspirin family, interrupts the arachidonic acid cascade, thus exerting analgesic and anti-inflammatory
effects. Salicylates control inflammation by inhibiting proinflammatory gene expression. Salicylic acid
decreases the frequency and severity of acne eruptions by mitigating acne-related inflammation and
delivering exfoliating activity to the pores. Because
it is lipophilic, it is better able than glycolic acid to
penetrate the sebum in skin pores, which accounts

Basic and Advanced Skin Care 11

for its popularity in OTC acne products. Salicylic acid
2% cleansers are effective treatment options for rosacea patients with oily skin.

Sulfur, usually an adjuvant therapy, is used primarily
to treat acne, seborrheic dermatitis, rosacea, scabies,
and tinea versicolor.35 Elemental sulfur and its various forms (e.g., sulfides, sulfites, and mercaptans)
act as anti-inflammatory agents and reportedly
display antifungal, antimicrobial, and antiparasitic
activity.36 Sulfur is often combined with sodium
sulfacetamide, a sulfonamide agent with antibacterial properties, specifically acting as a competitive antagonist to para-aminobenzoic acid (PABA),
an essential component for bacterial growth,37 and
Propionibacterium acnes.38 The keratolytic and antiinflammatory activity of sulfur and the antibacterial
properties of sulfacetamide in a topical formulation
render an effective treatment for acne vulgaris, rosacea, and seborrheic dermatitis.39 Sulfur is often
found with sodium sulfacetamide in cream, lotion,
gel topical suspension, cleanser, and silica-based
mask preparations. However, the odor of many of
these products has been likened to rotten eggs, thus
limiting their popularity.

Natural Ingredients
In the past 20 years, botanically derived products
have gained widespread use and interest in the United
States.40 Indeed, several such ingredients, including
aloe vera,41,42 chamomile,43,44 feverfew,45,46 ginseng,47,48
licorice extract,49,50 mushrooms,51,52 oatmeal,53 selenium,54,55 and turmeric, have been shown in recent
years to impart anti-inflammatory activity.56,57

Pigmented Skin
Skin color is derived fundamentally from the incorporation of melanin-containing melanosomes,
produced by the melanocytes, into epidermal keratinocytes and their subsequent degradation. The focus
of the BSTS system regarding this skin parameter is
on general treatments for hyperpigmentation.

Tyrosinase Inhibitors
Tyrosinase is the enzyme that controls melanin production, as it is the rate-limiting enzyme for the
biosynthesis of melanin in epidermal melanocytes.
Given what appears to be its pivotal role in melanogenesis, tyrosinase activity is targeted in various
products designed to decrease melanin formation by
suppressing tyrosinase.

12 Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery


Kojic Acid

The use of hydroquinone (HQ) leads to the reversible suppression of cellular metabolism by affecting
both DNA and RNA synthesis. In addition, HQ efficiently inhibits tyrosinase, diminishing its activity
by 90 %.58 Although HQ is effective alone, it is usually combined with other agents (e.g., azelaic, glycolic, and kojic acids, and tretinoin).59 For many years,
HQ was the first-line therapy for postinflammatory
hyperpigmentation and melasma.60 Concerns about
its safety, however, led to a ban for general cosmetic
purposes in Europe in 2000. In Asia, HQ is legal but
highly regulated. In the United States, the FDA has
long been considering the status of HQ, but it has
not yet decided whether to ban it in OTC products.
HQ has never been etiologically linked with human
cancer. Pigmentation of the eye and permanent corneal damage are the most serious adverse health effects seen in workers exposed to HQ.61 Exogenous
ochronosis is also associated with topically applied
HQ,62 although only 30 cases of ochronosis have
been ascribed to HQ use in North America.63 Skin
rashes and nail discoloration have also been linked
to HQ use. The safety debate within the FDA about
this standard-bearing tyrosinase inhibitor has provided the impetus for manufacturers to research
and develop newer, less problematic skin-lightening agents.

Kojic acid (5-hydroxy-2-hydroxymethyl-gammapyrone), a fungal metabolite of various species of
Aspergillus, Acetobacter, and Penicillium,69 inhibits tyrosinase activity, mainly by chelating copper,
leading to a cutaneous whitening effect.70 The combination of kojic and glycolic acids has been shown
to be more effective than 10% glycolic acid and 4%
HQ for the treatment of hyperpigmentation.71,72
Kojic acid 1% products are usually suggested for
twice-daily use for 1 to 2 months or until the desired cosmetic result is achieved; however, sensitization to 1% creams has been reported.73 Kojic acid
derivatives have been reported to exhibit enhanced
efficiency by dint of greater skin penetration.74 They
have been extensively used in cosmetic products,
especially in Japan.75

Derived from aloe vera, aloesin inhibits the hydroxylation of tyrosine to DOPA, as well as the oxidation
of DOPA to DOPAchinone, and it suppresses melanin
production in cultured normal melanocytes.64 In a
2002 study on the inhibitory effect of aloesin and/or
arbutin on pigmentation in human skin after UV radiation, investigators determined that pigmentation
was inhibited compared with control: 34% by aloesin, 43.5% by arbutin, and 63.3% by the co-treatment
with aloesin and arbutin.65 A study published that
same year indicated that aloesin and some chemically related chromones inhibit tyrosinase more effectively than arbutin and kojic acid.66

Arbutin, a naturally occurring B-D glucopyranoside
composed of a molecule of HQ bound to glucose, is
found in the leaves of pear trees and herbs such as
wheat and bearberry. The depigmenting mechanism
of arbutin involves a reversible inhibition of melanosomal tyrosinase activity, rather than blocking the expression and production of tyrosinase.67 Traditionally
used in Japan for depigmenting purposes, arbutin is
now thought to be less effective than a synthetic derivative. Indeed, deoxyarbutin has shown, in vitro and in
vivo, greater suppression of tyrosinase than arbutin.68

Licorice Extract
Glabridin (Glycyrrhiza glabra), a key active ingredient in licorice extract, suppresses tyrosinase activity in cell cultures without altering DNA synthesis.
In guinea pig skin, topical applications of 0.5% glabridin have exhibited the capacity to suppress UVBinduced pigmentation and erythema.76 In the clinical
setting, glabridin has been used effectively to treat
melasma77 and has also displayed a depigmenting
benefit greater than HQ.78

Emblica, an extract of the Phyllantus emblica fruit, contains the tannins emblicanin A and emblicanin B. Emblica is photochemically and hydrolytically stable and
is thought to be as effective as HQ and kojic acid, but
it has not been associated with adverse side effects. It
acts as an inhibitor of tyrosinase and/or tyrosinaserelated proteins (TRP-1 & 2) and peroxidase/H2O2,79
and as a broad-spectrum cascading antioxidant.

Melanosome-Transfer Inhibitors
Niacinamide, also known as nicotinamide, is the
biologically active amide of vitamin B3. It has been
demonstrated to suppress melanosome transfer to
epidermal keratinocytes by up to 68% in an in vitro
model and to render improvement in undesired facial pigmentation.80 It is important to note that the
effects of niacinamide on pigmentation have been
shown to be reversible.81 In a 2005 study, twice-daily
application of a 5% niacinamide preparation for 8
weeks yielded significant improvement in hyperpigmentation, as did the use of 3.5% niacinamide combined with retinyl palmitate.82


Basic and Advanced Skin Care 13



Soymilk and the soymilk-derived proteins soybean
trypsin inhibitor (STI) and the Bowmann-Birk inhibitor (BBI) can inhibit the activation of PAR-2, a G-protein-coupled receptor found to regulate the ingestion
of melanosomes by keratinocytes in culture,83 thus
spurring skin depigmentation.84 Significantly, topical soybean extract application has been shown in
human trials to lighten hyperpigmentations.85,86 Soy
is likely both safe and effective, with negligible side
effects, particularly since the suppressing of melanosome transfer is reversible. It is best to use soy that
has been chemically altered to remove estrogenic
properties. Formulation of soy is difficult, so brand
names are more reliable than generic products. The
authors have noted that Johnson & Johnson has one
of the best formulations using “active soy,” with estrogenic components removed and small soy proteins preserved.

For many years, retinoids, a family of compounds
derived from vitamin A, have been used topically
and systemically to treat dermatologic disorders,
especially acne. Indeed, more than 25 years ago,
female acne patients reported smoother skin and
fewer wrinkles after treatment.90 This led to a clinical trial showing that patients treated with tretinoin experienced improvement in sunlight-induced
epidermal atrophy, dysplasia, keratosis, and dyspigmentation.91 Additional findings from several
clinical trials led to the FDA’s approval of tretinoin
(Renova [Ortho Dermatologics, Quebec, Canada])
to treat photodamage. Renova and Avage (Allergan,
Courbevoie, France) are the only topical agents approved for this purpose.
Significantly, tretinoin may also play a role in the
prevention of cutaneous aging. UVB exposure upregulates the development of multiple MMPs; and the
activation of MMP genes promotes the production of
collagenase, gelatinase, and stromelysin, which fully
degrade skin collagen.92 However, the induction of
these MMPs has been demonstrated to be inhibited
by the application of tretinoin.93 Collagen synthesis
has also been shown to be diminished by dint of UV
exposure. Such a reduction in procollagen production has been demonstrated as a result of cutaneous
pretreatment with tretinoin; therefore, consistently
pretreating the skin with topical retinoids appears to
have the potential to prevent as well as treat photodamage.94 Collagen synthesis in photoaged human
skin has also been promoted by the use of retinoids.95
Specifically, levels of collagen type I have been partially restored by the topical application of tretinoin
0.1% to photodamaged skin. The metabolic precursor of tretinoin, retinol, is a key ingredient found in
various OTC cosmetic products advertised as “antiwrinkle” creams.96
Although they bear little structural resemblance
to retinol, the newest retinoids impart biological action via the same nuclear receptors modulated by the
active natural metabolite of vitamin A, retinoic acid.
Third-generation retinoids, of which there are now
more than 2,500 products,97 are more photostable
than the first- and second-generation formulations.98
However, a recent report by the Environmental Working Group has stirred controversy about one retinoid―
retinyl palmitate―suggesting that it may promote skin
cancer development.99 The American Academy of Dermatology has responded by denying that there is any
such evidence.100 What we do know is that retinyl palmitate delivers some sunscreen effects by absorbing
UVB, but it may also absorb UVA and act as a photosensitizer. Whereas it is undetermined whether retinyl
palmitate actually imparts a carcinogenic effect, it has
been established that retinol penetrates human skin

Lignin Peroxidase
Lignin peroxidase is produced extracellularly during submerged fermentation of the fungus Phanerochaete chrysosporium3 and then is purified from
the fermented liquid medium.87 Trademarked as
Melanozyme (Lonza of Switzerland, Zurich), lignin
peroxidase is a glycoprotein active at pH 2–4.5 that
identifies eumelanin in the epidermis and breaks it
down without impacting melanin biosynthesis or inhibiting tyrosinase. Melanozyme is proprietary and
available only in the new skin-lightening product
known as Elure (Syneron Medical Ltd., llit, Israel).
The product includes an activator containing hydrogen peroxide (0.12%) that oxidizes, thereby activating the lignin peroxidase, which otherwise would be
unable to lighten the skin.

Wrinkled Skin
Wrinkled skin is more readily prevented than successfully treated. Well-known effective behaviors to
avert photoaging include the use of broad-spectrum
sunscreen (blocking UVA and UVB) and sun avoidance during the peak hours of 10 am to 4 pm. A
routine skin-care regimen that entails topical retinoid application may also aid in the prevention and
treatment of cutaneous aging. Topical retinoids foster collagen synthesis and thwart the matrix metalloproteinases (MMPs) active in collagen and elastin
degradation.88,89 Also important in the dermatologic
arsenal against wrinkling are antioxidants, which
countervail the oxidative stress and free radicals created by UV irradiation.

14 Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery
more effectively than retinyl palmitate.100,101 In addition, several retinoids have been shown to exert anticarcinogenic effects. The authors recommend retinol
or tretinoin products, not retinyl palmitate.

Several antioxidants have demonstrated significant
capacity to exert photoprotective effects. Although
a suitable discussion of this subject is beyond the
scope of this chapter, it is worth noting that the
list of antioxidants or antioxidant-containing compounds associated with such effects includes, but
is not limited to, vitamins C102,103 and E,104 coenzyme
Q10,105 grapeseed extract,106,107 resveratrol,108,109 green
tea,110,111 lycopene,112 feverfew,113 turmeric,114 idebenone,115 and coffeeberry.111,112

Sun exposure deposits UV radiation into skin and is
known to not only to cause skin cancer, but also to
contribute to the appearance of aged skin, wrinkles,
and uneven skin tone due to mottled pigmentation.
UV radiation is made up of 96.5% UVA and 3.5% UVB
on an average summer day. UVB is more likely to
cause squamous cell carcinoma and can be blocked
by glass, whereas UVA is believed to be a cause of
melanoma and can penetrate glass. UVA can also
penetrate deep into the skin and cause wrinkles.
There are many different sunscreens available, all
with varying Sun Protection Factor (SPF) displayed
on the label. SPF numbers refer only to the amount
of protection against UVB and not UVA, meaning that
sunscreen SPF does not reveal how well the particular sunscreen guards against UVA absorption.
There are two types of sunscreens: physical blockers and chemical blockers. Physical blockers, otherwise known as “barrier sunscreens,” reflect UV
radiation. Because there is no systemic absorption,
physical blockers (e.g., titanium dioxide, zinc oxide,
and magnesium oxide) rarely cause an allergic reaction. Chemical blockers (e.g., avobenzone) are usually combined with physical blockers for periods of
increased sun exposure. Chemical sunscreens absorb
the UV radiation, and the chemicals in sunscreens are
systemically absorbed. Therefore, there is a risk of allergic reactions with chemical blockers, and they are
contraindicated in small children. The authors endorse a regimen that begins first with an antioxidant
product layer followed by an antioxidant-containing
sunscreen, or two different types of broad-spectrum
sunscreens. The best products include avobenzone
(now in a stable form known as Helioplex [Neutrogena, Los Angeles, CA]), Mexoryl (LaRoche Posay,
Clichy, FR)-containing products, and the physical
blockers zinc oxide and titanium dioxide.

Hydroxy Acids (Peels)
Alpha Hydroxy Acids
AHAs, a group of water-soluble, naturally occurring
compounds with a hydroxy group in the α position,
function as humectants and exfoliants. Lactic acid
(derived from sour milk), glycolic acid (from sugarcane), citric acid (from citrus fruits), malic acid
(from apples), tartaric acid (from grapes), and phytic
acid (from rice) are members of this versatile family of compounds.14 Lactic and glycolic acids were
the first AHAs to reach the market and remain the
most commonly used. For more than 35 years, topical formulations using AHAs have been known to
affect epidermal keratinization.15 Of note, the FDA
requires preparations containing AHAs to include a
label warning that sun protection should accompany
product use.

Lactic Acid
First used in 1943 to treat ichthyosis,16 lactic acid is
a popular AHA present in several at-home products
and prescription moisturizers. Lactic acid is the only
AHA that is also a component of the NMF, which,
as suggested above, plays an important role in skin
hydration. Notably, the application of the l-isomer
of lactic acid to keratinocytes increases the ratio of
ceramide 1 linoleate to ceramide 1 oleate, which is
significant insofar as a lower ceramide 1 linoleate
to ceramide 1 oleate ratio is associated with atopic
dermatitis and acne.17,18 Lactic acid also confers antiaging effects, as suggested by a double-blind vehiclecontrolled study in which an 8% l-lactic acid formula
performed better than vehicle in treating photoaged
skin, with statistically significant amelioration of
skin roughness, mottled hyperpigmentation, and

Glycolic Acid
Glycolic acid, known as “the lunchtime peel” because it can be completed effectively and discreetly
within a lunch hour without conspicuous signs, is
the AHA most often used in chemical peels in practitioners’ offices. In 1996, the application of AHAs
was shown through histological examination to increase skin thickness by 25%; augment acid mucopolysaccharides in the dermis; enhance elastic fiber
quality; and increase collagen density.20 Treatment
with AHAs has also been demonstrated to spur collagen synthesis in vivo and in vitro using fibroblast
cultures. Such results have been seen in vitro using
glycolic acid, which has also increased fibroblast proliferation.21 Glycolic acid, unlike several peels, must
be neutralized after use to prevent burning. Consequently, glycolic acid should be used only on small
areas of the body where it can be rapidly applied and


Beta Hydroxy Acid
Salicylic acid is a chemical exfoliant derived from willow bark, wintergreen leaves, and sweet birch; however, it is also available in synthetic form.22 Although
labeled as the only beta hydroxy acid (BHA) because
the aromatic carboxylic acid has a hydroxy group in
the β position, the carbons of aromatic compounds
are traditionally given Arabic numerals rather than
Greek letter designations typical for the nonaromatic
structures. The BHA label was bestowed for marketing purposes at the time the peels were introduced,
and to benefit from the popularity of AHAs. Although
the BHA peel is a newer category of chemical peels,
salicylic acid has a long and varied history of utility
in skin care.
As a chemical peel, salicylic acid is available in overthe-counter (OTC) home products, typically in 0.5 to 2%
concentrations suitable for treating acne, rosacea, photoaging, and hyperpigmentation. It is also included in
several in-office peels that combine ingredients, such
as the Jessner’s Peel, the PCA Peel (Physician’s Choice,
Inc., Chicago, IL), the Miami Peel (Quintessence, MiVideo 2.1, and the Pigment Plus Peel (Bioami, FL)
medic, IV Seasons Skin Care, Inc., Boulder, CO). Most
cosmetic dermatologists use preparations of 20 or 30%
salicylic acid for in-office peels, which―comparable to
the effects of AHA peels―have shown success in fading pigment spots, ameliorating surface roughness, and
diminishing fine lines.23 Unlike AHAs, however, BHA
impacts the arachidonic acid cascade, exhibiting antiinflammatory activity and provoking less irritation
than AHA peels. The lipophilic nature of salicylic acid
also renders a stronger comedolytic effect than AHA
peels, allowing BHA to penetrate the sebaceous material in the hair follicle and exfoliate the pores. BHA does
not need to be neutralized, as do the AHAs, and the
frost is apparent upon completion of the peel.

■■ Postoperative Care
Very little, if any, information is published from an
evidence-based standpoint regarding specific preand postfacial procedure skin care. However, the
authors of this chapter suggest strongly that careful
pre- and postprocedure skin care is paramount to
maximal outcome. Consideration should be given to
three layers of the face when studying optimal facial
enhancement. Skin, volume, and skeletal structure
correspond to the outer, middle, and deep layers of
the face. Only optimization of all three layers will
lead to the best results. A personalized day-to-day
skin-care system is important for all-around “outer
layer” maintenance, as discussed elsewhere in this
chapter. Other aspects of the skin-care regimen may
need to be added (or discontinued) for a period of

Basic and Advanced Skin Care 15

time when preparing for a procedure. Most importantly, all patients must wear a daily sunscreen with
SPF 30 or greater, whether or not a more invasive
procedure is imminent.
Most patients who seek facial enhancement from
peels and/or lasers hope to improve the appearance
of photoaging―rhytids, pigment, texture and/or erythema/telangiectasias. The majority of individuals
can tolerate and benefit from the use of a retinoid
for rhytid improvement, as previously discussed.
Given tretinoin’s proven benefit in neocollagenesis,88
the authors believe that the use of a retinoid product
up to 5 days prior to a peel or laser procedure safely
encourages increased laser or peel effectiveness and
healing.116,117 Patients who undergo superficial (epidermal only) peeling or nonablative laser treatments
can return to retinoid use approximately 1 week after
treatment; use can resume approximately 2 weeks
after ablative laser treatments.
Pretreatment with HQ is a well-documented practice for patients at higher risk for postinflammatory
hyperpigmentation. However, this exercise is limited by the fact that only epidermal melanocytes
are susceptible to HQ and these cells are removed
with ablative resurfacing, limiting utility of pretreatment HQ.110 If instituted, pretreatment should
begin 2 to 4 weeks prior to laser or peel. Posttreatment with HQ is usually reserved for unwanted
hyperpigmentation. A concentration of at least 4%
HQ combination therapy with added steroids and
retinoid may be even more effective.118,119 However,
other ingredients may be used prophylactically and
to maintain pigment improvement long term. Also,
nonprescription topical agents that incorporate ingredients such as soy, kojic acid, or glycolic acid are
documented to provide enhancement in pigment
and overall skin brightness, and can be added to
the daily skin-care regimen. An added advantage
of nonprescription topical products is that their
use may be continued to help maintain procedural results. Postlaser erythema is another potential
cosmetic problem that can be treated with the addition of a targeted cosmeceutical. A well-stabilized
vitamin C topical formulation has shown promise
in this area.120
Many companies market postlaser/postprocedure
“recovery” kits. Great care must be taken to avoid irritation and allergic dermatitis during the sensitive
days following procedures. The simplest occlusive,
such as petrolatum (Aquaphor [Eucerin, Wilton, CT]),
should be used for 24 to 72 hours after ablative laser resurfacing. In one study at the University of Miami Miller School of Medicine (unpublished data),
the use of one of two alternative marketed occlusive
dressings on one side of the chest after ablative resurfacing versus Aquaphor led to unacceptably high
rates of irritation, pruritus, and prolonged erythema
in the non-Aquaphor side.

16 Minimally Invasive and Office-Based Procedures in Facial Plastic Surgery

■■ Expected Results
Microdermabrasion is a painless resurfacing procedure requiring no anesthesia or recuperation time.
Without provoking side effects, microdermabrasion
diminishes fine wrinkles, enhances skin texture,
treats comedones, and eliminates excess skin oil.121
The microdermabrasion instrument drives sterile
micronized aluminum oxide crystals at the skin,
while using vacuum suction to remove these particles along with the desquamated skin. The force with
which the particles are propelled and the speed at
which the device is passed over the skin determine
the depth of the treatment. Microdermabrasion is
intended to remove the outer layer of the epidermis
to foster natural exfoliation.122 A concomitant benefit
is that it seems to facilitate transdermal delivery of
some medications.123,124 Microdermabrasion devices
are classified as cosmetic rather than medical and
are therefore not regulated by the FDA, allowing
manufacturers’ marketing claims to go unchallenged
or unproven. Acne, acne scarring, striae distensae,
and photoaging are the common indications for microdermabrasion.123 Consequently, this procedure is
used for facial rejuvenation, treating other dyspigmented areas, facilitating transdermal delivery of
medications, and selectively decreasing full-thickness SC without harming deeper tissues.125

Intense Pulsed Light
IPL devices emit noncoherent light with wavelengths
between 500 and 1,200 nm. IPLs look and act like lasers, but technically are not lasers because they lack
coherent, monochromatic light. The newer systems
can pump true laser devices in a separate handpiece.
Therefore, one system can be used for several indications. IPLs have been used to remove hair as well
as to treat acne, erythema, keratosis pilaris, lentigines, nevus flammeus, photodamage, poikiloderma,
spider veins, telangiectasias, and venous malformations.126 No topical anesthesia is required for IPL
A patient’s skin type and sun protection status
should be determined before treatment. For example, treating a recently tanned patient can cause hypopigmentation due to the absorption of melanin by
the device. Patients are cautioned to avoid solar exposure before and after treatments. Practitioners are
advised to lengthen pulse widths and delays between
pulses when using IPLs on patients with darker skin
types (Fitzpatrick IV and V).127,128 Pulses should be
placed close together for patients with severe photodamage. Far spacing can cause striping, which can
also occur when higher fluences are used and pulses

are not placed closely together. This complication
can be resolved by addressing the untreated areas. A
full-face procedure typically takes 15 minutes. Photodamage usually requires three to five sessions at
1-month intervals.129 IPLs allow for the management
of vascular and pigmented lesions with one instrument. In addition, they offer rapid treatment times;
therefore, patients can receive therapy during brief
windows, such as a lunch period. Consistent, reproducible results, with few if any side effects (e.g., minimal if any downtime and perhaps mild darkening of
treated lentigines, and erythema of treated areas) are
also associated with IPL procedures.

■■ Conclusion
To achieve optimal results for patients―whether
they are having surgery or receiving dermal fillers,
botulinum toxin injections, or laser treatments―the
proper skin-care regimen, including topical products,
must be recommended. Ascertaining the patient’s
Baumann Skin Type is the first step in ideal skin care.
Armed with an understanding of a patient’s BST, the
physician can select a skin-care regimen best suited
to the individual’s skin type. To improve the likelihood of patient compliance, the skin-care regimen
should be reviewed at each patient visit.

   1. Baumann L. The Skin Type Solution. New York, NY: Ban-

tam Dell; 2006

   2. Baumann L. How to prevent photoaging? J Invest Derma-

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itary-adrenal axis suppressi