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

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

Visualize the latest aesthetic plastic surgery techniques with step-by-step instructions and tips for success from the masters

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Commissioning Editor: Sue Hodgson
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For additional online content visit

Plastic Surgery

Bahman Guyuron


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

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

SAUNDERS is an imprint of Elsevier Inc.
© 2012, Elsevier Inc. All rights reserved.
DVD footage for chapter 123 Thigh and buttock lift, and post-bariatric surgery skin tightening Copyright
© 2007 Covidien. All rights reserved. Reprinted with the Permission of Covidien
First published 2009
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval
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Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK);
fax: (+44) 1865 853333; e-mail: You may also complete your
request on-line via the Elsevier website at
British Library Cataloguing in Publication Data
Aesthetic plastic surgery video atlas.
1. Surgery, Plastic–Atlases.
I. Guyuron, Bahman.
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress.
Medical knowledge is constantly changing. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowl; edge, changes in treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current product information
provided by the manufacturer of each drug to be administered to verify the recommended dose, the
method and duration of administration, and contraindications. It is the responsibility of the
practitioner, relying on experience and knowledge of the patient, to determine dosages and the best
treatment for each individual patient. Neither the Publisher nor the author assume any liability for
any injury and/or damage to persons or property arising from this publication.
The Publisher

Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

policy is to use
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User Guide
List of contributors


Aesthetic Plastic Surgery Video Atlas

1 Patient Assessment


Bahman Guyuron

2 Skin Care Including Chemical Peeling


Zoe Diana Draelos

3 Non-surgical Facial Rejuvenation with Fillers


Brian M. Kinney, David J. Rowe and David Stepnick
Clip 3.1: Non-surgical Facial Rejuvenation with Fillers
Brian M. Kinney

4 Botulinum Toxin


Michael A. C. Kane
Clip 4.1: Botulinum Toxin
Bahman Guyuron

5 Laser Facial Resurfacing and Dermabrasion


Richard O. Gregory
Clip 5.1: Laser Resurfacing and Dermabrasion
Thomas E. Rohrer

6 Management of Alopecia


Jack Fisher
Clip 6.1: Hair Transplantation
Robin Unger and Walter Unger

7 Forehead Rejuvenation


Bahman Guyuron
Clip 7.1: Forehead Rejuvenation
Bahman Guyuron

8 Periorbital Rejuvenation


Bahman Guyuron and Donald T. Hudak
Clip 8.1: Periorbital Rejuvenation
Bahman Guyuron

9 Facelift with SMAS Flaps


Timothy J. Marten
Clip 9.1: High SMAS Face and Mid-face Lift
Brian M. Kinney



10 Neck Rejuvenation


Patrick K. Sullivan and Erik A. Hoy
Clip 10.1: Neck Contouring
Bahman Guyuron

11 Primary Rhinoplasty


Rod J. Rohrich and Ronald E. Hoxworth
Clip 11.1: Primary Rhinoplasty
Rod J. Rohrich

12 Secondary Rhinoplasty


Bahman Guyuron and David Stepnick

13 Genioplasty


Bahman Guyuron and Adam Bryce Weinfeld
Clip 13.1: Genioplasty
Bahman Guyuron

14 Aesthetic Contouring of the Craniofacial Skeleton


Michael J. Yaremchuk
Clip 14.1: Chin Augmentation with Porous Implants
Michael J. Yaremchuk
Clip 14.2: Mandible Augmentation with Porous Implants
Michael J. Yaremchuk

15 Augmentation of Facial Structures with Autologous Fat


Sydney R. Coleman and Alesia P. Saboeiro

16 Breast Augmentation


Per Hedén
Clip 16.1: Breast Augmentation
Per Hedén

17 Breast Reduction


Elizabeth J. Hall-Findlay
Clip 17.1: Breast Reduction
Elizabeth J. Hall-Findlay

18 Mastopexy


G. Patrick Maxwell, Jeremy Waldman and Stephanie Stover
Clip 18.1: Mastopexy
Elizabeth J. Hall-Findlay

19 Liposculpture


Fabio X. Nahas, Marcus Vinicius Jardini Barbosa and Lydia Masako Ferreira
Clip 19.1: Liposculpture
Fabio X. Nahas

20 Abdominoplasty


Al S. Aly, Silvia Cristina Meneghetti Rotemberg and Albert E. Cram
Clip 20.1: Abdominoplasty
Al S. Aly

21 Bodylifts and Post-massive Weight Loss Body Contouring


J. Peter Rubin and Jeffrey Gusenoff
Clip 21.1: Post Bariatric Surgery Skin Tightening
J. Peter Rubin

22 Surgical Management of Migraine Headaches


Bahman Guyuron and Devra B. Becker



Aesthetic Plastic Surgery Video Atlas
The supporting website for the book, which includes all of the book’s
content, including the video and image downloads, can be found at


Implementing the knowledge attained from a book chapter in the
operating room, regardless of how detailed the description of the
procedure is in the text, often presents an enormous challenge since
some of the nuances would be commonly omitted. A combination
of proper description of the surgical technique and precise artistic
renderings along with clear videos provides the optimum source of
information for surgery, and overcomes this difficulty in execution in
most instances. With that in mind, we have prepared this book to
give the readers a practical tool that can be used to augment the safety
of the contemplated procedures. This atlas with accompanying videos
will not only serve residents and new graduates, who can read the
text, review the illustrations and observe the video prior to the surgery,
it will also help seasoned surgeons who may wish to refine their
technique. Especially for the latter group who has experience with

these techniques, some of the points that are demonstrated by the
experts in the videos may serve to facilitate the surgery, add to the
safety and improve the outcomes. We have asked highly respected
authors in the field to share their techniques with the readers using
as much detail as possible. The videos have been edited by our wellregarded colleague Dr. Brian M. Kinney, who is highly recognized for
his quintessential talent in this area, and we are utterly grateful to
him for his contribution to this volume. We are very much hopeful
that the readers are going to enjoy the content, the illustrations and
the videos. Finally, we would like to acknowledge and thank the other
editors of Plastic Surgery, Indications and Practice for their unselfish
and persevering work, expertise and wisdom which made this spin
off possible.
Bahman Guyuron, MD


Al S. Aly

Zoe Diana Draelos


Bahman Guyuron


Assistant Professor of Surgery
University of Iowa College of Medicine

Primary Investigator
Dermatology Consulting Services
High Point

Chapter 20 Abdominoplasty

Chapter 2 Skin Care Including Chemical

Clip 122.1 Abdominoplasty

Marcus Vinicius Jardini Barbosa


Collaborator Professor
Department of Surgery, Division of Plastic
Federal University of São Paulo
São Paolo
Chapter 121 Liposculpture

Devra B. Becker


Assistant Professor
Department of Plastic Surgery
Case Western Reserve University/University
Chapter 22 Surgical Management of Migraine

Sydney R. Coleman


Assistant Clinical Professor NYU School of
Tribeca Plastic Surgery
New York
Chapter 15 Augmentation of Facial Structures
with Autologous Fat

Albert E. Cram


Iowa City Plastic Surgery
Chapter 20 Abdominoplasty

Lydia Masako Ferreira


Full Professor and Chairwoman
Plastic Surgery Division
Federal University of São Paulo
São Paulo
Chapter 121 Liposculpture

Jack Fisher


Associate Clinical Professor
Department of Plastic Surgery
Vanderbilt University
Chapter 6 Management of Alopecia

Richard O. Gregory



Kiehn-DesPrez Professor and Chair
Department of Plastic Surgery
Case Western Reserve University/University
Hospitals Case Medical Center
Chapter 1 Patient Assessment
Chapter 7 Forehead Rejuvenation
Chapter 8 Periorbital Rejuvenation
Chapter 12 Secondary Rhinoplasty
Chapter 13 Genioplasty
Chapter 22 Surgical Management of Migraine

4.1 Botulinum toxin
7.1 Forehead Rejuvenation
8.1 Periorbital Rejuvenation
10.1 Neck Rejuvenation
13.1 Genioplasty

Elizabeth J. Hall-Findlay


Private Practice
Mineral Springs Hospital

Institute of Aesthetic Surgery

Chapter 17 Breast Reduction

Chapter 5 Laser Facial Resurfacing and

Associate Professor in Plastic Surgery

Jeffrey Gusenoff


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

Clip 17.1 Breast Reduction
Clip 18.1 Mastopexy

Per Hedén


Chapter 16 Breast Augmentation
Clip 16.1 Breast Augmentation

Ronald E. Hoxworth


Assistant Professor
Department of Plastic Surgery
University of Texas Southwestern Medical
Chapter 11 Rhinoplasty
Clip 11.1 Primary Rhinoplasty


Fabio X. Nahas


Department of Plastic Surgery
Brown University – Rhode Island Hospital

Chapter 19 Liposculpture

Chapter 10 Neck Rejuvenation

Donald T. Hudak


Assistant Professor of Plastic Surgery and
Case Medical Center
Assistant Professor of Ophthalmology
University of Cincinnati
Cincinnati Eye Institute

Clip 19.1 Liposculpture

Thomas E. Rohrer


Attending Surgeon
Manhattan Eye, Ear and Throat Hospital
New York
Chapter 4 Botulinum Toxin

Brian M. Kinney


Clinical Assistant Professor of Plastic
University of Southern California
Private Practice
Plastic and Reconstructive Surgery
Los Angeles
Chapter 3 Non-surgical Facial Rejuvenation
with Fillers
Clip 3.1 Non-surgical Facial
Rejuvenation with Fillers

Clip 9.1 High SMAS Face and
Midface Lift

Timothy J. Marten


Founder and Director
Marten Clinic of Plastic Surgery
San Francisco
Chapter 9 Facelift with SMAS Flaps

G. Patrick Maxwell
Maxwell Aesthetics
Chapter 18 Mastopexy



Director, Mohs Surgery
SkinCare Physicians of Chestnut Hill
Clinical Associate Professor
Department of Dermatology
Boston University
Clip 5.1 Laser Resurfacing and

Chapter 8 Periorbital Rejuvenation

Michael A. C. Kane


Associate Professor
Division of Plastic Surgery
Federal University of São Paulo
São Paulo

Rod J. Rohrich


Professor and Chairman
Crystal Charity Ball Distinguished Chair
in Plastic Surgery
Betty and Warren Woodward Chair in Plastic
and Reconstructive Surgery
Department of Plastic Surgery
University of Texas Southwestern Medical
Chapter 11 Rhinoplasty
Clip 11.1 Primary Rhinoplasty

Silvia Cristina Meneghetti Rotemberg

Associate Staff
Plastic Surgery
The Cleveland Clinic
Chapter 20 Abdominoplasty

David J. Rowe


Assistant Professor, Plastic Surgery
Department of Plastic Surgery
University Hospitals Case Medical Center
Chapter 3 Non-surgical Facial Rejuvenation
with Fillerss

J. Peter Rubin


Director of Body Contouring Program
Associate Professor of Surgery
Division of Plastic Surgery
University of Pittsburgh

Chapter 21 Bodylifts and Post-Massive
Weight Loss Body Contouring
Clip 21.1 Post Bariatric Skin Tightening

Alesia P. Saboeiro


Private Practice
Tribeca Plastic Surgery
New York
Chapter 15 Augmentation of Facial
Structures with Autologous Fat

David Stepnick


list of Contributors

Erik A. Hoy

Associate Professor, Facial Plastic Surgery
Department of Plastic Surgery
University Hospitals Case Medical Center
Case Western Reserve University
Chapter 3 Non-surgical Facial Rejuvenation
with Fillers
Chapter 12 Secondary Rhinoplasty

Stephanie Stover


Associate to Dr Maxwell
Nashville Plastic Surgery
Chapter 18 Mastopexy

Patrick K. Sullivan


Associate Professor
Plastic Surgery
Brown University
Chapter 10 Neck Rejuvenation

Robin Unger


Assistant Clinical Professor
Department of Dermatology
Mount Sinai Medical School
New York City
Clip 6.1 Hair Transplantation

Walter Unger


Clinical Professor
Department of Dermatology
Mount Sinai School of Medicine
New York
Clip 6.1 Hair Transplantation


list of Contributors


Jeremy Waldman


Plastic Surgeon
Private Practice
Plastic and Reconstructive Surgery
Waldman Plastic Surgery and Dermatology,
Chapter 18 Mastopexy

Adam Bryce Weinfeld


Michael J. Yaremchuk


Attending Plastic Surgeon
University Medical Center
Brackenridge and Dell Children’s Medical
Center of Central Texas

Clinical Professor of Surgery
Harvard Medical School
Chief of Craniofacial Surgery
Massachusetts General Hospital

Chapter 13 Genioplasty

Chapter 14 Aesthetic Contouring of the Craniofacial Skeleton
Clip 14.1 Chin Augmentation with
Porous Implants
Clip 14.2 Mandible Augmentation with
Porous Implants


To Bruce Achauer.


We would like to thank our families whose sacrifices and unselfish reduction
of demand on our family time makes our participation in endeavors like editing this book possible for us.
Bahman Guyuron: To Lora, Glen, Greg, and Grant
Brian M. Kinney: To my Mother and Father, and Pearl




Patient Assessment
Bahman Guyuron

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

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



Table 1.1 Alarming clues suggestive of further patient
assessment or avoidance of surgery


that a body part just does not look right). Rhinoplasty, liposuction and
breast augmentation are among the most frequently sought surgical
procedures by the patients afflicted with BDD.4,5 Seven to fifteen
percent of cosmetic surgery patients meet criteria for BDD.

You have an uncomfortable feeling about the patient
Patient exhibits clinical signs of emotional instability


Patient’s expectations seem unrealistic
Patient’s objectives are in conflict with your aesthetic judgment
Patient provides you with deceitful information
Patient demands guarantees
Patient makes disparaging remarks about the previous surgeon
Patient asks you to take part in keeping the truth about surgery
from the spouse
Patient treats you or your staff disrespectfully
Patient appears to have difficulty comprehending the
recommended course

Consumption of prescription, over-the-counter or herbal medications
should be investigated carefully (Table 1.2). These may have deleterious effects on surgery and recovery by causing intraoperative bleeding,
subsequent hematomas and delayed healing.
The condition and color of the skin is relevant to the successful
outcome of the final surgery in pivotal ways. The patients with lighter
skin (Fitzpatrick I or II) generally heal better and are more suitable
candidates for laser resurfacing or chemical peel, although their
dynamic lines, which appear on animation, would not respond favorably to resurfacing, while the static lines, which are present all the
time, improve notably with resurfacing. However, those with light
freckled skin and blue eyes, have a higher propensity to bleed excessively and develop hypertrophic scars after surgery. The patients who
possess darker skin (Fitzpatrick V or VI) are not ideal candidates for
resurfacing and any resurfacing on this group of patients will require
additional consideration. This group of patients, on the other hand,
usually does not exhibit deep dynamic lines.

Table 1.2 Medications and food products that have deleterious effects on surgery






Alka Seltzer






Arthrits Pain Formula







Bayer Aspirin

BC tab or Powder


Capron Capsules

















Duradyne Forte










4-Way Cold

Goody’s Tablets
















Parodyne Analgesic

Pepto Bismal







Sal-Payne Capsules


S-A-C Tablets





Sk-65 Compound






Stanback Tabs/

St. Joseph’s Baby





Telanil Tantab








Tenuate Dospan















Herbs: feverfew, ginko balboa, ginger and St. John’s wort.
Vitamins: E, fish oil, garlic tablets.
Cholesterol medications (should be stopped 2 weeks before surgery).
Foods containing salicylates (should be eaten in moderation): almonds, apples, apricots, berries (blackberry, boysenberry, raspberry, strawberry), cherries, Chinese black
beans, cucumbers, currants, grapes, pickles, prunes, tomatoes, wine and alcohol.

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

Front view of the upper zone
The harmony of the upper aesthetic unit can be marred by a highpositioned hairline, leading to an elongated forehead. This finding is
of particular significance when planning the incision for forehead
rejuvenation on a patient with a senescent forehead (Fig. 1.2). When
the forehead is long, the surgeon may forego a coronal incision or an
endoscopic forehead rejuvenation and choose a pretracehial incision,
using either the subcutaneous or subgaleal dissection to reduce the
forehead height.8,9
Deep wrinkles in the forehead area are commonly the result of
compensation of the frontalis muscle to minimize the effects of
eyebrow or eyelid ptosis (Fig. 1.3). Thus, it is critical for the surgeon
to relax the forehead before selecting a forehead rejuvenation procedure. This can often be accomplished by asking the patient to smile.
Usually a compensatory elevation of the eyebrow is eliminated while
smiling. The second approach is to ask the patient to close the eyes
tightly, and then gently start opening the eyes until the patient can

Three equal zones of the face


Facial Analysis

Patients in the age group of 50 years or older, and those with
known medical conditions that could potentially increase the risk
of surgery, should undergo a full medical check up, or an ophthalmology examination within 1 year of surgery if eyelid surgery is being
Completion of a comprehensive health form is the most effective
way to record information regarding a patient’s medical history. Most
seasoned surgeons have designed their own questionnaires to lead
patients in disclosing medical problems that may have an adverse
effect on the surgical outcome.
The most common medical condition that may have deleterious
influence on an aesthetic surgery outcome is hypertension. Undoubtedly, controlling the hypertension plays a prodigious role in reducing
the risk of postoperative hematoma development. The patient’s blood
pressure must be normalized during the several weeks before surgery.
If the patient is consuming medications that may contract the blood
volume, the surgeon must exercise caution for any developing intraoperative hypotension and, if it occurs, it should be corrected before
the incisions are closed. Otherwise, hypotension prevents visualization
of the transected blood vessels since they do not bleed, which can start
bleeding when the blood pressure rises to the normal level post operatively. In other words, it is the relative hypertension that may cause
postoperative hematomas.6
Diabetes is another condition that may lead to postoperative complications.7 Patients with a positive family history of diabetes may have
a weakened immune system without clinical or laboratory evidence of
diabetes, causing infectious complications that would not otherwise
occur under ordinary circumstances. A history of recurrent infection or
poor healing on a patient with a family history of this condition, may aid
in diagnosing previously undetected diabetes.7 When diabetes is suspected and the fasting blood glucose levels are normal, a simple glucose
tolerance test can help uncover an unrecognized diabetes. History of
easy bruising or prolonged bleeding, if no pharmaceutical products
which can cause bleeding have been consumed, should raise the suspicion of some type of coagulopathy, such as Von Willebrand’s disease.7a


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

see the viewer. The compensation will become evident as soon as the
patient is asked to open the eyes at libre. Analyzing the type of existing wrinkles also aids in choosing a more effective forehead rhytidectomy procedure. In general, deep forehead wrinkles do not respond as
favorably to a subgaleal forehead rhytidectomy or an endoscopic forehead rejuvenation. A subcutaneous approach may produce a more
successful result in patients with pronounced forehead wrinkling.10 A
combination of endoscopic forehead rejuvenation and laser resurfacing
is a logical choice for those who exhibit eyebrow ptosis and many fine
Because of the role they play in the selection of suitable corrective
procedures, the function of the corrugator and procerus muscles and
their effect on the overlying skin deserve attention. Visible vertical
frown lines may require removal of the corrugator muscle and subcutaneous placement of fat. An overactive depressor supercilii muscle
results in oblique lines medial to the eyebrows.

Profile view of the upper zone
Reviewing the lateral portion of the forehead helps the surgeon to
determine the position of the temple hair in relation to the lateral
canthus. If the hairline is receding at the temple area and the patient
is considering a facial rhytidectomy (Fig. 1.4), one may choose the
anterior hairline temple incision11,12 over the incision placed within
the hair-bearing temple.
The forehead profile contour should be smooth and pleasing. Any
imperfections, such as frontal protrusion and recession, can be the
result of a variety of pathologic conditions. Most commonly, the forehead contour abnormality results from bony protrusion caused by
sinus hyperaeration (frontal bossing) (Fig. 1.5) and, less commonly, it
results from soft tissue excess.13 Not only do these flaws reduce the
desirability of the forehead contour; they may influence the outcome
of other aesthetic procedures, such as rhinoplasty. A small ridge cranial
to the eyebrow is an acceptable masculine characteristic. Presence of
a ridge on a woman, or an exaggerated prominence on either gender,
may require aesthetic contouring of the frontal bone. Additionally, as


Fig. 1.4 Patient with significant forehead wrinkles and eyelid ptosis;
note eyebrow compensation.

Fig. 1.2 Frontal view of a patient with elongated forehead and
eyebrow ptosis who would be a better candidate for forehead
rejuvenation with pretrichial incision rather than endoscopic
forehead rejuvenation or coronal incision.

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

a consequence of aging, the round and slightly projected glabellar area
may appear flat or even depressed to varying degrees. Correction of
this flattening undoubtedly bestows a rejuvenated appearance to the

Front view of the middle zone


Fig. 1.3 Patient with iatrogenic receding temple hairline as a
consequence of rhytidectomy incision being placed at temple

Most imbalances involve the middle and lower areas of the face. The
upper border of the eyebrows should be located at least 2.5 cm above
the mid pupil level on a straight gaze.14 The medial end of a pleasing
eyebrow is caudal to the lateral extreme, and the highest portion of
the eyebrow arch is at the junction of the lateral third with the medial
two-thirds of the eyebrow, corresponding to the lateral limits of the
limbus in a straight gaze. Eyebrow ptosis results in crowding of the
orbital region and must be differentiated from blepharodermachalasia.
Any asymmetry in the level or the shape of the eyebrow arch may
require differential eyebrow ptosis correction.
The distance between the medial canthi (intercanthal distance)
that is normally approximately 31–33 mm, equals the distance between

Facial Analysis

Upper face

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

Fig. 1.6 Width of upper face is 5 times that of palpebral fissure. Of
five equal segments, two are occupied by eyes, one by nose and
two by temples.

the medial and lateral canthi (orbital fissure width) (Fig. 1.6). This
relationship becomes particularly important when dealing with rhinoplasty candidates who would benefit from refinement of the nasal
dorsum and adjustment of the alar bases. Adding to the radix creates
an illusion of reduced intercanthal distance, which is detrimental to
those patients who exhibit hypotelorism, whereas reduction of the
nasal dorsal projection produces the opposite effect.15 Even slight hypotelorism is undesirable and detracts significantly from the patient’s
attractiveness. Narrowing the distance of the nasal bones spawns an
illusion of decreased intercanthal distance.8
The individual with a slight increase in the intercanthal distance
may still be considered attractive. Yet, when the distance extends
beyond 36 mm, it leads to a grossly abnormal and displeasing appearance. Presence of hypertelorism or telecanthus is also consequential
when planning rhinoplasty because widening the distance between the
nasal bones literally or by virtue of an optical illusion, such as adding
a wide dorsal graft, will result in the appearance of more severe hypertelorism or telecanthus. While the surgeon must be conservative
when widening the nasal bridge of a patient with a wide intercanthal
distance, a wider bridge may prove salutary for the patient who has a
shorter intercanthal distance.
The upper portion of the midface can be divided into five equal
segments, two are occupied by the eyes; one extends from one medial
canthus to another, containing the root of the nose; and two extend
from the lateral canthi to the lateral boundary of the ipsilateral temple
area (Fig. 1.6). Disharmony of this area has a significantly ruinous
effect on the pulchritude of the face. Anteroposterior discrepancies of
the eyes cannot be fully noticed on a frontal view, but are more perceptible on a basilar view. Detection of level and depth abnormalities
of the eye is important so that the patient can be informed of structural
abnormalities that may fail usual efforts at achieving balance in this
part of the face.
Edema around the eyes in a blepharoplasty candidate may indicate
abnormal thyroid dysfunction or renal failure (Fig. 1.7). Bilateral or
unilateral exophthalmus may be the consequence of hyperthyroidism

Fig. 1.8 Patient seeking blepharoplasty to correct exophthalmus
was discovered to have hyperthyroidism.

(Fig. 1.8). On patients who are contemplating blepharoplasty, vision
and lacrimal function also should be assessed. A combination of slight
proptosis and dry eyes or borderline tear production is inauspicious
and can lead to a troublesome postoperative course.
The optimal vertical opening of one eye is approximately 10 mm,
placing the upper eyelid margin 1 mm below the upper limits of the
limbus. In the aesthetic surgery patient population, mild-to-moderate
upper eyelid ptosis is common, but can easily be missed. This condition is readily corrected using one of several available techniques. In
a harmonious face the lateral canthus is generally 2º higher than the
medial canthus, giving a slight slant to the eye fissure. The antipode
of this relationship gives the patient a tired and sad appearance (Fig.
1.9), typically seen in patients with craniofacial deformities, such as
Treacher-Collins syndrome, and in patients with lateral lid lag
following lower blepharoplasty (Fig. 1.10).
As stated, unilateral or bilateral proptosis is an important finding
that may present as only a slight asymmetry and excessive opening of
one eye or both eyes, or as a significant prominence of the globes.
Often this finding is an indication of a thyroid dysfunction and, therefore, it necessitates a careful medical evaluation before blepharoplasty.
Generalized thickening of the upper and lower eyelids may be a reflection of hypothyroidism, which should be investigated thoroughly
before any periorbital surgical endeavor. Occasionally the lacrimal
glands are ptotic and present as an excessive bulk along the lateral



portions of the upper eyelids. In this case, lacrimal gland suspension
should be discussed with the patient. Neither this condition nor
suspension of the gland is of functional significance.16
Ideally, the supratarsal fold is visible about 3–4 mm above the lid
margin on a straight gaze while this distance is about 10–11 mm when
the eyelids are closed. A levator dehiscence is suspected when the tarsal
show is increased in the cephalocaudal dimension with a more pronounced supratarsal crease. If eyelid ptosis is diagnosed, levator function must be checked because it is a crucial factor in the selection of
a corrective approach. Presence of Bell’s phenomenon indicates a
reduced risk of exposure keratitis if complications, such as lid lag,

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

Fig. 1.10 Patient with iatrogenic displacement of lateral portion of
lower eyelid and lateral canthus.

occur. To conduct the test for Bell’s phenomenon, the examiner asks
the patient to force the eyes closed while the examiner attempts to
open the eyelid by lifting the lid with a finger. With a positive Bell’s
phenomenon, the globe rolls cephalad, protecting the cornea under the
upper lid (Fig. 1.11). A negative Bell’s phenomenon may be indicative
of a potential for an increase in corneal exposure; hence, dryness
and ulceration of the cornea should a lid lag ensue post eyelid
A pleasing lower eyelid is located at the caudal limits of the limbus
or minimally overlaps it. An increased distance between the lower lid
and the limbus, with excessive sclera visible through the lids, is an
indication of a lower lid lag, which should be evaluated carefully. The
lower lid support system weakness could be congenital. Whether it is
congenital, iatrogenic or due to senescence, this condition should alert
the aesthetic surgeon to undertake a conservative lower lid surgery or
to incorporate a procedure that fortifies the lid support, such as canthoplasty or canthopexy. A lower lid lag should be differentiated from
an ectropion. The latter is characterized by outwards rotation of the
lid margin and the eyelashes. Checking the tone of the lower lid with
a pinch and traction test may aid the examiner in differentiating a
congenital caudal lower lid malposition from a weak lower lid support.
Swift return of the lid to its previous position, after it is pulled caudally
or pinched and released, indicates good muscle tone. Motility (cephalocaudal moveability) of the lateral canthus should be less than 7–
8 mm and the maximum distance from the globe while the lid is pulled
anteriorly should not exceed 7 mm.
The quality of the skin and the types of existing wrinkles guide the
surgeon in deciding between skin/muscle flap, conjunctive blepharoplasty, a lower lid laser resurfacing procedure, a chemical peel, or a
combination of these techniques. Generally, patients with thin skin
and fine wrinkles do not experience long-lasting results from laser
resurfacing, even though the initial improvement may be significant.
On the other hand, patients with thicker skin usually experience a
lesser degree of improvement that is of longer duration.
Any depression in the nasojugal area or cephalad to the infraorbital
rim may necessitate soft tissue repositioning or fat grafting. Malar
bone hypoplasia, although better judged in the profile view, may be
detected in the frontal view as well. When evaluating the nose, the
examiner must observe the width, direction and smoothness of the
dorsal contour. The cephalocaudal nose length, defined as the distance
from the nasion to the caudal border of the infra tip lobule, is twice
the distance from the columella-labial junction (subnasale) to the junction of the lips (stomion) and equals the distance from the stomion to
the menton (base of the chin) (Fig. 1.12). The nasal dorsum and the
tip should be in line with the midline of the other facial structures.
Any abnormalities can be easily ascertained by drawing an imaginary
vertical line starting from the glabella. The nose tip, the philtum
dimple and the center of the chin should all fall on the same line.
The quality of the nasal skin is a significant factor in planning
surgery and achieving the intended objectives.10 Patients who have
thicker skin usually are not optimal candidates for rhinoplasty because
the tip would not be as well-defined post operatively. On the other
hand, patients who have very thin skin tend to reveal every imperfection

Fig. 1.11 A, Positive Bell’s phenomenon
demonstrated by cephalad rotation of globe
when examiner attempts to separate eyelids
against patient’s resistance. B, Negative
Bell’s phenomenon depicted by failure of
globe to rotate cephalad when examiner tries
to separate eyelid and patient attempts to
keep them closed.




1/ 1/ 1/
3 3 3

Facial Analysis

Middle to lower face






Fig. 1.12 Proportions of the middle to lower facial areas.

in the nasal frame. Both extreme cases require a change in the surgical
planning, and the incidence of revisional surgery could be higher on
these patients because of these adverse conditions. A thorough explanation of the reasons for potential revisional surgery may result in
lesser postoperative dissatisfaction in these patients.
The nasal bones should line up symmetrically, allowing a graceful
transition of shadow from the eyebrows to the nasal tip through a pair
of smooth and pleasing dorsal lines. Any excess or deficiency of nasal
bone width, unilateral or bilateral may distort these lines.17
A portion of the nostril opening should be visible on the frontal
view. Inadequate nostril show may be an indication of a long nose or
caudally positioned ala, whereas excessive nostril show may denote a
short nose or retracted alar rims. Most rhinoplasty candidates have
wide and asymmetric nostrils. This becomes even more apparent when
the individual smiles. This imperfection has significant surgical connotations and must be elicited by asking to the patient to smile. Tip
overlap on the upper lip becomes more noticeable on animation. Furthermore, the form, symmetry and particularly the width of the lower
lateral cartilages can be judged easily on the front view.
The distance between the alar bases, as measured from the lateral
border of one alar base to its opposite counterparts, should be slightly
wider than the intercanthal distance. An imaginary line drawn vertically from the medial canthi should pass 1–2 mm on the inside of the
alar base, providing that the intercanthal distance is normal (Fig. 1.13).
If the intercanthal distance is abnormal, the alar base distance should
be 2 mm wider than the orbital fissure width (from the medial to the
lateral canthus).18 The pleasing nasal tip has two highlights. The distance between these two points matches the width of optimal nasal
dorsal lines.

Profile view of the middle zone
On the frontal view, the lateral boundaries of the ears are visible with
the helix slightly more projected lateral to the antihelix. The entire ear
contour creates a parallel vertical line relative to the face. Excess ear
projection results in greater visibility of the helix and disappearance of
the antihelical fold. The length of the ear equals that of the nose. A

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

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

Front view of the lower zone
In the frontal view of the lower facial zone, the upper lip length, as
measured from the base of the columella to the stomion, should be
half the distance from the stomion to the horizontal line, passing
through the most caudal portion of the chin. On a patient with a
normal underlying maxillary and mandibular frame, dentitions and
patent airway, the lips are sealed in repose. Lip incompetence, which
is habitual failure to close lips in repose, often is seen on patients with
a long face deformity on those who are mouth breathers due to nasal
blockage, patients with an open bite, or patients with iatrogenic or
muscular dystrophy related lower lip ptosis.
The upper lip is slightly thinner than the lower lip. The width of
the oral commissure equals the distance from one medial limbus to
the other side. On frontal view the lower jaw line is well defined in a
symmetric fashion, with the superficial musculoaponeurotic system
(SMAS) being tight and smooth. Ptosis of the SMAS and fat is an
integral part of gravity effects and the aging process, which causes jowls
to develop and the lower face to widen. A horizontal line connecting
the oral commissures runs parallel to the lines connecting the canthi.
The oral commissures are located horizontally on young patients,
whereas senescent patients demonstrate claudal tilt of the oral commissures. The philtrum dimple is bordered with a well-defined cupid’s
bow. Excess submental fat may obscure the chin definition and hide



enlarged or ptotic submaxillary glands and they can only be detected
by palpation.
A congruous tooth alignment is a material component of an attractive smile. When the lips are slightly apart, 2–3 mm of the upper
incisors should be visible between the lips. Any excess incisor show
may infer a long face deformity or a short upper lip. When the patient
is asked to smile, there is usually minimal gum show. Excess gum
show may indicate a long face deformity or a short upper lip. Normally
the central incisors and canines are slightly longer than the lateral
incisors. Crowding is an indication of discrepancy between the width
and number of teeth and the size of the dental arch. Patients with this
type of dental flaw may require orthodontic correction or combined
orthodontic preparation and orthognathic surgery. Dental occlusion
should be examined to ensure the presence of a normal relationship
between the mandible and the maxilla. Abnormal jaw growth and
speech difficulties can be the consequence of a large tongue, detection
of which is an integral part of a thorough facial evaluation.

include: excess skin, presence of platysmal muscle bands, excess subplatysmal and supraplatysmal fat, a malpositioned hyoid bone (Fig.
1.15),24 a receding chin, or a varying combination thereof. A ptotic or
enlarged submaxillary gland may also disturb the balance of the cervicomental region.

The basilar view
Evaluation of the face on basilar view is crucial to a thorough facial
assessment. In this view, any asymmetry of the forehead can be

Mouth and chin

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

The cervical region


Ellenbogen has described the attributes of an aesthetically pleasing
neck whereby a 100 angle is created between the chin and the neck.23
This angle can be altered by a variety of neck flaws. These could

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



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

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

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

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

1. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder.
J Nerv Ment Dis 1997; 185:570.
2. Phillips KA, Menard W, Fay C et al. Demographic characteristics,
phenomenology, comorbidity, and family history in 200 individuals with
body dysmorphic disorder. Psychosomatics 2005; 46:317.

3. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, 4th edn. Washington, DC: American Psychiatric
Association; 2000.
4. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and
cosmetic surgery. Plast Reconstr Surg 2006; 118:167E–180E.
5. Crerand CE, Phillips, KA, Menard W et al. Non-psychiatric medical
treatment of body dysmorphic disorder. Psychosomatics 2006; 46:549.
6. Beckenstein M, Guyuron B. Postrhytidectomy hematomas and “relative”
hypertension. Unpublished data, 1994.
7. Guyuron B, Rasqewski R: Undetected diabetes and the plastic surgeon,
Plast Reconstr Surg 86:471–474, 1990.
7a. Guyuron B, Zarandy S, Tirgan A. Von Willebrand’s disease and plastic
surgery, Ann Plast Surg 32:351–355, 1994.
8. Connell B: Brow ptosis: local reactions. Third International Symoseum
on Plastic and Reconstructive Surgery of the Eye and Adnexa, Baltimore,
1982, Williams and Wilkins.
9. Guyuron B, Davies B. Subcutaneous anterior hairline forehead
rhytidectomy. Aesthetic Plast Surg 1988; 12:77–83.
10. Guyuron B. Precision rhinoplasty. II. Prediction. Plast Reconstr Surg
1988; 81:500–505.
11. Guyuron B. Modified temple incision of facial rhytidectomy. Ann Plast
Surg 1988; 21:439–443.
12. Lewis CM. Preservation of the female sideburn. Aesthetic Plast Surg
1984; 8:91.
13. Guyuron B. Soft-tissue frontal bossing. Plast Reconstr Surg 1987;
14. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift.
Aesthetic Plast Surg 1991; 15:141–147.
15. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg 1991;
16. Guyuron B, DeLuca L. Aesthetic and functional outcomes of
dacryoadenopexy. Aesthetic Surgery Quarterly 1996; 16:138–141
17. Sheen J. Aesthetic rhinoplasty, 2nd edn, vol 2. St Louis: Mosby; 1987.


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

18. Guyuron B. Precision rhinoplasty. I. The role of life-size photographs and
soft-tissue cephalometric analysis. Plast Reconstr Surg 1988; 81:489–499.
19. Guyuron B, Davies B. Experience with the modified Putterman
procedure. Plast Reconstr Surg 1980; 82:775–780.
20. Powell N, Humphreys B. Preparation of the aesthetic face. New York:
Theime; 1984.
21. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome.
guidelines for surgery? Plast Reconstr Surg 1981; 68:249–252.
22. Reidel RA. An analysis of the dentofacial relationships. Am J Orthod
Dentofacial Orthop 1957; 43:103.
23. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the
youthful neck. Plast Reconstr Surg 1980; 80:823–837.
24. Guyuron B, Arons J. The chin, hyoid bone, and neck. World Plast 1995;




Skin Care Including Chemical Peeling
Zoe Diana Draelos

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

protein rich cells (corneocytes);
skin lipids that hold the corneocytes together (Fig. 2.1).


Structural damage to the corneocytes or to the lipids results in a defective barrier. With the aid of an electron microscope, it is possible to
see the covalently bound lipid layer between the corneocytes forming
an organized watertight seal over the body (Fig. 2.2).
Barrier damage occurs when:

the intercellular lipids are removed, typically by the chemical insult
of soaps;


the corneocytes are physically removed, such as through aggressive
scrubbing or the use of chemical peels.

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

Fair complected patients:

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




poor skin texture

Relative contraindications

Patients with dark skin (Fitzpatrick types IV and higher)


History of consumption of oral retinoids within the past year


Radiated skin.


Hypersensitivity to chemical peels


Keloid formation within 6 months after cessation of oral retinoids


Evidence of poor healing.



Skin peeling is a controlled removal and renewal of the various
layers of the skin, depending on the depth of the wound:



superficial peels wound the stratum corneum and possibly the
upper layers of the epidermis;


medium-depth peels wound the stratum corneum, epidermis, and
superficial dermis;

The stratum corneum
Corneocyte (protein)

Ordered epidermal lipids

Covalently bound lipid layer on corneocyte surface

Fig. 2.1 Stratum corneum. The stratum corneum is visually modeled
as a brick wall with the bricks representing the corneocytes and the
mortar representing the intercellular lipids.

Skin lipid












Skin lipid







deep chemical peels wound the stratum corneum, epidermis, and

The depth of the peel is controlled by the strength of the acid applied
to the skin surface and the length of time for which the acid is left in
contact with the skin.
Chemical peels are a carefully controlled wounding of the skin and
are designed to improve cosmetic appearance.
Any part of the body can be subjected to a chemical peel, but the
face produces the most dramatic and reliable results. This is because
the facial skin is thin and it heals with minimal scarring. The face is
the only body site where a deep chemical peel is performed.
Superficial chemical peels produce little effect on any area other
than the face where they are used to produce a mild exfoliation improving skin texture. This improved skin texture is appreciated by the
patient as increased facial shine (sometimes referred to as radiance)
and smoother facial cosmetic application.
Medium-depth chemical peels may be performed on the entire
body, but are most frequently used on the neck, chest, and arms.
Typically, higher concentration acids are used on the face with a
reduced concentration applied to any other body area.
Chemical peels produce the best results in fair complected individuals (Fitzpatrick type I and II) with predominantly pigmentary
photodamage. Darker skin types (Fitzpatrick type III and higher) are
more challenging to treat with chemical peeling because the inflammation induced by the superficial or medium-depth peel may result in
unsightly post-procedure hyperpigmentation. Darker skin types also
more frequently exhibit hypertrophic scarring and keloid formation,
predisposing to an undesirable outcome.
Deep chemical peels are never performed on darker skinned individuals because the acid may damage the melanocytes, resulting in
permanent hypo- or depigmentation, unless hypopigmentation is part
of the aesthetic goal.
A chemical peel can be performed for a variety of indications:

Fig. 2.2 Intercellular lipids. The intercellular
lipids that surround the corneocytes provide
waterproof characteristics to the skin barrier.

The intercellular lipids


superficial chemical peels can be used to enhance exfoliation,
improve skin texture, and minimize comedonal acne;


superficial peels damage the skin barrier and may be used to
enhance the penetration of topical medications, such as hydroquinone skin lightening cream or tretinoin, and


a superficial chemical peel is the first step in performing a mediumdepth peel, allowing deeper penetration of the acid into the skin;


medium-depth peels are used to improve defects in skin pigmentation (such as lentigenes and melasma), and fine lines around the
eyes and upper cheeks;

The best indication for chemical peeling is to improve facial

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

A detailed history must be obtained prior to a chemical peeling
procedure to ensure an optimal outcome and result longevity.

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

Operative Approach


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

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

Table 2.1 Chemical peel technique comparisons.
Chemical peel properties
and suitability

Glycolic acid superficial peel

Salicylic acid superficial peel

Trichloroacetic acid mediumdepth peel

Sensitive skin patient

Stinging and burning due to
rapid dermal penetration

Primarily epidermal effect; best
tolerated by sensitive skin;
salicylate is anti-inflammatory

Surgical procedure with
prolonged pain

Exfoliation benefit

Minimal exfoliation at 10%,
mild exfoliation at 20–30%,
moderate exfoliation at 40–70%

Minimal exfoliation at 10%,
mild exfoliation at 20–30%

Aggressive exfoliation at 25–35%,
severe exfoliation at 50%

Rhytid reduction

No permanent rhytid reduction
beyond post procedure edema

No permanent rhytid reduction
beyond post procedure edema

Reduction of fine rhytids around
eyes, lateral cheeks


Mild pigment reduction

Minimal pigment reduction

Excellent improvement in
epidermal pigmentation

Darker skin color

Must be used with care


Not suitable

Acne treatment

Minimal improvement in open

Excellent improvement in open

Not appropriate

Recovery period

No recovery period

No recovery period

1 week

Procedural pain






Glycolic acid peels

Superficial peel


Glycolic acid peels in concentrations of 10% or less may be applied
by unsupervised aestheticians in a spa setting, but concentrations of
20% or higher should be applied by a physician or in a carefully
supervised setting.
Glycolic acid peels are formulated by diluting a 70% stock saturated solution of glycolic acid in concentrations of 20, 30, 40, 50, and
60% with water. The most commonly used glycolic acid peels are:

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

Glycolic acid peels are water soluble and only peel a skin surface
devoid of oil, whereas salicylic acid peels are lipophilic and peel
not only the skin surface but also in the oily milieu of the pore.

10–20% concentrations of salicylic acid peels are solutions,
whereas 30–50% peels are shake lotions and the salicylic acid must
be resuspended prior to application.
Salicylic acid is unique in that it does not penetrate into the dermis
making it an ideal superficial peel for patients with sensitive skin,
rosacea, or other inflammatory skin diseases.

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


The first step in peeling is to degrease the face and remove all skin
care products and cosmetics. If the skin is not clean, the superficial
peel will not penetrate and no skin improvement will be perceived.
I prefer to use a triclosan solution to clean the face with aggressive
gauze scrubbing, but any soap-based cleanser can be used.


Following cleansing, the skin should be thoroughly dried and the
patient placed on the exam table with a bedside fan blowing a
gentle breeze across the face.


Next, a rectal swab should be used to apply the 2 mL of superficial
peel solution poured into a small shot glass (Fig. 2.3A).


The solution should be applied in three coats to the entire face. I
begin with broad strokes across the forehead, moving down to both
cheeks, then to the chin, upper lip, and lastly across the nose (Fig.


It is important to avoid applying the solution to the corners of the
eye, nose, and mouth. Any junction between cornified skin and
mucosa should be avoided because these areas tend to peel more
deeply and a painful erosion may result.


At all times, an eye should be kept on the skin of the patient to
determine the degree of barrier damage. Superficial peels should
only wound the stratum corneum and uppermost epidermis. The
depth of the peel can be assessed by asking the patient about their
level of discomfort. I typically ask the patient to rate the stinging
and burning on a scale of 1–10 with 10 indicating extreme pain.
The application of the peel solution should cease when the patient
complains of discomfort at the 4–5 level, even if three coats have
not been applied.


It is also important to watch for reddening and whitening of the
face. Reddening of the face indicates early wounding and vasodilation whereas whitening (also known as frosting) indicates deeper
wounding and protein coagulation. The more confluent the whitening of the skin, the deeper the peel (Fig. 2.3C). Very minimal scattered whitening is all that should be achieved with a superficial
peel. The peel is immediately neutralized with cool water on disposable washcloths wiped across the face until the stinging and
burning has resolved. Neutralization is extremely important in
glycolic acid peels because the acid will continue to wound the
skin until removed. However, salicylic acid peels are self-neutralizing because the acid crystallizes on the skin surface. Thorough
water rinsing is soothing to the skin surface. I usually completely
rinse the skin three times and follow this by an application of a
bland occlusive moisturizer, such as Cetaphil cream (Galderma,
Ft Worth, TX). Further skin care considerations are discussed in
the Skin care section.

20 and 30% for gentle skin exfoliation;
70% for mild dyspigmentation.

The peels can be administered in a weekly series with gradual 10%
increases in strength from 20 to 70% to achieve a cumulative effect
and enhanced improvement in photoaging. Glycolic acid peels
are water soluble and therefore only peel a skin surface devoid
of oil.





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



Once whitening has occurred with the prepeel, 25–35% trichloroacetic acid is quickly applied evenly to the entire face with a lightly
moistened rectal swab. The strength of acid selected depends on
the depth of the desired peel, which is determined by the degree
and confluence of facial frosting (Fig. 2.4A).


At this point, the fan should be blowing briskly across the patient’s
face and ice cold water compresses applied as soon at the desired
amount of frosting has occurred (Fig. 2.4B).


After the burning has subsided, the face should be examined for
any skip areas that might need to be touched up.


It is not necessary to neutralize either the Jessner’s prepeel or the
trichloroacetic peel because they are both self-neutralizing.


A heavy layer of petroleum jelly is then applied over the entire
face, followed by petroleum impregnated gauze, Telfa, and netting,
if desired. The face should be rinsed with warm tap water at least
twice daily and covered with petroleum jelly until re-epithelialization is well underway by postprocedure day 4. At this time, cosmetics can be worn and the patient is socially acceptable.

Deep chemical peels
Deep chemical peels:


Optimizing outcomes

There is tremendous variability in the medium-depth prepeel. Some
clinicians prefer glycolic acid, whereas others use a carbon dioxide
slush peel or a mechanical microdermabrasion peel. My preference is to use a combination prepeel with both lipophilic and
hydrophilic substances to prepare the skin surface and the pores
for the medium-depth peel procedure. This prepeel solution is
known as Jessner’s peel and is a combination of lactic acid, resorcinol, salicylic acid, and ethanol. It is applied in one to three
coats to the skin surface with a rectal swab until early whitening
of the skin is achieved.


are not commonly performed because most patients who desire
the results of a deep peel prefer to undergo a laser resurfacing

are performed with phenol, which is cardiotoxic, requiring intraoperative monitoring, and produces permanent pigment lightening.


It is most important to remove all grease from the skin surface
when a superficial peel is preparation for a medium-depth peel. I
prefer to use acetone on a gauze vigorously rubbed across the face
following triclosan cleansing. This removes all traces of oil from
the skin surface ensuring even uptake of all the peel solutions in
both oily and dry facial areas.


Initiate nightly application of a retinoid 3 weeks prior to
chemical peel.


Remove all sebum and cosmetics from the face prior to
initiating the peel.


Apply the peel solution quickly and evenly to the entire face –
if areas of the face are skipped, reapplication is required,
which prolongs the procedure time and pain.


Do not drip the peel solution into the eyes or outside the
desired peel skin area.


Some patients may prefer to take a sedative prior to the
procedure, though reassuring conversation, careful fan
placement, and quick application of ice cold towels can
provide adequate pain relief for the short duration of
the procedure.

Complications and Side Effects

Medium-depth peel

Optimizing a medium-depth peel result

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

Chemical peeling is a relatively safe procedure, but a few complications
should be avoided. Proper patient selection to avoid using the procedure in dark complected patients and those with healing disorders is


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



key to avoiding complications of scarring, hyperpigmentation, and
hypopigmentation. In addition, patients who have a history of frequent
herpes simplex infections of the peeled body area should be treated
with preventive acyclovir, famciclovir, or valacyclovir on the day of the
procedure to prevent dissemination of the herpes simplex virus in the
wounded area.

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

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

Moisturizers (Fig. 2.6)4–7 are applied to the skin following cleansing in
the post-surgical patient to minimize transepidermal water loss, so
creating an environment that is optimal for skin healing.
The three categories of substances that can be combined to
enhance the water content of the skin are occlusives, humectants,
and hydrocolloids:

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

There are a variety of skin cleansers,1–3 including soaps, syndets, and
combars (Table 2.2), which can be placed on a variety of cleansing
implements from the hands to a washcloth to a disposable face

Synthetic detergents (syndets), particularly in the form of a foaming
face wash, are the best post-procedure cleansers. Combars are a
combination of soap and syndet and are useful post-surgically for
the patient who is at risk for cutaneous infection.

Fig. 2.5 Cleansers. A variety of cleansers are illustrated, from left to
right, a syndet bar soap, a foaming facial cleanser, and a lipid free

Table 2.2 Skin cleanser categories and properties.


Type of cleanser (commercial examples)




Excellent cleansing thorough sebum removal

Can dry skin; not recommended for
sensitive, healing or diseased skin

Syndet (synthetic detergent)

More mild cleansing; recommended post-surgery;
may be used for sensitive or diseased skin

Not as thorough sebum removal


Good cleansing; commonly combined with
triclosan topical antibacterial; good choice for
high-risk wound infections or contaminated body

Fig. 2.6 Moisturizers. A variety of moisturizers are illustrated, from
left to right, a lotion, a cream, and an ointment.


occlusives are oily substances such as petrolatum, lanolin, mineral
oil, vegetable oils, dimethicone, and cetyl alcohol that retard transepidermal water loss by placing an oil slick over the skin


humectants are substances such as propylene glycol, hyaluronic
acid, glycerin, sorbitol, gelatin, urea, sodium lactate, vitamins and
proteins, that attract water to the skin, not from the environment,
unless the ambient humidity is 70%, but from the inner layers of
the skin – humectants draw water from the viable dermis into the
viable epidermis and then from the nonviable epidermis into the
stratum corneum;


hydrocolloids are physically large substances, such as peptides and
colloidal oatmeal, that cover the skin, therefore retarding transepidermal water loss.

A quality moisturizer will combine ingredients from all three categories to provide multiple mechanisms of moisturizing the skin.
A commonly marketed moisturizer formulation combines petrolatum (the most effective moisturizing ingredient presently known) with
dimethicone to minimize greasiness and effectively retard 99% of the
transepidermal water loss. The addition of glycerin to hold water in
the skin with a peptide to create an artificial barrier complete the
formulation. Incorporating vitamins, such as vitamin C or vitamin E,
or botanicals (such as aloe, green tea, or soy) add distinction among
products in the marketplace.
The biggest challenge in the delivery of anti-aging substances to
the skin is the stratum corneum. An intact stratum corneum is key
to the skin barrier and a necessary part of post-procedure healing,
but impedes the penetration of many substances into the skin. This
extremely important function means that the stratum corneum prevents infection and the entry of toxic foreign substances and allergens
into the body. However, the barrier also prevents most large molecular
weight proteins and botanicals from entering the skin and functioning
as modulators of collagen production or topical antioxidants.
Probably one of the most effective moisturizer additives is sunscreen, which has the ability to both prevent and reverse photoaging.

Sunscreens8–19 are an important part of post-surgical skin care. Inflammation resulting from a face peel or other skin wounding procedure
can cause hyperpigmentation, especially in the presence of UVA
radiation, which stimulates melanin production by melanocytes.
Photoprotective mechanisms may be endogenous (Table 2.3) or
externally applied (Table 2.4).

Cutaneous structure

Sun protective mechanism

Compact horny layer

Absorbs and scatters UV

Keratinocyte melanin


Carotenoid pigments

1. Membrane stabilizers
2. Quench oxygen radicals

Urocanic acid

Oxidized to stabilize UV-induced
oxygen radicals

Superoxide dismutase

1. Oxygen radical scavenger
2. Protects cell membrane from
lipoprotein damage

Epidermal DNA
excision repair

Repairs UV-induced DNA damage

UV absorbing filter
Free radical scavenger
Dissipates UV as heat
Undergoes oxidation in 300–360 nm
range to produce immediate
pigment darkening

Postoperative Care

Table 2.3 Natural cutaneous UV protective mechanisms.

Sunscreen ingredients can be classified into two major categories.

Chemical ingredients undergo a chemical transformation, known
as resonance delocalization, to absorb UV radiation and transform
it to heat. This reaction occurs within the phenol ring, which
contains an electron-releasing group in the ortho and/or para position. This chemical reaction is irreversible, rendering the sunscreen
inactive once it has absorbed the UV radiation.


Physical sunscreens, in contrast, are usually ground particulates
that reflect or scatter UV radiation, absorbing relatively little of the
energy. For this reason they have longer activity on the skin

Sunscreen ingredients can be divided into the following three groups:

UVA (320–360 nm) absorbers, such as oxybenzone, avobenzone,
menthyl anthranilate;


UVB (290–320 nm) absorbers, such as PABA derivatives, salicylates, cinnamates;


UVB/UVA blocks that reflect or scatter UVA and UVB, such as
titanium dioxide, zinc oxide.

Most modern sunscreen formulations are a blend of two to three different substances carefully selected to compliment one another and
enhance product performance (Fig. 2.7). However, raising the SPF
above 30 only confers an incremental increase in photoprotection
(Fig. 2.8).

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



Table 2.4 Sunscreen ingredient comparison.



Maximum photoprotection




320 nm

Used to stabilize avobenzone

Thick, greasy oil


Broad UVA

Only broad-spectrum chemical

Poor photostability, no photoprotection
after 5 hours’ sun exposure


336 nm

Excellent photostability

Thick, greasy oil


305 nm

Excellent photostability, 4.5%

Small chance of allergenicity


300–310 nm

Minimal allergenicity

Used as a secondary sunscreen due to
weak photoprotection

Titanium dioxide

Broad-spectrum protection
due to UV reflection

Long-lasting photoprotection,
good UV reflection with larger
micronized particles

May whiten skin

Zinc oxide

Broad-spectrum protection
due to UV reflection

Long-lasting photoprotection
enhanced by silicone-coated

Not compatible with some other
sunscreens, such as avobenzone

Sunscreen formulations
UV filter

Conc. (%)

UV Attenuation (nm)

Peak absorbance

Total (III)

Wavelength (nm)












PBSA (2-phenylbenzimidazole5-sulfonic acid)



OSAL (octyl salicylate)



HSAL (homosalate)



OPABA (octyldimethyl PABA)



OMC (octyl methoxycinnamate)



OCTO (octocrylene)



OXY (oxybenzone)



MAN (metnthyl anthranilate)



TiO2 (titanium dioxide)



ZnO (zinc oxide)



AVO (avobenzone)



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


UVB Protection Correlated to SPF Level

% UVB Protection












SPF Level
SPF rating scale is not linear

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



SPF and photoprotection

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

absorption at 336 nm. Meradimate is commonly used as a secondary
UVA photoprotectant because it is a sticky oil and can decrease sunscreen aesthetics.

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

Physical UVA/UVB absorbers
The physical UVA/UVB absorbers are titanium dioxide and zinc

Titanium dioxide is usually micronized to contain particles of many
sizes to provide optimal UV scattering abilities. It leaves a white
film on the skin and is used mainly for beachwear products.


Zinc oxide is usually available in a microfine form (i.e. it contains
small particles of one size), making it appropriate for day wear in
persons of all skin colors. Zinc oxide-based sunscreens provide the
most complete post-procedure photoprotection, especially after
completion of a chemical peel.

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2. Wortzman MS. Evaluation of mild skin cleansers. Dermatol Clin 1991;
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rinsability. J Soc Cosmet Chem 1986; 37:89–97.
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5. Flynn TC, Petros J, Clark RE, et al. Dry skin and moisturizers. Clin
Dermatol 2001; 19:387–392.
6. Rawlings AV, Harding CR, Watkinson A, et al. Dry and xerotic skin
conditions. In: Leyden JJ, Rawlings AV, eds. Skin moisturization,
New York: Marcel Dekker; 2002:119–144.
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dermatology. 2nd edn. New York: Churchill-Livingstone; 1995:83–95.
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Toxicology 2003; 189:21–39.
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cancer and photoaging. Semin Dermatol 1990; 9:25–31.
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Dermatol 1996; 135:867–875.
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on the skin. Toxicol Appl Pharmacol 2004; 195:298–308.
12. Wulf HC, Sandby-Møller J, Kobayasi T, et al. Skin aging and natural
photoprotection. Micron 2004; 35:185–191.
13. Kawada A, Noda T, Hiruma M, et al. The relationship of sun
protection factor to minimal erythema dose, Japanese skin type, and
skin color. J Dermatol 1993; 20:514–516.
14. Roelandts R, Sohrabvand N, Garmyn M. Evaluating the UVA protection
of sunscreens. J Am Acad Dermatol 1989; 21:56–62.
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Int J Cosmet Sci 1994; 16:47–52.
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products. Dermatol Clin 2006; 24:35–51.
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efficacy. Photochem Photobiol 1998; 68:243–256.
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appropriate use. Am J Clin Dermatol 2002; 3:185–191.
19. Tanner PR. Sunscreen product formulation. Dermatol Clin 2006;




Non-surgical Facial Rejuventation with Fillers
Brian M Kinney, David J Rowe and David Stepnick

1. Facial aging is multi-factorial, and often due to a combination
of ptosis, loss of skin tone, elasticity, perfusion, hydration,
muscle function, and subcutaneous tissue volume.
2. Soft-tissue fillers are rapidly increasing in use and
sophistication, but do not address all lost tissues.

the physiochemical properties of the filler types, but also must understand the differences in injection levels and techniques for each of the
fillers. A thorough aesthetic evaluation of the patient as well as a
complete discussion of the patient’s aesthetic goals and treatment
preferences must be performed in order to achieve a treatment plan
that is safe and realistic.

3. Very few patients’ conditions are correctable by injection
alone; a thorough understanding of combination therapy,
including surgery, is essential.


4. Natural fillers are safer and generally preferred to synthetic,
but do not last permanently.

Some of the features that a youthful face exhibits include smooth
contours, few wrinkles, except in dynamic expression, and full subcutaneous tissues with minimal or no soft-tissue atrophy (Fig. 3.1).
Nasolabial, glabellar and crow’s feet skin folds are almost uniformly
absent at rest, and minimally noticeable, even with muscular contraction. During aging of the normal, healthy adult, there is loss of softtissue fullness in the face, often beginning in the nasolabial folds and
progressing inferiorly along the marionette lines. Lines in the upper
face may show years earlier during dynamic expression than at rest.
Lipoatrophy can distress the aging patient with resultant low selfimage and self-esteem, depression and social isolation.1,2 With the
severe rise in obesity in recent years, loss of facial fat due to aging may
be partially offset due to fatty accumulation after weight gain.
In the normal aging face there is gravitational pull on sagging skin,
flattening of the youthful contours, accompanied by solar degeneration, variation in pigmentation, an increase in rhytids, capillary breakdown, loss of muscle tonicity and progressive thinning of the skin and
subcutaneous tissues (Figs 3.2 and 3.3). One of the hallmarks of aging
skin – and one for which we have essentially no topical or minimally
invasive corrective solution – is poor elasticity, breakdown of elastic
fibers and excess skin envelope. In essence, with an imbalance of soft
tissue volume to skin envelope, there are three basic approaches:
1) fill up the lost tissue volume, 2) chemically peel, laser, or mechanical dermabrade or excise the excess skin, or 3) live with the difference.
Because few patients have one isolated contributing factor, the ideal
approach would often include volume restoration and treating the skin.
However, many patients do not desire more aggressive treatment.
Chemical peels and lasers chemically denude the superficial layers of
the skin, but do not reduce the surface area of the skin sufficiently to
balance the loss of soft tissue volume in any but the mildest conditions
in the youngest patients. While they tighten the skin, in essence by
cross-linking collagen and other proteins, they do not restore the elasticity of youth.

5. Permanent fillers are synthetic, have more serious
complications and require extremely careful injection
6. As more fillers become available, more understanding is
required by the surgeon and more confusion is likely by the
7. While minimally invasive in nature, injections must be guided
by an accurate understanding of the surgical anatomy.
8. Complications are rare, but excellent results are more elusive
than generally appreciated.
9. The nasolabial folds and the marionette lines are generally
easier to manage than other regions.
10. Injections in the hands and on the trunk are less common,
well-studied and efficacious than in the face.

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

While less common, certain disease conditions cause premature loss
of soft-tissue volume; some are genetic and some acquired. Congenital
generalized lipodystrophy (autosomally recessive) results in lack of



Forehead Lines

Skin lines, wrinkles and folds

Facial Scars


Frown Lines

(outer layer of skin)



(inner layer of skin)

Crow’s Feet
(beneath the skin)

Vermilion Border
Smile Lines

Vertical Lip

Fig. 3.3 Architecture of rhytids.

Marionette Lines

Fig. 3.1 Location of rhytids in the aging face.

Acquired lipodystrophies arise from multiple mechanisms, but
more commonly small localized areas of fat loss may occur from drug
injections, local trauma or crush injuries, immune-mediated mechanisms, cancer or HIV, the most prevalent form. Highly active antiretroviral therapy (HAART) is associated with the condition, but its
actual mechanism is unknown. There appears to be some interaction
with protease inhibitors and nucleoside reverse transcriptase inhibitors. The HIV patient shows rapid loss of peripheral fat and fat in the
face, occurring within 1 year of treatment.3 Fat paradoxically accumulates in the abdomen, breast and dorsocervical spine. In the face, the
buccal and temporal fat pads are most locally affected; however, there
is loss of fat diffusely in the face. Fat loss may be rapid and progressive
and is often permanent, refractory to steroid administration and dietary
intervention. The prevalence has been reported as variable (18–83%)
due to differing definitions.4 Lipoatrophy in HIV patients can lead to
compliance issues, reducing the effect of HAART and accelerating
disease progression, fear of stigmatization and recognition.5,6


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


Nasolabial fold prominence


Marionette lines and secondary smile lines


Perioral lines


Paramental soft tissue atrophy


Tear trough atrophy


Temporal and buccal fat loss


Generalized cheek atrophy


Crow’s feet


Glabellar lines

adipose tissue from birth. Familial partial lipodystrophy (autosomally
dominant) causes progressive peripheral fat loss beginning at puberty
and, typically, the facial fatty tissue will stay the same, or rarely gain
fat, while the body atrophies. Mandibulosacral dysplasia (autosomally
recessive) shows two forms: type A demonstrates peripheral fat loss
with normal or excess facial fat, while type B shows generali