Advances in Cosmetic Surgery (Volume 2) – 2019 [2019 Edition] 9780323655453

Advances in Cosmetic Surgery includes the latest advances and breakthroughs in the field of cosmetic surgery from a mult

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Advances in Cosmetic Surgery (Volume 2) – 2019 [2019 Edition]

Table of contents :
Hairline-lowering surgery......Page 1
Title Page......Page 2
Copyright......Page 3
Editors......Page 4
Contributors......Page 5
Contents......Page 7
Introduction......Page 11
Preface......Page 13
Introduction......Page 14
Age-related diseases......Page 15
Assessment of female androgen deficiency......Page 16
Hormone replacement therapy and breast cancer concerns......Page 17
Men and andropause......Page 18
Safe administration: prostate cancer risk and other testosterone replacement therapy considerations......Page 19
Curcumin......Page 20
B vitamins......Page 21
References......Page 22
Facial beauty and attractiveness......Page 24
Physical examination: facial shape and form......Page 25
Facial Structural Platform......Page 26
Facial Soft Tissue Platform......Page 29
Midface zone......Page 30
Summary......Page 32
References......Page 33
Nature of the problem......Page 35
Bundled purchases......Page 37
References......Page 39
Background......Page 40
Surgical site infections in plastic surgery......Page 41
Evidence-based recommendations for the prevention of surgical site infections in plastic surgery......Page 42
Abdominoplasty......Page 43
Blepharoplasty......Page 44
Skin resurfacing......Page 45
Risk factors......Page 46
References......Page 47
Introduction......Page 52
Opioid prescribing for surgical care......Page 53
Alternative analgesic treatments: acetaminophen......Page 54
Summary......Page 55
References......Page 56
Mechanism of action......Page 58
Contraindications and treatment considerations......Page 59
Microneedling and rejuvenation......Page 60
Microneedling and scars......Page 62
References......Page 63
Combining soft tissue fillers with neuromodulators......Page 65
Soft tissue filler combinations......Page 66
Combinations with energy-based devices......Page 68
Nonablative lasers......Page 69
Ablative lasers......Page 70
Microfocused ultrasound......Page 72
Soft tissue filler and synthetic deoxycholic acid......Page 73
References......Page 74
Autologous fat injection......Page 78
Surgical technique for fat grafting......Page 79
Common side effects......Page 80
Filler......Page 81
Anesthesia and pain management......Page 82
References......Page 83
Anatomy of the submental area......Page 84
Deoxycholic acid patient evaluation......Page 85
Preprocedure......Page 87
Complications......Page 88
Preprocedure......Page 89
Submental liposuction patient evaluation......Page 91
Summary......Page 93
References......Page 94
Introduction......Page 97
Miniincision superficial musculoaponeurotic system/platysma plication......Page 98
Plasma skin tightening......Page 99
Renuvion: 360° tissue treatment......Page 100
Renuvion: minimal depth of thermal effect......Page 101
References......Page 103
Introduction: Nature of the problem......Page 104
Preoperative planning......Page 106
Preparation and patient positioning......Page 107
Injecting fillers......Page 108
Injecting neurotoxin......Page 109
Potential complications, risks, benefits, and limits......Page 110
References......Page 111
Chemical peels......Page 114
Immediate postprocedural care......Page 115
Preoperative planning......Page 116
Neuromodulators......Page 118
Prep and patient positioning......Page 119
Summary......Page 120
Immediate post-procedural care......Page 122
References......Page 123
Introduction: the nature of the problem......Page 127
Anatomy......Page 128
Risk Factors......Page 129
Transcutaneous or Transconjunctival?......Page 130
Preoperative Planning......Page 132
Preoperative Considerations for Planning Surgical Technique......Page 133
Prep and Patient Positioning......Page 135
Procedural Approach......Page 136
Discussion......Page 139
References......Page 140
Key points......Page 141
References......Page 148
Introduction......Page 149
Procedural approach......Page 150
Clinical results in the literature......Page 151
Complications, risks, and management......Page 152
Limitations......Page 153
Summary......Page 154
References......Page 155
Introduction......Page 156
Preoperative planning......Page 157
Preparation and Patient Positioning......Page 162
Clinical results in the literature......Page 163
References......Page 164
Understanding androgenic hair loss......Page 165
Minoxidil......Page 167
Low-level laser light......Page 168
Platelet-rich plasma......Page 169
Introduction......Page 170
Surgical procedures other than hair transplants......Page 171
Hair transplantation......Page 172
Preparation and patient positioning......Page 173
Procedural approach......Page 175
Post procedure care......Page 177
References......Page 179
Radiofrequency......Page 181
Preparation and patient positioning......Page 185
Microfocused ultrasound......Page 187
Summary......Page 189
References......Page 190
Aging process of the hands......Page 192
Hyaluronic Acid......Page 193
Potential Complications, Risks, and Limitations......Page 194
Ablative Resurfacing Lasers......Page 195
References......Page 196
Introduction......Page 198
The rise of nonsurgical options for vaginal rejuvenation......Page 199
Radiofrequency devices......Page 200
Lasers in vaginal rejuvenation......Page 201
Food and drug administration warning......Page 202
References......Page 203

Citation preview


COSMETIC SURGERY Gregory H. Branham, MD Jeffrey S. Dover, MD, FRCPC Heather J. Furnas, MD, FACS Marissa M.J. Tenenbaum, MD Allan E. Wulc, MD, FACS

Director, Continuity Publishing: Taylor Ball Editor: Jessica McCool Developmental Editor: Donald Mumford Ó 2019 Elsevier Inc. All rights reserved. This periodical and the individual contributions contained in it are protected under copyright by Elsevier and the following terms and conditions apply to their use: Photocopying Single photocopies of single articles may be made for personal use as allowed by national copyright laws. Permission of the Publisher and payment of a fee is required for all other photocopying, including multiple or systematic copying, copying for advertising or promotional purposes, resale, and all forms of document delivery. Special rates are available for educational institutions that wish to make photocopies for non-profit educational classroom use. For information on how to seek permission visit or call: (+44) 1865 843830 (UK)/(+1) 215 239 3867 (USA). Derivative Works Subscribers may reproduce tables of contents or prepare lists of articles including abstracts for internal circulation within their institutions. Permission of the Publisher is required for resale or distribution outside the institution. Permission of the Publisher is required for all other derivative works, including compilations and translations (please consult Electronic Storage or Usage Permission of the Publisher is required to store or use electronically any material contained in this periodical, including any article or part of an article (please consult Except as outlined above, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission of the Publisher. Notice No responsibility is assumed by the Publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer. Reprints: For copies of 100 or more of articles in this publication, please contact the Commercial Reprints Department, Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. Tel: 212-633-3874; Fax: 212-633-3820; E-mail: [email protected]. Printed in the United States of America. Editorial Office: Elsevier, Inc. 1600 John F. Kennedy Blvd, Suite 1800 Philadelphia, PA 19103-2899 International Standard Serial Number: 2542-4793 International Standard Book Number: 13: 978-0-323-65544-6


EDITORS GREGORY H. BRANHAM, MD Chief Medical Officer, Barnes-Jewish West County Hospital, Creve Coeur, Missouri; Professor and Chief, Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-HNS, Washington University School of Medicine, St Louis, Missouri JEFFREY S. DOVER, MD, FRCPC Director, SkinCare Physicians, Chestnut Hill, Massachusetts; Associate Clinical Professor of Dermatology, Yale University School of Medicine, New Haven, Connecticut; Adjunct Associate Professor of Dermatology, Brown Medical School, Providence, Rhode Island

HEATHER J. FURNAS, MD, FACS Adjunct Assistant Professor, Division of Plastic and Reconstructive Surgery, Stanford Medical School, Stanford, California MARISSA M.J. TENENBAUM, MD Associate Professor and Program Director, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri ALLAN E. WULC, MD, FACS Associate Clinical Professor, Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania; Adjunct Associate Professor, Department of Otolaryngology, Temple University, Philadelphia, Pennsylvania



CONTRIBUTORS RACHEL C. BAKER, BS Research Assistant, Section of Plastic Surgery, University of Michigan, North Campus Research Complex (NCRC), Ann Arbor, Michigan, USA DANIEL J. CALLAGHAN, MD Mohs Micrographic Surgery Fellow, SkinCare Physicians, Chestnut Hill, Massachusetts, USA FRANCISCO L. CANALES, MD Private Practice, Santa Rosa, California, USA YUNYOUNG CLAIRE CHANG, MD Physician, Union Square Laser Dermatology, New York, New York, USA ANNE CHAPAS, MD Physician, Union Square Laser Dermatology, New York, New York, USA JUSTIN COHEN, MD, FACS Glasgold Group Plastic Surgery, Princeton, New Jersey, USA STEVEN M. COUCH, MD, FACS Associate Professor of Orbital and Oculofacial Plastic Surgery, Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St Louis, Missouri, USA JEFFREY S. DOVER, MD, FRCPC Director, SkinCare Physicians, Chestnut Hill, Massachusetts; Associate Clinical Professor of Dermatology, Yale University School of Medicine, New Haven, Connecticut; Adjunct Associate Professor of Dermatology, Brown Medical School, Providence, Rhode Island, USA GORANA KUKA EPSTEIN, MD Foundation for Hair Restoration, Miami, Florida, USA JEFFREY EPSTEIN, MD, FACS Foundation for Hair Restoration, Miami, Florida, USA; Assistant Clinical Professor, Department of Otolaryngology, University of Miami, Coral Gables, Florida, USA

JILL A. FOSTER, MD, FACS Plastic Surgery Ohio/Ophthalmic Surgeons and Consultants of Ohio, Inc, Department of Ophthalmology, The Ohio State University, Columbus, Ohio, USA HEATHER J. FURNAS, MD, FACS Adjunct Assistant Professor, Division of Plastic and Reconstructive Surgery, Stanford Medical School, Stanford, California, USA ADELE HAIMOVIC, MD The Ronald O. Perelman Department of Dermatology, New York University Langone Health, New York City, New York, USA ANDREW HARRISON, MD Department of Ophthalmology and Visual Neurosciences, University of Minnesota Medical School, Minneapolis, Minnesota, USA MORRIS E. HARTSTEIN, MD, FACS Director, Ophthalmic Plastic Surgery, Assaf Harofeh Medical Center, Tel Aviv University-Sackler School of Medicine, Tel Aviv-Yafo, Israel LARRY KEVIN HEARD, MD Resident Physician, Department of Dermatology, University of South Florida, Tampa, Florida, USA SARA HOGAN, MD, MPH Cosmetic and Laser Dermatologic Surgery Fellow, SkinCare Physicians, Chestnut Hill, Massachusetts, USA OMER IBRAHIM, MD Chicago Cosmetic Surgery and Dermatology, Chicago, Illinois, USA PRASANTHI KANDULA, MD Cosmetic and Laser Dermatologic Surgery Fellow, SkinCare Physicians, Chestnut Hill, Massachusetts, USA




RYAN C. KELM, BS Univsersity of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA SHILPI KHETARPAL, MD Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA JENNIFER MACGREGOR, MD Physician, Union Square Laser Dermatology, New York, New York, USA KAVITA MARIWALLA, MD Founder, Mariwalla Dermatology, West Islip, New York, USA GUY MASSRY, MD Beverly Hills Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills, California, USA; Orbital Center, Cedars-Sinai Medical Center, Department of Ophthalmology, Division of Oculoplastic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA AMY PATEL, MD Beverly Hills Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills, California, USA, USA; Orbital Center, Cedars-Sinai Medical Center, Los Angeles, California, USA FORUM PATEL, MD Physician, Union Square Laser Dermatology, New York, New York, USA ALI A. QURESHI, MD Aesthetic Surgery Fellow, Marina Plastic Surgery, Marina del Rey, California, USA SHAWN ROMAN, BS Bovie Vice President of Research & Development, Safety Harbor, Florida, USA PETER M. SCHMID, DO, FAOCOOHNS, FAACS Private Practice, Longmont, Colorado, USA LORELEY D. SMITH, MD Resident Physician, Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St Louis, Missouri, USA JONATHAN SOH, MD University of Rochester Medical Center, Rochester, New York, USA

EMILY A. SPATARO, MD Assistant Professor, Washington University in St. Louis, St Louis, Missouri, USA; Division of Facial Plastic and Reconstructive Surgery, Washington University School of Medicine, Creve Coeur, Missouri, USA DANIEL G. STRAKA, MD Plastic Surgery Ohio/Ophthalmic Surgeons and Consultants of Ohio, Department of Ophthalmology, The Ohio State University, Columbus, Ohio, USA MARISSA M.J. TENENBAUM, MD Associate Professor and Program Director, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri, USA SAMANTHA A. THIRY, MSN, FNP-C Dr. Jennifer Walden, PLLC, Austin, Texas MARA WEINSTEIN VELEZ, MD University of Rochester Medical Center, New York, USA JENNIFER L. WALDEN, MD, FACS Clinical Assistant Professor, Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Private Practice, Austin, Texas, USA JENNIFER F. WALJEE, MD, MPH, MS Associate Professor, Section of Plastic Surgery, University of Michigan, North Campus Research Complex (NCRC), Ann Arbor, Michigan, USA YAO WANG, MD Department of Ophthalmology and Visual Neurosciences, University of Minnesota Medical School, Minneapolis, Minnesota, USA SUSAN WEINKLE, MD Assistant Clinical Professor, Department of Dermatology, University of South Florida, Tampa, Florida, USA CHRISTINA WONG, MD Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA JACK ZAMORA, MD Medical Advisory Board of Bovie, Medical Advisory Board of Vitro Biopharma, Limitless MD Founder, Jack Zamora M.D. Cosmetic Surgery & Aesthetics, Denver, Colorado, USA


VOLUME 2  2019

CONTENTS Editorial Board, iii

Surgical Site Infections in Cosmetic Surgery, 29

Contributors, v

By Emily A. Spataro

Introduction, xi By Gregory H. Branham, Jeffrey S. Dover, Heather J. Furnas, Marissa M.J. Tenenbaum, and Allan E. Wulc

Preface, xiii By Gregory Harris Branham

The Latest in Cosmetic Medicine: Supplements, Hormones, and Evidence, 1 By Samantha A. Thiry and Jennifer L. Walden Introduction, 1 Age-related diseases, 2 Hormonal changes in men and women associated with age, symptoms, and treatment options, 3 Summary, 9

Sculptural Aesthetic Surface Anatomy of the Face, 11 By Peter M. Schmid Introduction: the sculptor and surgeon, 11 Facial beauty and attractiveness, 11 Physical examination: facial shape and form, 12 Canons, Proportions, and Shape, 13 Facial Structural Platform, 13 Facial Soft Tissue Platform, 16 Summary, 19

Tricks for Patient Retention for Maintenance Care, 23 By Kavita Mariwalla Nature of the problem, 23 Discount programs, 25 Bundled purchases, 25 Summary, 27

Introduction, 29 Background, 29 Summary of current guidelines, 30 Surgical site infections in plastic surgery, 30 Evidence-based recommendations for the prevention of surgical site infections in plastic surgery, 31 Procedure-specific surgical site infection prevention, 32 Breast surgery, 32 Abdominoplasty, 32 Liposuction, 33 Rhytidectomy, 33 Blepharoplasty, 33 Rhinoplasty, 34 Facial alloplastic implantation, 34 Skin resurfacing, 34 Other dermatologic procedures, 35 Risk factors, 35 Summary, 36

Pain Control in the Age of an Opioid Epidemic, 41 By Rachel C. Baker and Jennifer F. Waljee Introduction, 41 Pain control: opioids, 42 Opioid prescribing for surgical care, 42 Alternative analgesic treatments, 43 Alternative analgesic treatments: nonsteroidal anti-inflammatory drugs, 43 Alternative analgesic treatments: acetaminophen, 43 Alternative analgesic treatments: behavioral techniques, 44 Summary, 44




Microneedling, 47 By Shilpi Khetarpal, Jonathan Soh, Mara Weinstein Velez, and Adele Haimovic Video content accompanies this article at http://www.advancesincosmeticsurgery. com. Background, 47 Mechanism of action, 47 Microneedling instruments, 48 Procedure, 48 Contraindications and treatment considerations, 48 Adverse events, 49 Microneedling and rejuvenation, 49 Microneedling and scars, 51

New Synergistic Tricks: Fillers D Neuromodulators D Technology 5 More than the Sum, 55 By Ryan C. Kelm and Omer Ibrahim Introduction, 55 Combining soft tissue fillers with neuromodulators, 55 Soft tissue filler combinations, 56 Combinations with energy-based devices, 58 Intense pulsed light, 59 Lasers, 59 Nonablative lasers, 59 Ablative lasers, 60 Microfocused ultrasound, 62 Radiofrequency, 63 Radiofrequency with microneedling, 63 Soft tissue filler and synthetic deoxycholic acid, 63 Summary, 64

Facial Rejuvenation: Fat Transfer Versus Fillers, 69 By Ali A. Qureshi and Marissa M.J. Tenenbaum The aging face, 69 Autologous fat injection, 69 Surgical technique for fat grafting, 70 Injection, 71 Common side effects, 71 Filler, 72 Anesthesia and pain management, 73 Common side effects, 74

Management of vasoocclusion, 74 Authors’ thoughts on fat versus filler, 74

Submental Fat Contouring: A Comparison of Deoxycholic Acid, Cryolipolysis, and Liposuction, 75 By Sara Hogan, Prasanthi Kandula, Daniel J. Callaghan, and Jeffrey S. Dover Introduction, 75 Anatomy of the submental area, 75 Evaluation of the patient with submental fullness, 76 Deoxycholic acid, 76 Deoxycholic acid patient evaluation, 76 Preprocedure, 78 Procedure, 79 Postprocedure, 79 Adverse effects, 79 Complications, 79 Clinical results, 80 Cryolipolysis, 80 Cryolipolysis patient evaluation, 80 Preprocedure, 80 Procedure, 82 Postprocedure, 82 Clinical results, 82 Adverse effects, 82 Submental liposuction, 82 Submental liposuction patient evaluation, 82 Preprocedure, 84 Procedure, 84 Postprocedural care, 84 Adverse effects, 84 Summary, 84

Subcutaneous Neck Skin Plasma Tightening, 89 By Jack Zamora and Shawn Roman Video content accompanies this article at Introduction, 89 Surgical technique, 90 Preoperative planning, 90 Procedural approach, 90 Miniincision superficial musculoaponeurotic system/platysma plication, 90 Plasma skin tightening, 91


Treatments for the Aging Lip, 97 By Larry Kevin Heard and Susan Weinkle Video content accompanies this article at Introduction: Nature of the problem, 97 Surgical technique, 99 Preoperative planning, 99 Preparation and patient positioning, 100 Procedural approach, 101 Injecting fillers, 101 Injecting neurotoxin, 102 Immediate postprocedural care and rehabilitation, 103 Clinical results in the literature, 103 Potential complications, risks, benefits, and limits, 103 Summary, 104

Nonsurgical Periorbital Rejuvenation, 107 By Loreley D. Smith and Steven M. Couch Video content accompanies this article at http://www.advancesincosmeticsurgery. com. Introduction, 107 Periorbital skin resurfacing, 107 Chemical peels, 107 LASER therapy, 109 Neuromodulators, 111 Surgical technique, 112 Dermal fillers, 115 Introduction, 115 Surgical technique, 115

Update on the Treatment of Postblepharoplasty Lower Eyelid Retraction, 121 By Daniel G. Straka and Jill A. Foster Introduction: the nature of the problem, 121 Anatomy, 122 Risk Factors, 123 Transcutaneous or Transconjunctival?, 124 Surgical technique, 126 Preoperative Planning, 126 Preoperative Considerations for Planning Surgical Technique, 127 Prep and Patient Positioning, 129 Procedural Approach, 130


Immediate Postprocedural Care and Recovery, 133 Potential complications, 133 Management, 133 Discussion, 133

Update on the Treatment of the Skeletonized Upper Eyelid, 135 By Morris E. Hartstein Video content accompanies this article at http://www.advancesincosmeticsurgery. com.

Defining the Brow Fat Pad: The Brow Fat Pad Suspension Suture, 143 By Yao Wang, Andrew Harrison, Amy Patel, and Guy Massry Video content accompanies this article at http://www.advancesincosmeticsurgery. com. Introduction, 143 Surgical technique, 144 Preoperative planning, 144 Preparation and patient positioning, 144 Procedural approach, 144 Immediate postoperative care, 145 Rehabilitation and recovery, 145 Clinical results in the literature, 145 Potential complications, risks, benefits, and limitations, 146 Complications, risks, and management, 146 Benefits, 147 Limitations, 147 Summary, 148

Platelet-rich Plasma for Hair Growth, 151 By Christina Wong and Shilpi Khetarpal Video content accompanies this article at http://www.advancesincosmeticsurgery. com. Introduction, 151 Procedural technique, 152 Preoperative planning, 152 Preparation and Patient Positioning, 157 Procedural Approach, 158 Immediate Postprocedural Care, 158 Rehabilitation and Recovery, 158 Clinical results in the literature, 158


CONTENTS Potential complications/risks/benefits/ limits, 159 Summary, 159

Hair Loss in Men and Women: Medical and Surgical Therapies, 161 By Gorana Kuka Epstein, Jeffrey Epstein, and Justin Cohen Video content accompanies this article at http://www.advancesincosmeticsurgery. com. Introduction, 161 Understanding androgenic hair loss, 161 Medical therapies, 163 Addressing underlying conditions contributing to androgenic alopecia, 163 Minoxidil, 163 Finasteride, 164 Low-level laser light, 164 Platelet-rich plasma, 165 Microneedling, 166 Mesenchymal regenerative cells, stromal vascular fraction, and adipose tissue injections, 166 Surgical therapies, 166 Introduction, 166 History of surgeries used to treat androgenic alopecia, 167 Surgical procedures other than hair transplants, 167 Hair transplantation, 168 Surgical technique, 169 Preoperative planning, 169 Preparation and patient positioning, 169 Procedural approach, 171 Post procedure care, 173 Future therapies, 175

Subcutaneous Body Skin Tightening, 177 By Forum Patel, Jennifer MacGregor, Yunyoung Claire Chang, and Anne Chapas Introduction, 177 Radiofrequency, 177 Micorfocused Ultrasound, 181 Surgical technique, 181 Preoperative planning, 181 Preparation and patient positioning, 181 Procedural approach, 183

Immediate postprocedural care, 185 Rehabilitation and recovery, 185 Potential complications/risks/benefits/ limits, 185 Management, 185 Summary, 185

Hand Rejuvenation, 189 By Prasanthi Kandula, Sara Hogan, Daniel J. Callaghan, and Jeffrey S. Dover Introduction, 189 Aging process of the hands, 189 Treatment, 190 Topical Agents, 190 Chemical Peels, 190 Soft-tissue augmentation, 190 Hyaluronic Acid, 190 Calcium Hydroxyapatite, 191 Poly-L-Lactic Acid, 191 Autologous Fat Transfer, 191 Potential Complications, Risks, and Limitations, 191 Vein treatments, 192 Sclerotherapy, 192 Laser/light sources and energy-based devices, 192 Intense Pulsed Light, 192 Nonablative Resurfacing Lasers, 192 Ablative Resurfacing Lasers, 192 Q-Switched Devices, 193 Photodynamic Therapy, 193 Pulsed Dye and Pulsed Green Potassium Titanyl Phosphate Lasers, 193 Summary, 193

Nonsurgical Vaginal Treatments, 195 By Francisco L. Canales and Heather J. Furnas Introduction, 195 Vaginal health issues, 196 Effect on women’s lives, 196 The rise of nonsurgical options for vaginal rejuvenation, 196 Vaginal laxity, 197 Radiofrequency devices, 197 Lasers in vaginal rejuvenation, 198 Stress urinary incontinence, 199 Food and drug administration warning, 199

Advances in Cosmetic Surgery 2 (2019) xi–xii



Gregory H. Branham, MD

Jeffrey S. Dover, MD, FRCPC


Heather J. Furnas, MD, Marissa M.J. FACS Tenenbaum, MD Editors

he desire for cosmetic surgery has infiltrated corners of society never seen before and is only expected to grow in the years ahead. As the number of cosmetic surgery procedures continues to rise throughout the world, so too does the number of specialists performing these important procedures. When working with a patient to create their ideal image, it’s critical to have the most current resources available to guide your practice and inform your decisions. Advances in Cosmetic Surgery, now in its second volume, aims to highlight the year’s latest advancements and breakthroughs in the field of cosmetic surgery. Experts from the four core specialties have come together to bring you, the reader, the most important advances in this rapidly evolving field. Subcutaneous body skin tightening, platelet-rich plasma for hair growth, microneedling, subcutaneous neck plasma skin tightening, facial rejuvenation, and treatments for the aging lip are just a handful of topics covered in this issue. High-quality images and videos accompany many of the articles, helping to further deepen the reader’s understanding of these techniques and procedures. Whether you are planning to perform the procedures discussed here or learning about them for the first time, we think 2542-4327/19/ © 2019 Published by Elsevier Inc.

Allan E. Wulc, MD, FACS

you will find value in what this exciting series has to offer. The editors would like to thank the authors for their insightful contributions, and all the pioneers in this field working to bring us better tools, techniques, and ways of making the seemingly impossible possible for our patients. We hope you will enjoy reading this issue as much as we enjoyed putting it together. It is our sincere hope that the articles presented here will help further break down barriers between specialties and shed new light on current cosmetic treatments. Gregory H. Branham, MD Facial Plastic and Reconstructive Surgery Department of Otolaryngology-Head and Neck Surgery Washington University School of Medicine St Louis, MO, USA Jeffrey S. Dover, MD, FRCPC SkinCare Physicians Chestnut Hill, MA, USA Yale University School of Medicine New Haven, CT, USA Brown Medical School Providence, RI, USA



Introduction Heather J. Furnas, MD, FACS Division of Plastic and Reconstructive Surgery Stanford Medical School Stanford, CA, USA

Allan E. Wulc, MD, FACS Department of Ophthalmology University of Pennsylvania Philadelphia, PA, USA

Marissa M.J. Tenenbaum, MD Plastic and Reconstructive Surgery Washington University School of Medicine St Louis, MO, USA

Department of Otolaryngology Temple University Philadelphia, PA, USA E-mail address: [email protected]

Advances in Cosmetic Surgery 2 (2019) xiii



Gregory H. Branham, MD, Editor


elcome to the second volume of Advances in Cosmetic Surgery. Our diverse editorial staff has once again solicited contributions that will be of interest to all those providing cosmetic surgery and procedures to patients. Whether you are engaged in a surgically oriented practice or an officebased or minimally invasive practice, there is something for everyone in this volume. Our learning is enhanced immeasurably when we share and compare our techniques and results. To that end, you will see several approaches to the same problem or issue that you may encounter in your practice. In keeping with our commitment to be at the forefront of esthetic practice, we have curated an exceptional group of topics that will allow the reader to develop a grasp of what is new and permit the reader to make sense of what is effective and what is not. Topics in this volume range from cosmetic medicines and pain control in the age of the opioid epidemic to surgical and nonsurgical treatments for correction of the overoperated patient. There are so many new products and procedures being developed, and we are in a time of accelerated development of technology and devices. As you read these articles, please consider how they can be used to inform 2542-4327/19/ © 2019 Published by Elsevier Inc.

you of what might be useful in your practice and also what should require caution or at least careful consideration prior to adoption. Many thanks to all of the contributors who have taken the time to share their expertise with us and allowed us to share that with you. We hope that you will find this volume as engaging and stimulating as our first volume. We seem to have an endless flow of ideas but would welcome any suggestions for future topics that you would like to see included in future volumes. The editors would also like to thank Jessica McCool and all the editorial staff at Elsevier who have made this volume possible. Their commitment to excellence in this endeavor is evident in the quality of the publication, and we trust that will be apparent to you as well. Gregory H. Branham, MD Facial Plastic and Reconstructive Surgery Otolaryngology–Head and Neck Surgery Washington University 1020 North Mason Road St Louis, MO 63141, USA E-mail address: [email protected]


Advances in Cosmetic Surgery 2 (2019) 1–10


The Latest in Cosmetic Medicine Supplements, Hormones, and Evidence Samantha A. Thiry, MSN, FNP-C*, Jennifer L. Walden, MD, FACS 5656 Bee Caves Road, Suite E201, Austin, TX 78746, USA


 Age-related diseases  Antiaging  Supplements  Hormone replacement therapy  Andropause  Menopause KEY POINTS

 Provider opinions have an effect on the use of hormone replacement therapy (HRT) within practices. It is important for providers to be educated regarding the evidence behind HRT so they may safely prescribe HRT for specific patients who understand the risks versus the benefits. A patient-centered approach should be used with this treatment option.  The true risks versus benefits of HRT and disease processes, such as prostate cancer and breast cancer risks, must be presented to patients by educated providers without bias. It has been proved that provider attitudes contribute to use of antiaging medical methods. This can, in turn, negatively affect a patient’s quality of life by not providing them with safe, monitored, and effective treatment.  Supplements to help prevent age-related diseases continue to be researched for their true beneficial possibilities. Evidence exists regarding specific supplements and their chemopreventive and antioxidant properties. Cancer is an agerelated disease and many supplements are aimed at reducing the risk of its occurrence. Supplement use is a patientdriven demand.  Providers must become more informed about supplements by receiving appropriate education regarding the evidence so they can give patients appropriate feed-back when patient inquiries arise.

INTRODUCTION Patients are seeking care to stop the effects of aging not only from an external standpoint but also from an internal standpoint. As the demand for antiaging therapy with hormones and supplements increases, it is imperative that health care providers understand the evidence supporting proper management and information regarding alternative treatment options with hormones and supplements [1]. Age-related diseases continue to be researched for prevention and optimization [2]. Antiaging specialists use a medical framework that targets age-associated

diseases as symptoms of aging. The concept of a fountain of youth has been around for centuries but now, with modern medicine and advancements in technology, antiaging practitioners have developed as a specialty, with the requirements of understanding diseases associated with age and how to physiologically decrease a patient’s risk of acquiring an age-related disease. Various dietary and pharmacologic interventions have been shown to increase lifespan [3]. Also, although aging is considered a natural life process, optimization of quality of life continues to be a focus. To meet this demand, an increasingly popular focus has

Disclosure Statement: The authors have nothing to disclose. *Corresponding author, E-mail address: [email protected] 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.



Thiry & Walden

been geared toward preventing existing disease processes from worsening, as well as treating disease processes through therapeutic management with hormones or supplementation [3,4]. Patients have shifted the focus of surviving to thriving throughout their lifetime. Improving a patient’s quality of life is an important concept in antiaging medicine [2]. Hormonal shifts occur during the aging process that cause several physiologic changes and clinical presentation of symptoms. For women, symptoms of menopause can severely affect overall quality of life as radical shifts and imbalances of estrogen and testosterone hormones occur [5]. Andropause, defined as a continual decline in testosterone with age, affects both men and women [5,6]. Hormone therapies are effective in the treatment of symptoms of age-related hormonal changes for men and women, which makes it is important to understand the evidence regarding risk versus benefit of the treatment prescribed. It has been proved that many providers’ opinions on hormone therapies are not congruent and often misinformed, causing bias [7]. This tends to cause a lack of credibility with specific treatment protocols. Patients can end up suffering with symptoms of hormonal shifts and the physiologic changes of age due to lack of appropriately prescribed care and information regarding the true risks versus benefits of treatment [7,8]. This article examines the multifactorial approach to antiaging medicine with hormone replacement therapy (HRT) and treatment using nutraceuticals to help patients achieve an improved quality of life, as well as decrease risk for development of disease process by optimizing their health from a physiologic evidencebased standpoint. It examines what symptoms of aging can be improved, as well as how aging is defined, to improve patients’ overall quality of life. Potential risks and benefits of HRT, as well as nutraceutical supplementation, are discussed. Assessment of providers’ knowledge and the options of these types of therapies are examined, as well as appropriate assessment and treatment in men and in women [4–8].

Age-related diseases Antiaging medicine is an evolving movement with the intent to help patients decrease the development of age-related disease, as well as improve the quality of the normal aging process [2]. This movement has been in place for decades but has recently become much more advanced through research and technology. One way to define aging is that it is the result of continuous interaction between an individual’s genetic makeup and environmental factors, characterized by

lifelong damage accumulation and progressive loss of tissue and organ functionality [9]. Aging is directly associated with an increased risk of disease development. Common age-related diseases include neurodegenerative disorders, cardiovascular disease, diabetes, osteoarthritis, and cancer [9]. Hypertension, high glucose, cholesterol, and triglyceride levels are age-related risk factors for morbidity that increase with age. The concept of targeting age-related diseases through prevention on a molecular level is important to understanding which treatment methods will decrease the effects of aging, not only from a physiologic standpoint but also from a symptomatic standpoint [9]. Directly targeting the aging process on a molecular level versus targeting agerelated diseases or symptoms is a viable strategy [9,10]. To slow the aging process, therapies that are considered nonstandard, such as blood-based therapies, are being prescribed and tried [9]. As patients continue to seek out ways to diminish or decrease the effects of aging, it is important for providers to be up-to-date on current treatment options. Hormone therapies and supplements are becoming increasingly popular as treatment and prevention of age-related conditions. Age-related conditions are the leading causes of death, not only in the United States but also worldwide. They are also the leading cause of health care expenditures [9]. By delaying the aging process, the delay of age-related diseases occurs. Delaying aging, resulting in 2.2 years of additional life expectance, would yield the United States $7 trillion dollars in savings over 50 years. The target of single pathologic conditions, such as cancer or heart disease, yields less savings [9]. Because antiaging science has huge potential financial benefits, it has tremendous commercial opportunities. Scientific breakthroughs have led to antiaging science having a more valid reputation [9]. Provider opinions and approaches are often skewed when it comes to subjects such as off-label administration of medication management [7,8]. Therefore, presenting the evidence behind some HRT and nutraceutical blood-based approaches of antiaging is important when creating a patient-centered plan of care [1]. Given the multiple genes, processes, and pathways associated with aging, there are many opportunities to develop pharmaceuticals to target these pathways [9]. To understand the antiaging process, one must first understand what causes aging and the specific signs and symptoms of the aging process [2,3]. The description of aging as a time of decline and suffering is evident because agerelated diseases often cause the physiologic decline of a patient, in turn causing the patient to suffer [2,3].

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Hormonal changes in men and women associated with age, symptoms, and treatment options Age-related hormonal changes in women A significant age-related hormonal change for women is menopause. Menopause is used to define the natural, systemic decrease of endogenous estrogen production from the ovaries, caused by physiologic depletion of a woman’s ovarian reserve [11]. This process occurs in the aging woman and manifests as the cessation of menses and subsequent end of fertility. In many women, vasomotor symptoms occur, as well as other physiologic issues. Vasomotor symptoms commonly experienced during menopause include vaginal dryness, hot flashes, and irregular menstrual pattern. Menopausal symptoms can greatly affect a woman’s overall quality of life and patients will bring these to a provider’s attention in search of relief [11,12]. A progressive decline in androgen levels also occurs as a woman increases in age. Serum concentrations of testosterone in women older than the age of 50 years are approximately half of that of women in aged 20 to 30 years [13,14]. There are several symptoms of andropause in women, including unexplained fatigue, low libido, and decreased sense of wellness. Testosterone therapy has been administered to women for decades to improve sexual dysfunction [11,15]. Female sexual dysfunction is an issue for approximately 43% of women 18 to 59 years of age [14]. Menopause is characterized by a decreased production of both estrogen and androgen [5,11]. It is important to understand the process of aromatization, which is the conversion of the body’s excess testosterone into estrogen. Expression of aromatase is important to the adipose tissue, skin, and bone because it slows the rate of postmenopausal bone and collagen loss [5]. Testosterone levels decline gradually with age, rather than showing a precipitous decrease at the menopause transition [13]. Different typical HRT plans of care are used in premenopausal, perimenopausal, and postmenopausal women due to hormone shifts during each phase of her sexual maturation [11]. Each phase is assessed differently for risks and benefits associated with HRT, therefore making it increasingly difficult for a provider to manage a patient’s symptoms to improve quality of life through HRT [11]. Female sexual dysfunction and hyposexual desire are diagnoses that are reviewed as issues that can occur in the premenopausal, perimenopausal, or postmenopausal phases [12]. Some studies have shown that up to 50% of women suffer from female sexual dysfunction. Female sexual dysfunction is characterized by low sexual desire,


diminished sexual arousal, vaginal dryness, and difficulty achieving orgasm. Some women enter into menopause naturally, whereas others enter into menopause via surgical means such as a hysterectomy [11]. In the United States, a national survey concluded that nearly half of women aged 57 to 85 years experience at least 1 sexual problem, the most common issue being low sexual desire. There has been a landmark study performed by Laumann and colleagues [12] that found that 32% of women ages 30 to 39 years had low sexual desire. Therefore, it is not only perimenopausal and menopausal women who are seeking a solution for a decreased quality of life likely due to hormonal disruption. Understanding the mechanism of action of androgens in relation to the female body is important when considering the overall benefit for patients seeking relief of androgen deficiency symptoms [12].

Androgen deficiency in women The organs directly responsible for production of testosterone in women are the ovaries and adrenal glands, although testosterone is also converted peripherally from androstenedione, which is also produced in the ovaries and adrenals [11]. Androgen deficiency in women causes decreased lean body mass, increased body fat, thinning or loss of hair, osteopenia, or osteoporosis, which present as clinical signs. Symptoms of androgen deficiency include low libido, fatigue, lack of a sense of wellbeing, orgasmic dysfunction, arousal disorder, vasomotor symptoms, insomnia, and depression [11,16]. Beta endorphins increase with testosterone levels, causing mood-enhancing effects [5]. A woman’s quality of life is greatly affected by a decrease in androgens, not simply because of sex hormones. Multiple organs rely on androgens for action such as increasing bone mass, causing erythropoiesis, augmenting certain cognitive behaviors, stimulating muscle growth, stimulating kidney growth, and modifying the pattern of adipose tissue deposit [5]. Interestingly, the thyroid, breast, endometrium, colon, lung, skin, and adrenals are all affected because androgens have a direct effect on the tissue of each organ [5]. Androgens may affect sexual desire, bone mineral density, muscle mass, and strength, as well as adipose tissue. The addition of testosterone therapy in testosterone-deficient women has an effect on estrogen production in the brain, bone, and skin fibroblasts, among other tissues [5].

Assessment of female androgen deficiency Female androgen deficiency is assessed through subjective questionnaires and, therefore, a lack of objective information can cause lack of consistency between


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provider assessment and the treatment plan. The idea that androgen deficiency is assessed through subjective means causes controversy among providers [8,12]. There have been several tools designed to screen women for hyposexual desire disorder (HSDD) [12]. The Decreased Sexual Desire Screener (DSDS) is a validated diagnostic tool for generalized, acquired HSDD. The DSDS is meant to be approximately sensitive and specific for diagnosis of HSDD in women, independent of menopausal status. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, lists specific criteria for the diagnosis of female sexual interest or arousal disorder; 3 out of 6 symptomatic screening assessments must be answered with a yes for diagnosis [11]. Interpretation of laboratory data associated with decreased available androgens for women include the review of free and total testosterone, as well as sex hormone-binding globulin (SHBG) [13]. Free testosterone is biologically available testosterone, whereas the bioavailability of testosterone for the conversion into estrogens depends on the levels of SHBG. In a normal scenario, only 1% to 2% of total testosterone circulates unbound. SHBG binds about 66% of total circulating testosterone. The rest of testosterone circulating is bound by albumin. It is assumed that the non–SHBGbound circulating testosterone is biologically active [13]. Estrogen and thyroxine increase SHBG. Testosterone and glucocorticoids, growth hormone, and insulin suppress SHBG. It is difficult to measure testosterone levels in women when they are at very low levels [13].

Testosterone therapy in the aging woman Data from several studies suggest that combined HRTandrogen therapy may be beneficial to women who are postmenopausal who complain of low libido despite estrogen therapy or as monotherapy in women who are postmenopausal with female sexual dysfunction. Studies have concluded that no significant increase of liver enzymes or cardiovascular risk factors occurred with the administration of testosterone therapy [11]. There are multiple forms of testosterone therapy in various routes of administration available to women [5]. Subcutaneous hormone implants; intramuscular injection; and transdermal, oral, and vaginal administration of hormone replacement are among those offered to women in search of androgen deficiency symptom relief [5].

Safe administration of hormone replacement therapy for women It is extremely important for the patient and prescriber to understand the risks versus benefits of HRT for

women. Each individual, due to family and personal history, have variables that are important for a provider to consider when developing a tailored treatment plan for the patient’s needs. Women must have an active relationship with their obstetrician-gynecologist, and documented history must be reviewed by the treating physician [11]. Abnormal menses, hirsutism, elevated blood pressure, and mood swings are some of the associated issues that may occur during androgen therapy for women [11].

Women, hormone replacement therapy, and cardiovascular evidence Notably, estrogen has antiatherosclerotic and antiinflammatory properties that may protect women from cardiovascular disease development through modification of the lipid profile [17]. It is noted that women who are premenopausal have higher high-density lipoprotein cholesterol and lower low-density lipoprotein cholesterol levels compared with men, which significantly reverses after menopause [17]. Testosterone is known to be produced by the ovaries and some of the female body’s testosterone is converted into estrogen, primarily when androgen levels are higher during the premenopausal state [5,17]. The converted estrogen has beneficial effects on vascular endothelium and smooth muscle tissue. Menopause and the postmenopausal period may be risk factors for developing coronary heart disease. Directly following menopause, there is a hormonally related risk for the development of hypertension, coronary artery disease, congestive heart failure, and cerebrovascular disease, which are also age-related diseases [2,17]. The Danish Osteoporosis Prevention Study recently noted in a controlled randomized trial that menopausal hormone therapy can have the beneficial effect of a reduced rate of coronary artery disease. Hormonal therapy may be harmful and is not advised in the setting of preexisting coronary disease, cerebrovascular disease, or a history of thromboembolic disease [11]. Hormonal therapy must be observed for risks and benefits by the administering provider using a patient-centered approach and individualized discussion [11,17].

Hormone replacement therapy and breast cancer concerns It has been reviewed that there are no valid randomized or observational clinical studies to provide appropriate evidence that testosterone has an influence on breast cancer risk when added to conventional postmenopausal hormone therapy [14]. This is a significant point

The Latest in Cosmetic Medicine of information to provide to patients inquiring about HRT [14]. Breast cancer diagnosis represents about 23% of all cancers in women. It is no surprise that it is an important subject because it is typically an agerelated disease and is a common concern for patients considering HRT [18]. Breast cancer incidence is increasing worldwide. Weight gain in adulthood is associated with an increased risk of breast cancer in postmenopausal women. Studies suggest that weight gain before and around menopausal age may be a determinant for the development of breast cancer in postmenopausal women [18]. Increasing a woman’s testosterone level to a more optimal level has the benefit of decreasing central visceral fat, increasing metabolic rate, and decreasing or even treating obesity. Testosterone also has the benefit of increasing the beta endorphins responsible for sense of wellbeing [13]. If a woman is feeling a better sense of wellbeing she is more likely to be physically and sexually active [13]. Decreasing obesity risk for women before and during menopause via testosterone therapy decreases a risk factor for the development of breast cancer [18,19]. Recent clinical data support a role for testosterone in breast cancer prevention [19]. Women with symptoms of hormone deficiency who are treated with doses of testosterone alone or in combination with anastrazole via subcutaneous implants have shown a reduced incidence of breast cancer. In addition, testosterone therapy along with anastrazole has been studied to alleviate symptoms of hormone-deficient breast cancer survivors and was not associated recurrent disease [19]. Studies have shown that testosterone and anastrazole subcutaneous implants placed in tissue surrounding malignant tumors significantly reduces breast cancer tumor size. Testosterone therapy has been reviewed and there are several supporting data that note the direct antiproliferative, protective, and therapeutic effects [19].

Provider opinions of hormone replacement therapy despite evidence There are differing opinions regarding hormone replacement therapies that affect not only a physician’s willingness to prescribe but also a patient’s willingness to use hormone replacement as a therapy. Part of this disarray is due to a lack of protocol and continued controversy about normal androgen levels in women. It is also difficult to assess for androgen deficiency in women because the symptomology overlaps with several other medical diagnoses [8,11]. The provider must rule out other complications that could be presenting as risks to patient’s health. Providers’ opinions


have been observed via survey and it has been noted that respondents correctly identified the risks of HRT only 28% of the time, and 67% of providers overestimated the risks and benefits of HRT. Multiple sources of valid data suggest that combined HRT-androgen therapy may be beneficial to women [11]. Providers need to be educated regarding studies that concluded that no significant increase of liver enzymes or cardiovascular risk factors occurred with the administration of testosterone therapy [16].

Men and testosterone supplementation Testosterone supplementation in the United States has increased substantially over the years. Testosterone prescriptions increased by 1700% from 1994 to 2003 and do not show any signs of decreasing in popularity [4]. As this patient-driven popularity of testosterone supplementation increases, it is important for providers to understand the signs and symptoms associated with the decline of testosterone in the male body, as well as appropriate treatment options and risk factors [4]. To ignore the increased patient demand for treatment of the associated symptoms of andropause causes skewed perspectives regarding the true risks and benefits of HRT for men throughout the aging process [4].

Men and andropause Men undergoing the aging process, especially andropause or the progressive decline of testosterone, often search for symptom relief. Decreased testosterone levels are also referred to as hypogonadism [20]. Low libido is the symptom most associated with hypogonadism, although erectile dysfunction, decreased muscle mass and strength, increased total body fat, decreased bone mineral density, anemia, gynecomastia, decreased mental capacity, and skin and hair alterations also occur [20]. Decreased quality of life, a diminished sense of wellbeing, and insomnia are additional symptoms present in androgen-deficient men. On clinical presentation, decreased muscle mass and strength, decrease in bone mass, osteoporosis, and increased central body fat may be noted in a patient with testosterone deficiency [20,21]. When assessing for testosterone deficiency, it is important for the provider to use an approach that considers other age-related diseases by using objective information, such as laboratory work, to assess the patient for issues that may be present in addition to androgen deficiency. Testosterone deficiency is also associated with increased cardiometabolic risk. For example, total testosterone levels are inversely associated with risk of cardiovascular events. Testosterone deficiency is


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associated with endothelium damage and testosterone therapy enhances endothelial repair and function, and increases synthesis and release of endothelial nitric oxide in the body’s vascular system [20]. Testosterone deficiency is associated with increased systolic blood pressure and increased arterial stiffness, which are risk factors that can lead to further development of agerelated diseases, such as coronary artery disease, hypertension, and hypercholesterolemia [2,4,20].

Diagnosing low testosterone in men The decline of testosterone for men is about 1% per year after the age of 30 years and reaches a 30% decline by the eighth decade of life [4]. The Androgen Deficiency in the Aging Male (ADAM) questionnaire is an important assessment tool when assessing for male androgen deficiency. Testosterone declines as men age and the symptoms associated with this decline cause an abundance of unwanted patient symptoms that affect their overall wellbeing [4]. Assessment regarding the subjective presence of the most commonly reported androgen deficiency–associated symptoms must be performed by a diagnosing provider. The symptoms associated with this decline cause an abundance of unwanted patient symptoms, such as fatigue and depression, and a decreased sense of wellbeing [4]. When assessing for the reasons for existing symptoms of hypogonadism, it is important to check patient’s serum total testosterone, free testosterone, and SHBG, as well as the total prostate-specific antigen (PSA) if appropriate for patient’s age range, when considering prescribing testosterone therapy [21].

Testosterone therapy benefits reported Benefits of testosterone therapy in men include increased libido, sexual function, bone density, muscle mass, body composition, mood, erythropoiesis, cognition, quality of life, and decreased cardiovascular disease. Improved sexual desire, function, and performance are reported by men receiving testosterone replacement therapy (TRT) [4,6,20]. The cognitive effects of androgen deficiency are associated with decline in visual and verbal memory. Men with higher ratios of testosterone to SHBG show a decreased risk of Alzheimer disease. This was found in the Baltimore Longitudinal Study of Aging, a prospective longitudinal study. It was noted that risk for Alzheimer disease was reduced by 26% for each 10 unit (mmol/mmol) increase in free testosterone at 2, 5, and 10 years. There are also well-reported data for a strong correlation between serum levels of testosterone and cognitive performance in mathematical reasoning

and spatial abilities [6]. Testosterone therapy in hypogonadal men may have some benefit for cognitive performance, especially in older men who are at an additional risk of developing dementia or Alzheimer because these are typically age-related diseases [6]. Glycometabolic and cardiometabolic functions, as well as body compositions, are negatively affected by testosterone deficiency or hypogonadism [20]. Testosterone and its metabolite, 5 alpha-dihydrotestosterone, regulate energy metabolism, muscle growth, and maintenance and inhibit adipogenesis. An inverse relationship between testosterone and insulin resistance has been postulated and higher physiologic levels of testosterone seem to be protective against the development of type II diabetes mellitus [20,21]. The prevalence of type II diabetes mellitus and men with hypogonadism is as high as 33% [21]. It has been shown that TRT causes an improvement in glycemic control, as well as insulin resistance, in men with type 2 diabetes [21]. Subcutaneous hormone implants, intramuscular injection, transdermal, and sublingual administration of hormone replacement are among those offered to men in search of androgen deficiency symptom relief [6].

Safe administration: prostate cancer risk and other testosterone replacement therapy considerations Prostate cancer and the role of testosterone in the disease often results in confusion. It has not been assessed that testosterone replacement directly causes prostate cancer, although its administration in the presence of a carcinoma can enhance the carcinoma present [4]. Prostate cancer is a common, androgen-dependent cancer. Therefore, testosterone administration is absolutely contraindicated in men with clinical prostate cancer. Some men are diagnosed with prostate cancer less than 4, therefore establishing a baseline is important [4]. Assessing for prostate cancer risk is important when assessing the risks versus benefits of testosterone therapy in symptomatic, androgen-deficient men. Data have shown that suggest administration of testosterone in androgen-deficient men can produce modest incremental increase in serum PSA levels. These increments should generally be less than 0.5 ng/mL; increases exceeding 1.0 ng/mL over 3 to 6 months are unusual. Recommendations for monitoring prostate-related adverse experiences during TRT in older men include a baseline evaluation of a digital rectal examination, serum PSA, and an AUA symptom score for benign prostatic hypertrophy. Also, follow-up evaluations should occur at 3, 6, and 12 months, then annually, with review of the previously mentioned monitoring tools [4].

The Latest in Cosmetic Medicine Some clinicians practice safe administration of TRT in men by performing a prostate biopsy when there is a clinical presentation of prostate cancer risk before prescription of TRT. High-grade prostatic intraepithelial neoplasia (PIN) has been postulated to be a precancerous condition [21]. An examination of prostates removed at radical prostatectomy for prostate cancer revealed high-grade PIN in 86% of cases. It has been shown that there was no increased risk of prostate cancer in hypogonadal men with PIN treated with testosterone for 1 year [21]. Continued studies must be performed for long-term analysis. To date, no study has definitively shown a relationship between TRT and prostate cancer. Many providers are hesitant to treat patients for androgen deficiency owing to fear of increasing the risk for prostate cancer, whereas evidence does not support this clinical precaution [21]. Therefore, prescribers refrain from prescribing TRT to men who suffer androgen deficiency symptoms and side effects owing to presumptions that are not evidencebased [21]. PSA levels increase with age in men regardless of prostate cancer status, which is why proper thorough examination and evaluation with established baselines are such important components when considering TRT risks versus benefits of therapy [21]. Lack of consistency regarding the prescription of TRT for men with hypogonadism leads to provider confusion. During the assessment, the provider must understand the process of deciding what specific symptoms of aging need to be addressed. Androgen deficiency symptoms commonly affect an individual’s quality of life and vital physiologic functions [4,6]. To restore overall wellbeing, balancing these hormones to the levels of a younger, more youthful, and more well self is often the goal of HRT [4,6]. It is thought that a consistent decline in testosterone occurs as a direct cause of age; therefore, restoring testosterone levels to that of a younger age is thought to help reduce certain agerelated signs and symptoms [4,6,12,20,21]. This has been evident because patients have had positive physiologic and psychological outcomes associated with TRT. Because of a recent paradigm shift, it is important for providers to be educated about the true risks of therapy and to understand when referral to a gynecologist or urologist is an appropriate and vital component for safe administration of TRT [13,22]. Potential risks of TRT must be discussed with the patient and informed consent of receiving this knowledge should be documented [13]. TRT can cause erythrocytosis, which in turn can have adverse cardiovascular or neurologic events. TRT can also cause testicular atrophy


and infertility. Symptoms of BPH may worsen with therapy, although they could also improve. Acne and other skin disorders, such as hirsutism, as well as exacerbation of sleep apnea, may occur with TRT [20].

Nutraceuticals and antiaging An extensive amount of research is still required to explore the profiles and extents of the benefits that natural compounds provide, although there is increasing evidence that a nutritional approach provides a tool to combat age-related diseases. Senescent cells have been identified as the cause of organismal aging. Both natural and synthetic compounds have been suggested to have antisenescence activities, otherwise known as senolytics [9]. Understanding proinflammatory signals and prooxidant signals is important to develop management with antioxidants and antiinflammatory compounds for healthier aging [9]. Polyphenol-rich foods are one of nature’s antisenescent compounds [9]. Specific types of polyphenols have properties that not only promote cell death of aging cells but also delay the death of healthy tissue. Many supplements use polyphenol extract to produce concentrated polyphenol with the intent of health promotion for the consumer. Antioxidant and antiinflammatory properties of polyphenols reduce the risk of developing age-related disease [9]. There is evidence that polyphenols contain cardioprotective and neuroprotective functions such as the reduction of postprandial hyperlipemia and insulin resistance. A reduction in glucose uptake in tumor cells induced by certain polyphenols suggests an anticancer effect in several human cancers [9]. Although polyphenol-rich nutrients are a source of chemopreventive, antioxidant, and antiaging properties, there are other nutrients that have been observed and are viewed as having similar effects on the human body. The following descriptions explore popular forms of supplementation widely available and sometimes marketed with antiaging properties. Chemopreventive and antisenescent properties are the focus of properties of each nutraceutical or supplement described [9].

Curcumin Curcumin is a polyphenol-rich source often used in the form of a spice. Curcumin is a root also known as turmeric or Curcuma longa. It is an ingredient that is often used in cooking and is one of the ingredients in curry powder. Curcuminoids are the bioactive components of curcumin [1,9,23]. These have been of interest for years in chemoprevention because they can inhibit carcinogen activation by way of cytochrome enzymes.


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Curcuminoids also exhibit antioxidant and antiinflammatory properties [1,23]. There is evidence of curcumin’s ability to inhibit growth of cancer stem cells; therefore, this supplement has been hypothesized to have the potential to act as an adjunct treatment to conventional cancer treatments, including chemotherapy [1]. Curcumin is poorly absorbed by the body, therefore making therapy a challenge [1]. Much of the available research on curcumin focuses on the prevention of colorectal cancer. The thought is that because of poor absorption of curcumin by the body, the spice has direct mucosal contact with the colorectal tract [1,23]. Curcumin treatment has been seen to increase the lifespan in some animal models. Owing to the obstacle of poor absorption of its hydrophobicity and poor oral bioavailability, new strategies, such as curcumin-loaded micelles, are being explored to improve delivery of curcumin to the body [9]. An important study was conducted in 2006 by Cruz-Correa and colleagues in which participants who had familial adenomatous polyposis received curcumin 480 mg and quercetin 20 mg orally 3 times a day for 9 months. Participants had an average decrease of polyp number by 60.4% from baseline and the mean decrease in polyp size from baseline with treatment was 50.9%. Additional studies must be completed to understand the true benefits of curcumin, although there are evident benefits of supplementation concluded from prior research [1,9,23].

Probiotics Probiotics have received increasing popularity for health benefits and many patients are inquiring how they may be of benefit. Probiotics are live microorganisms found in fermented foods such as yogurt and kefir. Probiotics are found in concentrated forms in supplement products [1]. Probiotics may have chemopreventive benefits for the gastrointestinal tract and are of particular interest in preventing colorectal cancers. Lactobacillus species are commonly provided in probiotic supplement capsules. Bifidobacterium is another colonized organism that proves to have gut health benefits [1]. Their mechanisms of action, which are thought to be chemopreventive, are many. Probiotics have the ability to alter gut microbiota and, as a result, inhibit or induce colonic enzymes that regulate growth of harmful bacteria, which in turn benefits immune function and stimulates active anticancer metabolite production. Yogurt is fermented milk that breeds the organisms used in probiotic supplements. Studies in women have found an inverse association between consumption of fermented milk and breast cancer risk [1].

The EPIC Italy study followed 45,241 adults for 12 years and found that yogurt consumption may reduce the risk of colorectal cancer by up to 35%. This conclusion suggests a promising role for probiotic organisms and the prevention of colorectal cancer. Trials are ongoing to research the benefits of probiotics. The chemotherapeutic effect has also been noted in patients diagnosed with superficial bladder cancer. Those taking oral supplementation had a higher 3-year recurrence-free survival rate [1]. Increasing evidence notes that the gut microbiota is involved in the development of human diseases such as obesity, metabolic syndrome, diabetes, cardiovascular disease, cancer, and neurodegenerative disorders, which are commonly associated with agerelated diseases [1,9].

B vitamins B vitamins continue to be researched for their necessary role in a person’s health status and there is evidence that supports specific physiologic functions of B vitamins. Vitamins B3 (niacin), B6 (pyroxene), B9 (folate), and B12 (cobalamin) work in a synergistic fashion as watersoluble vitamins with proven vital roles in brain and nerve function by supporting general metabolic function as a mechanism of action [1]. Whole grains, dairy products, potatoes, legumes, and bananas, as well as fish, organ meats, and poultry, are commonly consumed food sources that contain B vitamins [1]. In the United States, as well as many other countries, B vitamins are included as an enrichment in flour. There is some observational evidence that has suggested the protective role of B vitamins against some cancers. Vitamin B3 (niacin) protects DNA from damage when consumed in high doses. There are also studies that show that daily supplementation of folic acid and vitamin B12 over 2 years resulted in a methylation of genes associated with abnormal cell development and carcinogenesis [1]. Vitamin B9 (folate) originates mainly in green leafy vegetables, as well as certain fruits, and is required for DNA synthesis and DNA methylation. The biological roles of B vitamins continue to be explored and it is hypothesized that they could potentially be important in cancer prevention [18]. The protective role of B vitamins on DNA continues to be explored, including their role in breast cancer because protective effects have been observed in populations with low folate status. However, more research is needed to develop more conclusive support for this hypothesis [18]. A randomized controlled study completed in New Zealand and Australia showed that daily supplementation with vitamin B3 was associated with lower incidence of nonmelanoma skin cancers. Research regarding B vitamins continues to be

The Latest in Cosmetic Medicine performed and is needed to draw more conclusions regarding B vitamin benefits to the body’s immunologic system and their ability to support DNA in prevention of carcinogenic effects [18].

Diindolylmethane supplement or cruciferous vegetables Diindolylmethane (DIM) and indole are major bioactive molecules of cruciferous plants known to act on enzymes responsible for the metabolism of estrogen [24]. The most potent dietary indole is DIM because it is the most potent estrogen blocker associated with lowering risk of breast cancer [24]. The cancer preventative potency of DIM is under clinical investigation because of its important role of blocking estrogen via its ability to maintain higher levels of 2-hydroxesterolne. Higher levels of estrogens are associated with breast, uterine, and cervical dysplasia. DIM’s ability to reduce these specific estrogens causes a reduction in clinical presentation of breast, uterine, and cervical dysplasia. Cruciferous vegetables have many other physiologic functions that are chemopreventive. DIM supplements are widely available and used as a chemopreventive nutraceutical [24].

SUMMARY Patients are seeking treatment options to reduce the signs and symptoms associated with age and agerelated diseases [2]. Antiaging medicine must continue to be explored, streamlined, researched, and better understood by providers and patients, including decreasing risk of age-related diseases through hormone replacement therapies and with supplements that have proven health benefits, [1,2,10]. As the popularity of hormonal and nutraceutical supplemental therapies increases, it becomes increasingly important for providers develop better information sets for patients and to not allow their opinions to obscure the facts that present the benefits and risks of supplementation and HRT. Use of HRT and supplements as a means of physiologically decreasing the effects of aging must be done with proper knowledge of the risks versus the benefits when creating an individualized plan. Using a patient-centered approach, the risk of development of several age-related disease processes can be reduced [1]. Although much of the research regarding TRT focuses on treatment of men, women also substantially benefit from treatment with testosterone [5,6,12]. When assessing for risk factors of age-related diseases, it is important to use appropriate assessment tools and diagnostic procedures to understand when


appropriate referrals must be made [11]. By building credibility through increased education of providers regarding evidence of the benefits of dietary and nutraceutical supplements, as well as HRT, patients will start to receive the treatment of symptoms and health issues that have a significant impact on their quality of life [1,13]. This article examines the multifactorial approach to antiaging medicine with treatment using HRT and nutraceuticals to help patients achieve an improved quality of life, as well as decrease the risk for development of disease process by optimizing their health from a physiologic, evidence-based standpoint. Understanding signs and symptoms of aging is important when managing a patient’s quality of life through HRT and supplementation. Potential risks and benefits of HRT, as well as nutraceutical supplementation, must be postulated on a case-by-case basis for the safest, most effective approach in management by the responsible provider. Assessment of providers’ knowledge and options of these types of therapies as appropriate treatment in men and in women must continue be explored [1,5,6,11].

REFERENCES [1] Sanders K, Moran Z, Shi Z, et al. Natural products for cancer prevention: clinical update 2016. Semin Oncol Nurs 2016;32(3):215–40. [2] Mykytyn CE. Anti-aging medicine: a patient/practitioner movement to redefine aging. Soc Sci Med 2006;62(3): 643–53. Available at: login?url5 true&db5cmedm&AN516040177&site5ehost-live. Accessed October 30, 2018. [3] de Magalhães JP, Stevens M, Thornton D. The business of anti-aging science. Trends Biotechnol 2017;35(11): 1062–73. [4] Bhasin S, Singh AB, Mac RP, et al. Managing the risks of prostate disease during testosterone replacement therapy in older men: recommendations for a standardized monitoring plan. J Androl 2003;24(3):299–311. Available at: Accessed September 12, 2018. [5] Maia H Jr, Casoy J, Valente J. Testosterone replacement therapy in the climacteric: benefits beyond sexuality. Gynecol Endocrinol 2009;25(1):12–20. [6] Bassil N, Alkaade S, Morley JE. The benefits and risks of testosterone replacement therapy: a review. Ther Clin Risk Manag 2009;5(3):427–48. Available at: http://ezproxy. login.aspx?direct5true&db5cmedm&AN519707253&site5ehost-live. Accessed October 1, 2018.


Thiry & Walden

[7] Levens E, Williams RS. Current opinions and understandings of menopausal women about hormone replacement therapy (HRT)-the University of Florida experience. Am J Obstet Gynecol 2004;191(2):641–6. Available at: 15343254&site5ehost-live. Accessed August 29, 2018. [8] Williams RS, Christie D, Sistrom C. Assessment of the understanding of the risks and benefits of hormone replacement therapy (HRT) in primary care physicians. Am J Obstet Gynecol 2005;193(2):551–6. Available at: 16098892&site5ehost-live. Accessed August 29, 2018. [9] Gurau F, Baldoni S, Prattichizzo F, et al. Anti-senescence compounds: a potential nutraceutical approach to healthy aging. Ageing Res Rev 2018;46(1):14–31. [10] Janson M. Orthomolecular medicine: the therapeutic use of dietary supplements for anti-aging. Clin Interv Aging 2006;1(3):261–5. Available at: http://ezproxy.lib.utexas. edu/login?url5 direct5true&db5cmedm&AN518046879&site5ehostlive. Accessed September 10, 2018. [11] Swords KE. Hormone therapy for menopausal women in the primary care setting. J Nurse Pract 2017;13(8):562–9. [12] Khera M. Testosterone therapy for female sexual dysfunction. Sex Med Rev 2015;3(3):137–44. [13] Davis SR, Tran J. Testosterone influences libido and wellbeing in women. Trends Endocrinol Metab 2001;12(1): 33–7. Available at: url5 Accessed August 28, 2018. [14] Bitzer J, Kenemans P, Mueck AO. Breast cancer risk in postmenopausal women using testosterone in combination with hormone replacement therapy. Maturitas 2008; 59(3):209–18.

[15] Shufelt CL, Braunstein GD. Safety of testosterone use in women. Maturitas 2009;63(1):63–6. [16] de Paula FJF, Soares JM Jr, Haidar MA, et al. The benefits of androgens combined with hormone replacement therapy regarding to patients with postmenopausal sexual symptoms. Maturitas 2007;56(1):69–77. Available at: 16822626&site5ehost-live. Accessed October 29, 2018. [17] Svatikova A, Hayes S. Menopause and menopausal hormone therapy in women: cardiovascular benefits and risks. Revista Colombiana de Cardiología 2018;25(S1): 30–3. [18] Chajes V, Romieu I. Nutrition and breast cancer. Maturitas 2014;77(1):7–11. [19] Glaser R, Dimitrakakis C. Testosterone and breast cancer prevention. Maturitas 2015;82(3):291–5. [20] Traish AM. Benefits and health implications of testosterone therapy in men with testosterone deficiency. Sex Med Rev 2018;6(1):86–105. [21] Rhoden EL, Morgentaler A. Testosterone replacement therapy in hypogonadal men at high risk for prostate cancer: results of 1 year of treatment in men with prostatic intraepithelial neoplasia. J Urol 2003;170(6 Pt 1): 2348–51. Available at: login?url5 Accessed August 30, 2018. [22] Patrick Selph J, Carson CC. Testosterone replacement therapy in men with prostate cancer: what is the evidence? Sex Med Rev 2013;1(3):135–42. [23] Vemuri S, Banala RR, Subbaiah GPV, et al. Anti-cancer potential of a mix of natural extracts of turmeric, ginger and garlic: a cell-based study. Egypt J Basic Appl Sci 2017;4(4):332–4. [24] Manchali S, Kotamballi N, Murthy C, et al. Patil Crucial facts about health benefits of popular cruciferous vegetables. J Funct Foods 2012;4(1):94–106.

Advances in Cosmetic Surgery 2 (2019) 11–21


Sculptural Aesthetic Surface Anatomy of the Face Peter M. Schmid, DO, FAOCOOHNS, FAACS Private Practice, 1308 Sumner Street, Suite 100, Longmont, CO 80501, USA


 Aesthetic surgery  Cosmetic surgery  Facial anatomy  Facial aesthetic surgery  Facial cosmetic surgery  Facial canons  Art and science KEY POINTS

 Artistic training emphasizes line, shape, and form in human anatomy.  Sculpting teaches perfect practice.  Lighting critically discloses nuances of surface form.  Aesthetic anatomy directs cosmetic therapy.  Comparative anatomy defines gender differences.

To capture nature, you must see and understand her. —EDOUARD LANTERI (SCULPTOR)

INTRODUCTION: THE SCULPTOR AND SURGEON Cosmetic surgeons are the sculptors of human form. To surgically alter the human face, best practices require a profound understanding of anatomic form, function, structural aesthetics, and harmony (Fig. 1). Complex by design, outward appearance is fabricated by age, genetics, gender, and ethnicity, which are all continuously remodeled over time. Although cultures impart unique biases on iconic beauty, the challenge to aesthetic surgery is to appeal to the patient’s visual and emotional needs. An ideal training model for studying aesthetic facial anatomy is through art education. Sculpting in clay is a powerful discipline that trains the eye and hones the surgeon’s visual assessment, dexterity, acumen, and finesse to optimize one’s surgical results. It allows the mind to create visual, tactile, and communicative

connections otherwise missed. Such training deepens the understanding of aesthetic anatomy, its construction, and nuances of 3-dimensional facial form. It broadens perspective and perceptions, and from sense (the ability to recognize shapes) is translated from the skeleton to the surface of the body. Working from the live human model and using sculptural principles, the facial structure is appraised by sculptural ratios, proportion, symmetry, silhouette lines, angles and planes, mass, shape, volume, form, interrelationships, distinction, and physical rhythm (Fig. 2). Albert Einstein once stated that “after a certain level of technical skill is achieved, science and art tend to coalesce in esthetics, plasticity and form.” As such, the integration of art into science as the sculptural principles of facial anatomy follows.

FACIAL BEAUTY AND ATTRACTIVENESS Humans are hardwired to respond to visual images of the human face and body, and this response is likely linked to evolutionary ties [1]. Attractive faces possess

E-mail address: [email protected] 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.



Schmid homogenous 3-dimensional curves and arrangements, precisely layered over skeletal form, resulting in even reflective highlights, and in some predominant light and shadow effects portraying volumetric sculptural aesthetic markers (Box 1). Beauty is an order to form, a subtle synergistic composition of geometry, proportion, volumes, and planes. The more symmetric the face, the more attractive is its perception in both sexes. Facial beauty, however, is curiously intriguing for its subtle imperfections and differences. Asymmetry to a millimeter or degree creates an interest and unique aesthetic to appearance in certain individuals. Woman attractive beauty is outlined by flowing curvilinear shapes and forms, whereas man attractiveness is framed by definition, planes, squareness, and angularity. The surgeon must remain vigilant to discerning these dimorphic discrepancies of gender-specific anatomy or the variations of form that occur in the typical or the aging patient.

PHYSICAL EXAMINATION: FACIAL SHAPE AND FORM FIG. 1 Appraising facial harmony. (Ó 2019 Peter M. Schmid.)

a constellation of mature, neotenous, and expressive facial features. Aesthetic judgments of facial beauty are grounded in mathematical averageness, symmetry, youthfulness, sexual dimorphism, familiarity, sizingup, and other specific tangibles [2]. Attractive and youthful faces exude pleasing harmony through vibrant skin tone, balanced volumetric fullness, and complementary features. The tissue shapes are blended into

Facial appearance is composed of organic shapes arising from the foundation of the cranial and facial bones, juxtaposed by soft tissue and complementary features. Facial characteristics should be studied like the sculptor, by both visual inspection and soft tissue palpation. Keen observation discerns the subtleties of form unique onto the patient, and relevant to gender, ethnicity, age, or the footprints of previous surgeries. The face is initially examined as a “whole,” saving the facial details and subcomponents for last. Facial shape and form should be appreciated (oval, round, oblong, heart, triangular square, rectangular diamond,

FIG. 2 Integration of art and science. (Ó 2019 Peter M. Schmid.)

Sculptural Aesthetic Surface Anatomy of the Face


Sculptural aesthetic markers 

Lateral orbital rim (f)

Malar eminence (f)

Lip volume and shape (f)

Temporal plateau (m)

Submalar plane (f 1 m)

Mandible shape and definition (f 1 m)


analysis. The balanced face is divided into equal vertical halves, by equal vertical facial fifths (note: beyond width of skull), or by horizontal facial thirds (note: hairline to the chin) (Fig. 6). The lower facial third can be subdivided into an upper third by gauging the length of the upper lip, with the lower two-thirds from the stomium to the mentum [3]. Artistic canons serve as objective guidelines to establish conversation with the patient, educating them about their presenting clinical facial findings, whether asymmetries, disproportions, imbalances, or attributes.

Abbreviations: f, female; m, male.

inverted, pear, peanut, and others) as they relate to the shape of the neck and jawline (Fig. 3). Under adequate lighting, the seated patient should be examined in multiperspective views, to study facial shape, asymmetries, apparent or virtual silhouette profile lines, and volumetric distributions or imbalances (Fig. 4). High-contrast lighting should be used to appraise anatomic landmarks, bony prominences, facial planes, dominant reflective highlights and shadows, and underlying soft tissue deficiencies, depressions, flatness, or curve distortions. Soft ambient lighting exposes skin qualities, soft tissue discrepancies, and surface irregularities secondary to subtle underlying anatomic shapes and masses. Facial features are reviewed last (Fig. 5). The facial bones and soft tissues should be delicately palpated to assess position, densities, and deficiencies. Tissues should be manually repositioned to present proposals exemplifying restoration of form. Facial animation provides insight into soft tissue dispositions, ptosis, and redistributions. A chronologic photo gallery of the patient’s aging images should be reviewed. Communication via a mirror, computerized digital imaging, and sculptural dialogue establishes commensurate objectives and trust.

Canons, Proportions, and Shape Canons, proportions, and the golden ratio (phi; 1:1.618) provide a general reference system for facial

Facial Structural Platform The bony craniofacial armature suspending the soft tissues and retaining ligaments of the face imparts exquisite curvilinear contour and shape. The facial framework consists of integrated structural platforms, namely, the cranial, midfacial, mandibular, and nasal complexes (Fig. 7). Unique facial height and dimensions equate to craniofacial growth influenced by genetics and gender. The woman skull and facial bones are petite, and the man counterparts are thick and robust. Defining bony landmarks present in both are the frontal prominence, supraciliary arch, nasal bones, malar eminences, angles of the mandible, and the mental tubercle, each displaying unique surface form and reflective highlights. The face as a unit is wide posteriorly and tapers anteriorly by curvilinear 3-dimensional form. The greatest width of the skull is at the biparietal eminence, camouflaged by the scalp. The upper cranial platform insets within the midfacial maxilla-zygomatic complex. The spherical human skull is interfaced with convexities, concavities, ridges, and planes. The woman skull by nature is 70% to 90% the size of the man cranium [4]. The forehead of the woman is vertically short and broad spanning, demonstrating a central frontal roundness with highlights as it blends softly into the lateral temporoparietal regions and flows downward onto the orbital rims. The masculine forehead, in comparison, often reflects 5 distinct

FIG. 3 Facial shapes. (Ó 2019 Peter M. Schmid.)



FIG. 4 Three-dimensional sculptural appraisal. (Ó 2019 Peter M. Schmid.)

angulated forehead planes wrapping horizontally into the temple zones. The paired temporal crests descend vertically onto the lateral orbits, creating a visible squareness contributing to the “chiseled” appearance of the man upper face. On profile view, the woman skull demonstrates a vertically oriented forehead with a 7 inclination, blending gracefully downward onto soft supraorbital rims. The man frontal table slopes posteriorly with a 10 inclination [5,6]. Pneumatization of the frontal sinuses in the man skull creates a prominent supraorbital bossing with paired, horizontally oriented highlighted ridges over the medial lower forehead. This suprabrow fullness masculinizes the forehead, contributing to the

appearance of a deep-set smaller eye [7]. The nasofrontal angle demonstrates subtle concavity in the woman skull, or an acute angle in the man skull, possessing larger projecting paired nasal bones. The midfacial skeletal platform, consisting of the zygoma and maxillary bones, imparts width and height to the central face. The malar eminence of the zygoma fuses with the frontal, maxillary, and temporal bones and affords shape to the cheek and midface [8]. The zygomatic arch extending laterally forms a horizontal buttress interfacing the temporal fossae above and the submalar zone below. Three paired planes course around the anterior face from the nasofacial junction to the preauricular zone. The midfacial bizygomatic

FIG. 5 Multidirectional lighting: underlight, direct, and overlight. (Ó 2019 Peter M. Schmid.)

Sculptural Aesthetic Surface Anatomy of the Face


FIG. 6 (A) Facial halves. (B) Facial horizontal thirds. (C) Facial vertical fifths. (D) Lower facial third subdivided thirds. (Ó 2019 Peter M. Schmid.)

distance assumes the widest dimension of the face. Although the midfacial skeleton of the woman face is structurally smaller than the man face, it appears proportionally more prominent anterolaterally at the malar eminences, creating a fullness and beauty to the central face. Man cheekbones by nature appear smaller or even depressed due to a flatter zygomatic arch and wide lower face (Fig. 8). The woman orbits relative to the upper skull appear rounder, larger, and higher in comparison to the squarer man orbit [8]. The vertical height of the maxillae and dentition establishes the midfacial proportions. The V-shaped mandibular platform supporting the lower third of the face is structurally the largest bone of the facial mass. Inset beneath the midfacial platform, the mandible is confined within to the bimalar width. The bigonial width of the posterior jaw is narrower in the woman, thus accentuating the overriding

cheekbone prominences. Structurally wider, the man bigonial jawbone approximates the bimalar width and creates a central and lower facial squareness, and with a vertically longer and thicker ramus with larger condyles, it lengthens the lower facial third [4]. Although the tapered woman jaw appears curvilinear and lifted, in the man jaw, it visually imparts a stabilizing supportive platform. The masculine anterior symphysis is square, bulkier, and wider in comparison to the delicate rounded woman chin [9]. On profile view in the man, there exists a squareness to the angle of the jaw, with a gonial angle of 90 in comparison to a 9 to 12 angulation found in the woman mandible [10,11]. In the attractive woman, the graceful jawline arches and overrides a distinct submandibular shadow, serving as an important sculptural aesthetic marker. The lower jawline edge parallels the inclination of the zygomatic arch, creating an aesthetic balance to the lower

FIG. 7 Structural platforms: cranial (C), maxillary (Mx), nasal (N), mandibular (Mn) complexes. (Ó 2019

Peter M. Schmid.)



FIG. 8 (A) Facial structural analysis cranial view. (B) Biparietal width (black bidirectional arrow) Zygomatic

arches and width (black linear arrows), Skull tapering (oblique faint green arrows). (C) Malar 3-dimensional projection. (D) Female midfacial. (E) Male midfacial with reduced zygoma projection. (Ó 2019 Peter M. Schmid.)

third of the face. Degrees of mandibular protrusion effect the visual balance of the face and nasal profile silhouette lines. The nasal osseocartilaginous platform is the keystone to midfacial proportion and balance. Anatomically, this vertically elongated triangular feature oriented in the central third of the face influences spatial orientations both “actual and illusionary” to the appearance of the intercanthal distance, ocular depth, bimalar width, midfacial projection, the chin, and profile aesthetics. The nose is constructed of subtle shapes and planes and is individually unique in size, shape, length, and type. Examined from multiple views, specific appraisals should include the nasal width, dorsal height, tip projection and angulation, dorsal-to-tip ratios, and attitude. The quality and thickness of the skin blanket or express underlying osseocartilaginous form. The aesthetic nose should be symmetric and straight, proportionately balanced, and should subtly blend with the face, bridging the upper and lower facial thirds. The attractive feminine nose is smaller; the nasal tip is refined, and the nostrils are soft and round. The nose

should display a structural smoothness with curvilinear flow from the medial supraorbital rim to the lateral nasal vault and complement the adjacent the facial features. In profile, there is a sweeping profile flatness often with an elegant soft leading tip, and a flowing Sshaped curve on profile from the forehead to the chin. The alar/columella shape is “gull winged” on the frontal view. The masculine nose is dominantly large, chiseled, and angulated, with a fuller nasal tip and thicker skin reflecting a rounded tip definition. Man nasal profiles may range from a prominent hump to a straight dorsum carrying linear reflective dorsal ridge highlights. Favorably, the nasolabial angle approximates 100 to 110 in the woman profile and 90 in the man profile. The ideal upper lip-to-tip projection should approximate a 1:1 ratio [12].

Facial Soft Tissue Platform Encompassing the skeletal framework is a soft tissue envelop comprising an interwoven arrangement of dermal, fatty, glandular, and myofascial tissues each

Sculptural Aesthetic Surface Anatomy of the Face unique in consistency, thickness, and disposition. Youth and beauty are defined by flawless radiant skin and suspended facial volumes positioned on a healthy bony framework. The bulk of the facial mass comprises subcutaneous fat and temporalis and masseter muscle. Structurally organized into layered deep and superficial fat “compartments,” facial adipose tissue contributes significantly to volumetric shape of the entire face [13]. The woman by nature has abundant subcutaneous facial fat, creating an even homogenous contour [14]. Retaining ligaments maintain soft tissue shape, vitality, and support. Understanding compartmental fat distribution guides the eye as to its influence on surface form (Fig. 9).


to the lid cheek junction and onto the upper cheek platform. The lower eyelid, cheek, and ogee contour are maintained by the orbitomalar and zygomaticocutaneous ligaments, orbicularis oculi muscle, and lower lid and cheek fat components [17,18]. The prominent superior orbital rim in the man contributes to anatomically smaller and slitlike masculine eye appearance. The man infrabrow eyelid skin often drapes over the upper eyelid as a dominant oblique linear edge, with an overlying horizontal coarse brow. The galea fat pad and corrugator/glabellar muscles contribute to a central fullness at the glabellar zone in both sexes. Temple fullness, flatness, or depression reflects the volumetric status of the temporalis muscles and the temporal fat pads.

Periorbital and temple zones Orbital aesthetics comprises a framing bony orbit, the globe, and periorbital soft tissue volumes, interfaced with a variety of arches and curves. The lateral supraorbital rim in women demonstrates a sculptural aesthetic marker by a sweeping lateral infrabrow fullness, supporting a gracefully tapered and often arched brow. This volume reflects the contributions of the orbicularis oculi muscle, retro-orbicularis oculi and periocular fat, and orbital rim contour [15]. The upper eye is horizontally draped by an angulated upper eyelid skin and framed above by infrabrow soft tissue fullness, thus creating a visibly arched or hidden superior palpebral crease, and degrees of upper eyelid exposure. Similarly, the lower eyelid drapes the globe from below, sweeping medially to laterally with an upward inclination (4.1 mm in the woman and 2.1 mm in the man) as it inserts into the lateral orbital rim [16]. This angulated canthal tilt creates an aesthetic “almond shape” to the woman eye. The aesthetic or youthful lower lid will often form a vertically short 5- to 12-mm lower lid crease, and a seamless surface flow inferiorly, blending

Midface zone Woman facial beauty emanates from the midfacial zone. The malar eminences draped by volumetric fat pads construct a visually inverted “Triangle of Beauty” tapering downward from the bizygomatic prominences to the chin (Fig. 10). From oblique frontal views, healthy cheek contour extends inferiorly as flowing ogee curves. Attractive woman faces exhibit a confluence of cheek fullness spanning the midfacial platform from the nasofacial junction to the preauricular zone. Cheek contour overriding the malar zones ranges from elliptical to a crescent-shaped fullness (never “stuck-on”). As its sweeping form flows around the zygoma, it tapers laterally and obliquely above the posterior zygomatic arch edge. The prominent cheek 3dimensional fullness creates a dominant curving reflective highlight peaking at the upper anterolateral cheek. The “high cheekbone” appearance is an extraordinary sculptural aesthetic marker, genetically found in some [19,20].

FIG. 9 (A) Sculptured facial anatomy, fat pads, and planes. (B) Volumes and highlights in clay. (C) Live model. green: volumetric facial prominences and highlights. red: malar fad pad projection. (Ó 2019 Peter M. Schmid.)



FIG. 10 Female facial aesthetics with triangles of beauty. (Ó 2019 Peter M. Schmid.)

In the attractive man with chiseled features, there exists inverted facial Trapezoids of Masculinity. Notably, such shape spans from the bimalar width angulating inferio-obliquely into the lateral paramental squareness of the chin (Fig. 11). The cheek pad is broad-based superiorly and positioned anteromedially, with a tapering caudal soft tissue apex that extends downward into the lower midface. Underprojection of the man cheek creates a flatness to the malar zone. Often, the shape of the malar complex appears skeletonized and tapers posterolateral as a well-defined triangular form overlying the outline of the zygomatic arch. The man cheek pad at times appears “stuck on,” especially with aging. Expanding downward from the horizontal zygomatic arch to the mandibular edge are submalar facial planes.

Within this region the densities of the parotid gland, the masseter muscle, and deep facial fat pads exist. The parotid glands provide volume to the preauricular zone overlying the ascending ramus and angle of the mandible. The masseter muscle creates an oblique surface form in many, because it originates off the inferior zygomatic arch and maxillary process and inserts inferiorly into the angle and lower ramus of the mandible. This powerful contractile muscle in the man (and in select lean women) may render a chiseled linear shadow off its anterior muscular edge and add bulk to the bigonial mandibular width. The zygomatic major muscle extending from the malar eminence to the modiolus of the mouth defines an oblique aesthetic line to the anterior submalar zone. The buccal fat pad of Bichat

FIG. 11 Male facial aesthetics and Trapezoids of Masculinity. (Ó 2019 Peter M. Schmid.)

Sculptural Aesthetic Surface Anatomy of the Face contributes to premasseteric submalar fullness [21]. There is a visual aesthetic tension by the juxtaposed curvilinear shape of the midface with the chiseled angularity of the mandibular platform.

Perioral complex: mouth and chin Mouth appearance is a synthesis of form and function unique in size, shape, and volume. The mound of the mouth is arched, contouring the maxillary and mandibular alveolar ridges and dentition. Woman lips are anatomically shorter and full, with length often the distance between the medial limbus of the iris. In the man, the upper lip is thinner and longer, with horizontal length approximating the width of the midpupillary distance. Youthful mouths maintain a lower facial inverted triangle of beauty from the bicommissure labial width to the chin. In contrast, the masculine mouth reveals a masculine trapezoid lip-to-chin relationship, based ona square-shaped chin. The upper lip is M-shaped and conforms to a shorter underlying W-shaped lower lip. The upper lip becomes aesthetically appealing by its raised and curvilinear vermillion edge, which blends medially into Cupid’s bow. The upper white lip consists of 2 lateral planes meeting centrally at a U-shaped concavity named the philtrum or “love charm.” Philtral columns extend from the base of the nose to the vermillion border as inverted V-shaped linear ridges varying in definition [22]. The philtral columns intersect Cupid’s bow at the Glogau-Klein points, the 2 sites of greatest prominence and a highlight point to the upper lip [23]. The vermillion edges and tubercles of the mouth create distinct aesthetic reflective highlights and forms of expression. The pink upper lip vermillion structurally consists of 3 tubercles, and the lower lip consists of 2 tubercles. Anatomically, the central upper lip tubercle, bounded by the 2 lateral tubercle masses, interlocks with the 2 horizontal tubercles of the lower lip, overprojecting the lower lip by 1 to 3 mm on profile view [24]. The lower lip tubercles fused centrally as cylindrical forms and taper laterally to rest on a lower lip shelf, as it blends into the concavity of the oral commissures. Two oblique soft tissue pillars formed by the depressor muscles support the lateral lower lip, and centrally a sublabial plane and shadow course downwards to the mental crease. The contemporary ideal vertical upperto-lower lip height ratio is defined as 1 to 1.618, with side-to-side symmetry following the same ratio. Cultural beauty defies this dictum, as variable lip ratios may reflect heightened beauty. Excessive elongation or flatness to the upper lip is unappealing in the woman. Contingent upon volume, shape, and size, the mouth


may reflect a sensual sculptural aesthetic marker of high regard. The chin presents in various shapes and forms, whether average, overprojected, retrognathic, square, tapered, rounded, cleft, witchlike, or dimpled. Ideally, the chin should be delicate and round in the woman and strong and chiseled in the man. Strong chins are aesthetically pleasing in the man, whereas slight underprojection and vertically aligned with the upper in profile view are favorable in the woman. The shape of the chin creates a central reflective mass, the “chin pad,” anatomically situated as a projecting fleshy prominence at the front of the chin rather than off the lower edge of the mandible. It typically overrides the labiomental crease, which is set back 4 mm from chin profile [25]. The chin pad may be characteristically dimpled or cleft in some.

SUMMARY Human facial appearances are distinct complex physical arrangements of structural anatomy, features, and form. With sculptural training, the cosmetic surgeon can advance observational skills, form sense, aesthetic judgment, and intellect for 3-dimensional facial aesthetics and form (Fig. 12). An artistic directive promotes perfect practice and productive refinements in performance, applicable through the various stages of analysis, planning, and delivery of cosmetic surgical

FIG. 12 Sculpting and form sense: serenity in bronze.

(Ó 2019 Peter M. Schmid.)



FIG. 13 (A) Connections and translations from artistic sculpting in clay to cosmetic surgery. (B) Artistic planning

and multiperspective analysis. (C) Deliberate volumetric AFT replacement, jawline suture reshaping, and lipectomy and lipocontouring to selectively sculpt and shape surface form. AFT, autologous fat transfer. (Ó 2019 Peter M. Schmid.)

technique. This heightened tool set can achieve the ultimate goal: natural-looking results and highly satisfied patients (Fig. 13). Video: Full HD:

REFERENCES [1] Rhodes G. The evolutionary psychology of facial beauty. Annu Rev Psychol 2006;57:199–226. [2] Thornhill R, Gangestad S. Facial attractiveness. Trends Cogn Sci 1999;3(12):452–60. [3] Powell N, Humphreys B. Proportions of the aesthetic face. New York: Thieme Medical Publishers; 1984. p. 15–39.

[4] Krogman W. Sexing skeletal remains. In: The human skeleton in forensic medicine. Springfield (IL): Charles C. Thomas; 1973. p. 112. [5] Farkas L. Anthropometry of the head and face in medicine. New York: Elsevier; 1981. [6] Bartlett S, Wornom I, Whitaker L. Evaluation of facial skeletal aesthetics and surgical planning. Clin Plast Surg 1991;18(1):1–9. [7] Habal M. Aesthetics of feminizing the male face by craniofacial contouring of the facial bones. Aesthetic Plast Surg 1990;14(2):143–50. [8] Hage J, Becking AG, de Graaf FH, et al. Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg 1997;99(7):1799–807.

Sculptural Aesthetic Surface Anatomy of the Face [9] Stewart T. Attributions of sex. In: Stewart TD, editor. Essentials of forensic anthropology. Springfield (IL): Charles C. Thomas; 1979. p. 85–92. [10] Horowitz H, Thompson R. Variations of the craniofacial skeleton in postadolescent males and females. Angle Orthod 1964;34:97. [11] Liew S. Contemporary beauty. UBM Medica e-newsletter, Modern Medical Network; 2009. p. 84–5. [12] Simons R. Nasal tip projection, ptosis, and supratip thickening. Ear Nose Throat J 1982;61(8):452–5. [13] Rohrich R, Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–27. [14] De Greef S, Claes P, Vandermeulen D, et al. Large-scale in-vivo Caucasian facial soft tissue thickness database for craniofacial reconstruction. Forensic Sci Int 2006; 159(1):S126–46. [15] Codner M. Adipose compartments of the upper eyelid: anatomy applied to blepharoplasty. Plast Reconstr Surg 2004;113(1):379–80. [16] Whitaker L. Selective alterations of palpebral fissure form by lateral canthopexy. Plast Reconstr Surg 1984;74:611. [17] Nahai F. The art of aesthetic surgery: principles and techniques. St. Loius (MO): Quality Medical Publishing Inc; 2005.


[18] Rohrich R, Arbique GM, Wong C, et al. The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg 2009;124(3): 946–51. [19] Swift A, Remington K. Beautification: a global approach to facial beauty. Clin Plast Surg 2011;38(3):347–77. [20] Hinderer U. Malar implants for improvement of the facial appearance. Plast Reconstr Surg 1975;56(2): 157–65. [21] Stuzin J, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990;85(1):29–37. [22] Sarnoff D, Gotkin R. Six steps to the “perfect” lip. J Drugs Dermatol 2012;11(9):1081–8. [23] Goodman G. Duckless lips: how to rejuvenate the older lip naturally and appropriately. Cosmet Dermatol 2012; 25(6):276–83. [24] Ricketts R. Esthetics, environment, and the law of lip relation. Am J Orthod 1968;54(4):272–89. [25] Iblher N, Kloepper J, Penna V, et al. Changes in the aging upper lip-a photomorphometric and MRI-based study (on a quest to find the right rejuvenation approach). J Plast Reconstr Aesthet Surg 2008;61(10): 1170–6.

Advances in Cosmetic Surgery 2 (2019) 23–27


Tricks for Patient Retention for Maintenance Care Kavita Mariwalla, MD Mariwalla Dermatology, 1253 Montauk Highway, West Islip, NY 11795, USA


 Patient retention tactics  Loyalty programs  Discount programs

 Patient communication strategies


 Patient retention is the key to the success of an aesthetic practice.  Encouraging patients to continue maintenance treatments can be more difficult than it seems.  There are some common strategies that have proven themselves over time, namely, loyalty programs, bundling procedures, and discount events.  Not all patient retention needs to involve a decreased dollar value off services.  Consistent communication, aesthetic ambassadors, and creating a welcoming environment can also make patients want to return.

NATURE OF THE PROBLEM It is widely known that for a procedure such as botulinum toxin injections, patients return on average 1.4 times per year [1]. Understanding that the toxin typically has a duration of action of 90 days, that leaves a gap in the 4 treatments per year expectation. It begs the question, what is preventing these patients from coming back? Or to change the reference, what can a practice do to encourage their return? The underlying issue most aesthetic practices face is how to retain and encourage patients to continue maintenance care. This becomes more complicated when the procedure done has a longer duration of action. However, there are ways to continue to pique patients’ interest and encourage them to return to the office not just for repeat treatments but also to explore new treatments as they age. Acquiring leads is the start to building any aesthetic practice; however, failure to retain existing patients can be devastating. According to [2], studies have shown that 68% of

appointments come from existing patients. The same website cites that 12% to 15% of patients who are faithful to a single practice represent 55% to 70% of appointments. Losing a patient wastes 7 times the resources used in converting a lead to a patient. If the goal is to encourage patient loyalty, one must remember that the key to loyalty is patient satisfaction. According to the Technical Assistant Research Programs, if 1 customer is satisfied, the information reaches 4 others. If 1 customer is alienated, it spreads to 10 customers, or even more if the problem is serious. Therefore, if 1 customer is annoyed, 3 other patients will need to be satisfied just to stay even. Assuming the results of any procedure performed met expectations, the next step to patient satisfaction is making the person feel valued. One way to demonstrate this is through appreciation or tokens of gratitude for being loyal which can, in turn, engender repeat visits. There are many ways to accomplish this. Loyalty

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programs, discount programs, and bundled purchases are easy-to-implement ways to enhance patient retention for maintenance care. In this article, the author reviews these options as well as the pros and cons for each.  Loyalty programs  Loyalty programs are the most common method used by practices and even cosmetic companies to drive repeat business. In this model, patients receive points or have to spend a certain amount of money in order to get a discount. There are some national programs that practices should participate in because patients may ask for them by name, and more importantly, these programs are at no cost to the practitioner.  Two such programs are Brilliant Distinctions, which encourages patients to stay within the Allergan suite of injectables, and ASPIRE, which promotes Galderma products.  How they work: Depending on what the patient buys, they are eligible for points, which they can use for future discounts on products in that suite of offerings. For example, $500 in Botox can result in $15 in discounts for a repeat Botox or any Juvederm injection if using Brilliant Distinctions. This discount is then reimbursed to the practice.  The disadvantage to these programs is that they are somewhat cumbersome to administer because often times patients register for them with an e-mail address they do not remember. Also someone is needed who can register the patient for these rewards and then remember to ensure that rebate checks for discounts passed to patients are recouped by the practice from the company (which is why this is no cost to the practice). This can be time consuming, and if trying to register a new patient to the program, the checkout process for other patients can get backed up. The practitioner can offer their own loyalty program, which can take several forms, as follows:  A card, which results in an automatic dollar value discount after a certain amount is spent.

 This card can be printed in house on thick paper stock or even as a “credit card” printed on plastic. Several companies print such customized plastic membership cards, which can be branded to the practice.  A standard discount that is given to anyone who spends over a certain amount per year  The cautionary tale here is that if procedures are discounted outright for repeat customers, the practitioner runs the risk of eventually driving down their own price permanently.  A discount for a person for a repeat procedure if they bring in a friend for a similar procedure (thus potentially getting an additional patient)  An alternate option to a broad loyalty program is to consider procedure-specific targeting.  For example, if patients do not return 3 to 4 times per year for toxin injections (most do not), consider an “Early Buyer’s Club.” In other words, the patient pays in advance for 3 treatments to be performed in a year and the last treatment will be 30% off. The result is that the net discount is 10% per treatment, but the advantage is a doubling of the average repeat rate for treatment (average is 1.4 treatments per year).  For large procedures, instead of a discount, offer an additional less expensive treatment at 6 months after the procedure is completed that is in line with what they have already spent. For example: If a patient completes a series of laser hair removal treatments, offer a chemical peel 6 months later at no cost.  The net cost to the practitioner will be minimal, but it will entice the patient to return for their “free treatment” and will give the practitioner another touch point to introduce them to a different service the practice offers. If a patient has done a radiofrequency tightening treatment, at the 1-year mark, offer a 20% discount on a toxin treatment. Although this may seem like a deep discount, remember that this patient has already spent a considerable amount in the practice and therefore may be willing to spend money on additional,

Tricks for Patient Retention for Maintenance Care more expensive treatments once introduced to them.  Loyalty programs can also be combined with services from other local health and wellness vendors.  For example, if there is a popular gym or fitness class center in the area, it may be worthwhile to offer a small discount on services for anyone who is a member of that gym or center.  Alternately, approach a local gym or fitness center and ask if they will offer a sample class or free 1month membership to a patient who has done a body-contouring service (most fitness centers are also always looking to attract new clients).  Similarly, if there is a popular bridal salon in town or event planner, it may be beneficial to offer a discount to mothers of the bride or the brides themselves as a way to attract new patients and create a loyal referral source for the practice. As part of this package, offer the bride a free service for a certain dollar value on their wedding anniversary for the first 3 years.


 The most common discount program is “Friends and Family,” whereby a standard discount is given to all family members of employees.  Depending on the size of the practice, this can be a sizable expense; however, there are ways to administer this. One can limit the definition of family to nuclear family (so no cousin’s cousin). Another option is to limit the time of year these discounts can be used so the discounted procedures do not take up time slots during busy times of year.  Offer employees a “golden ticket” on a yearly basis. They can give this ticket, which is for a specific procedure or carries a specific dollar value, to 1 person of their choosing.  This kind of program does improve employee morale but also engenders loyalty among their family members, who can in turn encourage others to visit the practice because of their good results.  Live-learning programs  A monthly or quarterly educational program featuring the physician is a good way to teach patients about procedures, especially lasers, and can be an avenue to encourage patients to return to the practice for learning without feeling pressure. At this information session, discounts can be offered if patients treat more than 1 area or


book more than 1 treatment at the time of the meeting. Consider offering a passport program that rewards patients for returning to these live learning sessions with a giveaway after attending a certain number of them.  Seasonal specials  Seasonal specials are quite popular; however, if seasonal specials occur at regular intervals, the practice can end up cannibalizing their own patients because the patient will just wait until the next promotion before booking a service, which can result in consistently discounted procedures.  If the practice chooses to go with seasonal specials, the specials should be very specific. In other words, instead of a standard percent discount off a procedure, offer a discount on lip filler around Valentine’s Day if toxin is purchased in the month of December.  Milestone events  A simple birthday coupon for patients offering a standard dollar amount off of cosmetic procedures is also an excellent way to keep patients coming back. An e-mail program tied to the patient database can be configured to send out these birthday wishes the day before the start of every month, and patients have that particular month to redeem the coupon. Be aware of aesthetic patients who may be celebrating a milestone event, such as a 50th birthday; consider a free birthday gift with purchase in addition to the standard coupon.  Consider a month-long bridal skin boot camp or even a mother-of-the-bride boot camp. Map the timeline out visually and post this in the waiting area or even create a beautiful album showcasing brides from the practice so that patients can be reminded that, when they reach such a milestone, the practice is available to help them look their best.


 Bundling purchases is a good way to ensure patients not only maintain results but also continue to return for additional services.  Ideally, bundling occurs with 2 “like” services.  Summer is typically a slower month for laser procedures; however, summer may be the ideal time to offer maintenance treatments at a discount if a laser procedure is done in the fall.



Mariwalla  In other words, if an intense pulsed light is performed in the fall, offer a spring refresher facial or a discount on sunscreen for the summer. Not only will this keep patients in a routine but also could potentially improve their results. If a body-sculpting treatment is done in the fall, consider a discount for laser hair removal for a small area, such as armpits, to make sure they are “summer ready”. Create a communication platform to reach out to patients at a specific interval after a procedure is done.  For example, a year after Ultherapy, reach out to patients to make sure they are still satisfied with their results and discuss a repeat treatment at a discount. Do not think of maintenance as simply procedure based. Consider skincare as well. For example, if during a consultation a patient is given a sample of product, offer them a 10% discount if they return the empty sample and decide to buy that product. It gives them incentive to actually try the sample and to return. Obviously, limit the samples! Depending on how much a patient purchases, include a gift with purchase, which can be a lip plumper (which you do not necessarily have to have as part of your normal inventory) or a bag (often available from the cosmeceutical companies themselves). Organize a once a year cosmeceutical discount event. Do not do this at regular intervals; otherwise, all products are permanently discounted. At this once a year event, offer a substantial discount, like 20% on all products purchased. If this becomes an annual event, patients will look forward to it and plan on buying accordingly and will return to the practice for their purchases. Limit the number of any 1 product a person can buy to avoid someone buying 20 of 1 thing and then reselling them later online. Consider a box-style subscription program. For a fixed dollar amount over a 12-month period, patients can come in and pick up products appropriate for each season. For example, for $X, patients can stop in after March 21 for a specific moisturizer; after June 21, for a specific sunscreen; after September 21, for a retinol; and after December 21, for an antiaging product. By coming in seasonally, patients can then be exposed to appropriate materials, highlighting procedures that are particularly useful for that time of year. Although this article so far has focused on discounts, bundling, and loyalty programs, there are ways to maintain patient loyalty without decreasing

the dollar value of any service offered. This involves communication, as follows: Intake questionnaire  The cosmetic questionnaire can be as cumbersome or as streamlined as the office wants.  Regardless of how many questions are in this questionnaire, there are data that may not be considered part of their treatment. Consider the inclusion of soft data that will help you target your marketing efforts.  For example, make sure to collect zip codes of patients to help with targeted e-mailing via online social media apps like Facebook (not just home zip codes but also work zip codes).  Ask patients about their occupation and consider events such as nurse appreciation events or teacher appreciation events if you find you have a critical number of patients in this demographic.  Ask patients if they belong to any “mom groups” on Facebook.  Many of these groups will allow advertising of a business on certain days of the week, which can help you target your patient demographic. Follow-up communications  After any cosmetic service, patients should be contacted 3 days later and again 10 days later.  Patients should not receive more than 12 e-mail communications per year from the office because this can be overwhelming.  According to, practices that communicate with their patients 10 times per year have 300% more profit than those that lost contact with patients. Schedule follow-up visits  In a study by White and colleagues [1], patients who did not have a mandatory follow-up visit after neurotoxin injection had a 55% retention rate. Once a mandatory 2-week follow-up posttreatment evaluation visit was instituted, that retention rate went up to 67%. Create a welcoming environment  By cultivating a clean and aesthetically pleasing office environment, patients will want to return, having gained trust in the totality of their treatment experience.  This welcoming environment can include a small bottle of water at check-in along with a practicebranded napkin.

Tricks for Patient Retention for Maintenance Care  Healthy snacks can be offered for patients who are waiting for their appointment more than 15 minutes.  Cosmetic ambassadors can be hired, whose job it is to remember patients and look through charts the day before to make notes on the day sheet so at checkout the receptionist is cued to ask friendly questions. For example, how is your son XXX, or how was the college reunion? The key of course is to keep such notes in the patient chart.


tenance care can involve the creation of programs that reward dollars spent, loyalty for repeat treatments, and bundling of packages. However, in addition to tangible surprises like these for patients, low-cost strategies like e-mails and a concerted communication campaign can help. Losing an existing patient not only wastes the effort spent in converting a lead to a patient but also can erode the foundation a practice is built on.



[1] White L, Tanzi EL, Alster TS. Improving patient retention after botulinum toxin type A treatment. Dermatol Surg 2006;32(2):212–5.

Ultimately, patient retention tactics are not just helpful to grow an aesthetic practice but are critical for practice success. Implementing ways to retain patients for main-

[2] Available at: Accessed January 12, 2019.

Advances in Cosmetic Surgery 2 (2019) 29–40


Surgical Site Infections in Cosmetic Surgery Emily A. Spataro, MD Division of Facial Plastic and Reconstructive Surgery, Washington University School of Medicine, 1020 North Mason Road, Building 3, Suite 205, Creve Coeur, MO 63141, USA


 Surgical site infection  Cosmetic surgery  Plastic surgery  Evidenced-based medicine  Wound complications KEY POINTS

 Surgical site infections occur at a lower rate in cosmetic surgery than in general surgery; however, surgical site infections can still be a major source of morbidity for patients.  Prevention of surgical site infections includes identifying factors that place patients at risk for infection, as well as implementing evidence-based guidelines shown to decrease the incidence of surgical site infection.  Owing to the heterogeneity of cosmetic surgery procedures, cosmetic surgeons should be familiar with the current literature and clinical practice guidelines for each procedure they routinely perform.

INTRODUCTION It is estimated that more than 1.5 million cosmetic surgeries were performed in the United States in 2017, and this number is far larger worldwide [1]. Surgical site infections (SSIs), although occurring with a lower incidence in cosmetic surgery patients than in general surgery inpatients, can still be a major source of morbidity and even mortality in this patient population. This argument is especially true because most of these patients are healthy, and infection is considered by some as a catastrophic consequence in the cosmetic surgery population [2]. Therefore, the prevention of this complication includes identifying factors that place patients at risk for SSIs, as well as implementing evidencebased guidelines shown to decrease the incidence of SSI.

Background SSIs are defined by the Centers for Disease Control and Prevention (CDC) as infections at or near the surgical site occurring within 30 days of an operative procedure,

or within 90 days if prosthetic material is implanted [3]. Currently, the rate of SSI for inpatient procedures is estimated between 2% and 5%, and up to 60% of SSIs have been estimated to be preventable through implementation of evidence-based guidelines [3]. The incidence of SSIs are monitored by the CDC’s National Healthcare Safety Network as well as the National Surgical Quality Improvement Program [4]. Additionally, the Centers for Medicare and Medicaid Services require hospitals to reports SSI rates, which are then publicly available on their web site [4]. Risk factors for SSI include both patient and procedural factors, such as age, tobacco use, diabetes, body mass index (BMI), emergency surgery, duration of the procedure, and wound class [3]. Although some of these factors cannot be changed, SSIs can be reduced by targeting modifiable factors through the implementation of evidence-based guidelines. This goal is accomplished by implementing SSI data tracking and providing feedback, improving the safety culture of institutions, and developing checklists

Financial Disclosure: The author has nothing to disclose. E-mail address: [email protected] 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.




or guidelines shown to reduce infection rates. For instance, the Agency for Healthcare Research and Quality designed an intervention that systematically incorporated the World Health Organization surgical checklist, as well as methods to improve the safety culture of participating institutes, and were able to reduce the SSI rate by 16% between 2010 and 2015 [4].

SUMMARY OF CURRENT GUIDELINES Both the CDC and World Health Organization have recently updated their evidence-based recommendations and guidelines regarding SSI prevention [5,6]. A summary of these findings include that patients should shower or bathe with soap (either plain or antimicrobial) or an antiseptic agent at least the night before the operation; however, there is no evidence to support chlorhexidine gluconate wash as being superior in preventing SSI. Decolonization for Staphylococcus aureus with mupirocin is only recommended for cardiothoracic and orthopedic operations, but may be considered for other procedures. Antibiotic prophylaxis should be given when indicated based on published clinical practice guidelines and timed such that the bactericidal concentration is established in the tissues before making an incision. Hair removal should be done with clippers only, because shaving is strongly discouraged at all times, whether preoperatively or in the operating room. Skin preparation should be done with an alcohol-based agent unless contraindicated, and there is a recommendation against using antimicrobial sealants after surgical site skin preparation. Preoperative hand scrubbing can either be performed with antimicrobial soap or an alcohol-based hand scrub. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. There is no evidence regarding whether different types of sterile drapes/gowns are better at preventing SSI, and there is insufficient evidence for saline wound irrigation. However, iodine irrigation may help, and antibiotic irrigation was shown not to help decrease SSIs. Negative pressure dressings do help to decrease SSI in high-risk wounds. No recommendations could be made regarding changing surgical gloves or instruments during the procedure. Finally, there was a recommendation against the use of topical antibiotic agents applied to surgical incisions [5,6]. Additionally, there is a recommendation to administer nutrient-enhanced formulas for underweight patients undergoing major operations and to not

discontinue immunosuppressive medications. During surgery, glycemic control should target blood glucose to less than 200 mg/dL, normothermia should be maintained, and an increased fraction of inspired oxygen should be delivered, both during the procedure as well as in the immediate postoperative period in patients with normal pulmonary function. Last, the transfusion of blood products should not be withheld to prevent SSI [5,6].

SURGICAL SITE INFECTIONS IN PLASTIC SURGERY SSI rates tend to be lower in cosmetic surgery procedures than for the general surgery inpatient procedures owing to a lesser number of comorbidities in these patients, as well as the outpatient nature of these procedures [4]. However, reported SSI rates of various cosmetic surgery procedures vary widely within the literature, depending both on procedure type, as well as method of recording incidence of SSI, such as institutional chart review or database use. For instance, 1 study of SSI in breast surgery and abdominoplasty used 2 different databases: the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database and the CosmetAssure database [7]. The TOPS database is a self-reported plastic surgery database that captures SSI treated in the office, compared with the CosmetAssure database, which is based on insurance claims for cosmetic procedures and only captures infections requiring hospital or emergency readmission, or a subsequent procedure, thus, including only major SSIs. Therefore, SSI rates were not only different between the 2 procedures, but also between the 2 databases used: for abdominoplasty, a 3.5% SSI rate was found in the TOPS database and a 0.7% SSI rate was found in the CosmetAssure database; for breast surgery, a 0.3% SSI rate was found in the TOPS database, and a 0.1% SSI rate was found in the CosmetAssure database. Thus, the infection rate was greater not only for abdominoplasty, but also with use of the TOPS database, because it captured more minor infections [7]. As demonstrated, the incidence of SSI in the literature varies significantly by procedure. The literature regarding breast augmentation has reported SSI rates between 0.001% and 7.000%; breast reduction between 0.11% and 22.00%; abdominoplasty between 0.16% and 32.60%; and body lift between 3% and 25% [8– 31]. Rates of SSI using the CosmetAssure database for these same procedures were 0.2%, 0.5%, 1.0%, and 1.9%, respectively [32]. There were also very low infection rates for liposuction and facelift, both occurring at

Surgical Site Infections in Cosmetic Surgery a rate of 0.1%, which is comparable with the literature reporting an incidence of less than 0.3% for both procedures [31–36]. Factors contributing to wound infection include patient factors, anesthetic factors, and surgical factors [37]. Patient factors include diabetes, tobacco use, malnutrition, chronic renal failure, alcohol use, jaundice, obesity, age, poor physical condition, medication, and chemotherapy or radiation exposure. Anesthetic factors include tissue perfusion, volume status, body temperature, blood oxygen tension, pain, and blood transfusion. Surgical factors include wound classification, skin preparation, surgical site, procedure duration, procedure complexity, suture material, the presence of a foreign body or implant, suturing quality, preexisting infection, antibiotic prophylaxis, occurrence of hematoma, and mechanical stress on the wound [37]. These factors may lead to decreased collagen synthesis (generally patient factors), increased vasoconstriction (both patient and anesthetic factors), and increased immunosuppression (all factors), which then causes decreased wound tensile strength, as well as decreased neutrophil bactericidal activity and lowered tissue oxygenation, all contributing to wound infection [37]. Large, multicenter studies established factors affecting SSI rates in clean surgery to be age, BMI, preoperative shaving, surgical drains, perioperative antibiotics, preoperative skin decolonization, perioperative hypothermia, and nicotine use [38,39]. Likewise, risk factors associated with SSI using the CosmetAssure database analyzing 129,007 patients found an increased risk of SSI with advanced age, female gender, BMI, smoking, a hospital or ambulatory surgery setting, and trunk and extremity procedures, as well as combined procedures after multivariable analysis [32]. In addition to determining rates of SSI and associated risk factors, the usefulness of systemic antibiotic prophylaxis in plastic surgery has also been investigated. A systematic review regarding the use of antibiotic prophylaxis to prevent SSI in plastic and reconstructive surgeries concluded that systemic antibiotic prophylaxis was recommended for clean breast surgery and contaminated surgery of the hand or head and neck, but not recommended to reduce infection in clean surgical cases in hand, skin, head and neck, or abdominoplasty [40]. Additionally, there was heterogeneity regarding types and doses of antibiotics used, so recommendations could not be made regarding optimal antibiotic type or dose, because each study included a single dose of antibiotic preoperatively, but all had variable antibiotic durations postoperatively [40]. Many referenced studies showed no benefit from


longer term antibiotic prophylaxis [41–45]. This finding was also reflected in another systematic review of antibiotic prophylaxis in plastic and reconstructive surgery procedures, with evidence supporting that antibiotic prophylaxis decrease postoperative SSI in clean plastic surgeries with high-risk factors and cleancontaminated plastic surgeries only. A short course administration regimen was adequate; however, there remains a need for more high-quality prospective trials on larger scales to further confirm these findings [46].

EVIDENCE-BASED RECOMMENDATIONS FOR THE PREVENTION OF SURGICAL SITE INFECTIONS IN PLASTIC SURGERY A 2015 systematic review by Dauwe and colleagues [37], regarding SSI prevention recommendations for facelift surgery, used data from studies of clean surgery owing to a lack of studies pertaining specifically to facelift. Because these recommendations were drawn from clean surgeries, and most cosmetic surgeries fall into this category, most recommendations can be applied to cosmetic surgery procedures in general. Decolonization recommendations include routine presurgical showering; however, the use of chlorhexidine or iodine was not shown to decrease SSI risk. Although an alcohol-based chlorhexidine surgical preparation is generally recommended, this study recommends parachlorometaxylenol for facial surgical preparation to avoid the ocular toxicity and ototoxicity of chlorhexidine; however, ophthalmic iodine paint can also be safely used to avoid toxicity [37]. Patients should be screened preoperatively with nasal swabs for S aureus colonization, and S aureus carriers should be treated with preoperative intranasal mupirocin to reduce risk of S aureus SSI [37]. Antibiotic recommendations include a single dose of preoperative antibiotic administered within 1 hour of surgical incision (or 2 hours for vancomycin or a fluoroquinolone), with cefazolin as the first-line agent for all clean procedures (clindamycin for patients with a beta-lactam allergy) and vancomycin for those with methicillin-resistant S aureus risk factors, and to discontinue prophylactic antibiotics within 24 hours of surgery [37]. Additionally, perioperative hypothermia should be prevented to reduce risk the of postoperative SSI, and surgeons should consider not operating on patients who cannot abstain from nicotine use, because all nicotine products should be stopped 4 weeks before and continued abstinence should extend to 4 weeks after surgery. The use of a preoperative urine nicotine test may be used to assess compliance with smoking



abstinence [37]. Postoperative monitoring recommendations include a thorough examination of all incisions, even in the late postoperative period, because delayed atypical infections have been described. Immediate initiation of antibiotic therapy should occur with the observation of erythema or other signs of infection, and treatment with empiric antibiotics should cover skin flora, especially methicillin-resistant S aureus, even in patients without risk factors. Finally, wounds should be surgically drained and debrided of infected or devitalized tissue, and fluid or tissue removed from the wound cultured for directed antibiotic treatment [37].

PROCEDURE-SPECIFIC SURGICAL SITE INFECTION PREVENTION As stated, the incidence of SSI in the literature varies both by study methodology, as well as type of procedure performed. Understanding the presentation, risk factors, and prevention recommendations for SSI in each surgical procedure is important toward reducing their incidence. Herein, the literature regarding SSI for each of these procedures is discussed individually.

Breast surgery Breast surgery includes both cosmetic breast reduction and augmentation, as well as reconstruction after mastectomy. SSIs associated with breast surgery may occur either in the acute postoperative period or much later, and most infections are caused by gram-positive organisms [47]. Acute infections are usually associated with fever, breast pain, erythema, and drainage, whereas late onset infections may present with chronic pain, persistent drainage, failed healing of the incision site, or migration of the implant [47]. In 1 study, the rates of early and late onset SSI was 1.7% and 0.8%, respectively, and more recent studies show a similar distribution of early and late onset infections, but with slightly lower percentages [48–50]. Diagnosing SSI is usually clinical and, when suspected, patients should be started on empiric intravenous or oral antibiotics depending on infection severity and closely monitored for signs of improvement, followed by culture-directed therapy [47]. However, implant removal is often necessary, especially in patients worsening on empiric antibiotics, showing signs of systemic toxicity, or who have cultures showing atypical mycobacteria or fungal infections [47]. Postmastectomy implants are associated with a higher risk of infection compared with cosmetic breast augmentation implants [47]. Studies have shown that,

for breast reconstruction after mastectomy, axillary node dissection, and chemotherapy or radiation, patients are at up to 10 times higher risk of SSI than for cosmetic breast surgery [10,51–54]. Infection was shown to be less likely to occur with delayed implant placement (2-stage surgery) [48,55]. Other risk factors include obesity, diabetes, renal failure, active skin disorders, and tobacco use [56,57]. The assessment of surgical factors have shown no difference between silicone and saline implants, but the use of acellular dermal matrix is associated with higher infection rates compared with submuscular reconstruction, and the use of drains have variable results on SSI rates [11,58,59]. Late onset SSI is thought to occur from seeding of implants from remote sources [47]. Treatment generally requires implant removal, antibiotics for 10 to 14 days, and some advocate delayed reimplantation by 4 to 6 months [47]. A literature review regarding SSI prevention in breast implant surgery shows there is support for the use of perioperative antibiotics in implant-based breast reconstruction, with extended coverage for high-risk patients [60]. In a metaanalysis of randomized, controlled trials, the use of antibiotics in clean breast surgery compared with no antibiotics showed an odds ratio for SSI of 0.16 (95% confidence interval, 0.04–0.61), or 94 fewer infections per 1000 patients [40]. Regarding the postoperative use of antibiotics, a retrospective review of 353 patients undergoing breast surgeries received either preoperative antibiotics, or both preoperative and postoperative antibiotics, reported a 7.8% overall rate of SSI, with no difference in SSI rate per group. Therefore, the use of postoperative antibiotics for non–high-risk patients was not advocated [61]. Other methods to decrease SSI in breast surgery include laminar air flow in the operating room, minimizing operating room traffic, shorter duration of operative time, washing the implant pocket before placement, double gloving, and conductive warming of the patient [60]. There is no evidence that implant type, surgeon experience, or incision site affects the SSI rate [60]. Additionally, there are varied results regarding S aureus screening and treatment, but because this is the most common pathogen cultured from these infections, a recommendation was made for S aureus screening with appropriate treatment of carriers preoperatively [60].

Abdominoplasty The infection rates for abdominoplasty have been shown to vary between 0.16% and 32.6% [25–27]. A study of SSI in abdominoplasty from a self-reported

Surgical Site Infections in Cosmetic Surgery plastic surgery database, the TOPS database, showed a 3.5% rate of SSI [7]. In another study using the CosmetAssure database, postabdominoplasty infection occurred at a rate of 1.1% [62]. Risk factors for complications included male sex, age greater than 55 years, BMI greater than 30, multiple procedures, or hospital/ surgical center location compared with an office-based procedure [62]. Other studies have also shown increased rates of complications for abdominoplasty in obese patients, in particular wound complications, seromas, and venous thromboembolism [63–65]. Smoking has been shown to increase wound complication and infection rates in abdominoplasty as well. One study evaluating 132 abdominoplasty patients, of whom 53.8% smoked, found a 48.9% wound complication rate in smokers compared with a 14.8% rate in nonsmokers [26]. Likewise, Araco and colleagues [66], found a 12-fold increase in infectious complications in smokers undergoing abdominoplasty. Other potential risk factors for increased SSI rate in abdominoplasty such as age, sex, and diabetes, have shown more variable results in the literature [62].

Liposuction Infection rates in liposuction are generally very low, occurring in less than 1% of cases, especially when not combined with other procedures [33,67–69]. It is thought that the most common cause of SSI is the presence of a hematoma in the subcutaneous tissue, resulting in secondary bacterial contamination [68]. The most common bacteria cultured in liposuction SSIs are S aureus, Group A Streptococcus, and S pyogenes [70–72]. Postliposuction infections are often difficult to diagnose because they often have an indolent course, but localized wound infections can progress to necrotizing fasciitis with very serious outcomes [71–77]. Thus, if an infection is suspected, antibiotic therapy against these pathogens should be initiated. When analyzing risk factors for major complications after liposuction, higher rates were found with combined procedures (greatest risk factor), age, BMI, and performance in a hospital setting [78]. Infection occurred at a rate of 0.1% in this study, and only an increased BMI was associated with SSIs specifically [78]. BMI was also found to be an independent risk factor for SSI in cosmetic surgical procedures in another study [32]. Several studies have shown obesity to increase the rate of infections, seromas, wound related complications and venous thromboembolism after surgery [12,14,16,17,63–65]. Other studies have found association of SSI after liposuction with age greater than 50, diabetes, alcohol abuse, drug use, peripheral vascular


disease, gastrointestinal malignancy, immunosuppression, and malnutrition [76]. No difference in postliposuction SSI incidence was found when assessing the amount of fat aspirated during the procedure [33].

Rhytidectomy Owing to the extensive vascularity of the face, infection is rare in rhytidectomy, with reported rates of less than 1% [79,80]. In general, complications in facial cosmetic surgery are infrequent, with reported rates ranging between 0.003% and 0.600% [79,81,82]. Despite the low infection rates, in a survey of cosmetic surgeons, 68% prescribe some combination of preoperative and postoperative antibiotics for rhytidectomy, because infection is considered a catastrophic consequence in cosmetic patients [2]. No clinical trials could be found investigating infection rates with and without antibiotic use in facelift specifically but, owing to the low infection rate, antibiotics are unlikely to show benefit [83]. A literature review with recommendations for facelift based on the evidence from studies of clean surgeries was summarized previously [37]. The main weaknesses of these recommendations are the lack of studies applying directly to facelift surgery and the inclusion of expert opinion [37]. Therefore, risk factors for SSI after rhytidectomy are drawn from those for clean surgery such as age, BMI, preoperative shaving, surgical drains, hypothermia, and nicotine use [38,39].

Blepharoplasty As with other facial surgeries, the infection rate in blepharoplasty is very low, occurring in less than 1% of cases owing to the clean wound classification and rich vascularity of the orbit [84,85]. When infections occur, patients present with tender, erythematous, and edematous eyelids [86]. The most common organisms cultured are Staphylococcus and Streptococcus species [86]. However, although rare, infections from blepharoplasty can lead to preseptal or orbital cellulitis, and the progression to orbital cellulitis is considered a visionthreatening complication [87]. Despite this fact, case reports of even serious infections resolve when treated early with antibiotics [88–91]. In a retrospective review of 1627 blepharoplasties, all patients were treated with topical antibiotics, and only 11 were treated with oral antibiotics for prosthetic joints or heart valves, resulting in an infection rate of 0.2%. All infections resolved with a course of oral antibiotics [84]. Thus, it was concluded that topical antibiotic use is sufficient for blepharoplasties, but not 100% effective in preventing SSI [84]. Surveys of cosmetic surgeons found that the antibiotic prescribing practices for routine eyelid surgeries



vary widely throughout the world, but use has increased significantly over the last 25 years, despite there being no standard of care requiring the routine use of postoperative antibiotics [92–94]. Because systemic antibiotics have not been proven necessary, and given the potential for compilations with systemic use, topical antibiotics are prescribed more commonly [95,96].

Rhinoplasty The incidence of SSI in rhinoplasty and septoplasty surgery has been reported between 0% and 18% [97,98]. Although infections are uncommon owing to the high local vascularity and generally healthy patient population, infections can occur at the skin–soft tissue envelope, at sites of sutures, in the implanted cartilage or alloplastic implants, or result from other complications such as septal hematoma [99]. As with most facial infections, the most common pathogens are Staphylococcus and Streptococcus species [100,101]. The sequelae of an infection include unacceptable cosmetic results and scar formation including synechia, nasal tip drop, septal perforation, and saddle nose deformity [102]. Indications for postoperative antibiotic use in septorhinoplasty include the prevention of septicemia in patients with valvular heart disease or immunocompromise, as well as complex revisions with extensive cartilage grafting [103,104]. One study assessing antibiotic use in rhinoplasty showed a decrease complication rate with antibiotic use for revision rhinoplasties only [105]. In studies comparing the use of preoperative antibiotics in septorhinoplasty compared with both preoperative and postoperative antibiotics, there was found to be no added benefit from the addition of postoperative antibiotics [98,106,107]. In addition, SSI rates have been reported at less than 1% in studies where no prophylactic antibiotics were used [103,108,109]. Furthermore, patients undergoing endonasal septorhinoplasty with autologous cartilage were shown not to benefit from prophylactic antibiotic use [107]. In case reports of rhinoplasty patients with SSI, culture-driven antibiotic regimens resulted in the resolution of the infection and minimal long-term functional or cosmetic consequences [110,111]. As a result, the most recent rhinoplasty clinical practice guidelines recommended against the use of postoperative antibiotics in rhinoplasty [112].

Facial alloplastic implantation Facial alloplastic implants are most often used to augment the chin, nose, and malar area. Various types of implant material are available, including silicone, polytetrafluoroethylene (with the trade names Teflon,

Gore-Tex, and Proplast), and high-density polyethylene (trade name Medpor) [113]. Infections usually occur from the transfer of intraoral flora during the placement of the malar or chin augmentation transorally, and are more common if the implant is not well-fixated, with some authors advocating either fixation of the implant with screws or suture and some advocating precise pocket formation without the need for fixation [114–117]. Additional techniques include the use of perioperative and postoperative antibiotics, as well as soaking the implant and irrigating the pocket with an antibiotic solution [114,118]. One case report described infection of malar and chin implants owing to poor oral hygiene of the adjacent teeth as well as nonfixation of implants several years after placement [115]. Infection rates for alloplastic chin implants have been reported to be between 5% and 7% [119], another study found rates of 0.7% for silicone chin implants and 7.6% infection rate for Proplast chin implants [120]. Malar implants have a reported infection rate that varies from 2.3% to 14.6% [120,121]. A metaanalysis of rhinoplasty implants reported infection rates of between 0% and 10% [122]. Higher SSI rates were found in patients with revision rhinoplasty, diabetes, septal perforation, and more porous implants [83]. Signs of infection include pain, drainage, skin erythema, or fistula [114]. Although generally the implant requires removal when infected, reports of implant salvage have been described with oral antibiotics and irrigation of the cavity with an antibiotic solution [114].

Skin resurfacing Most data regarding infections after skin resurfacing arises from literature for laser resurfacing, and specifically ablative CO2 laser resurfacing. Infection rates vary greatly, reported at between 0.0% and 8.3% [123–127]. In a large study of patients who underwent CO2 laser resurfacing, acne occurred at a rate of 15%, milia at a rate of 11%, contact dermatitis at a rate of 10%, and herpes simplex virus infection occurred in 7.4% of patients, regardless of prior herpes simplex virus history [128]. General methods of infection prevention include sterile technique, appropriate skin preparation, and diligent postoperative wound care [123–127]. Higher rates of infection have been associated with closed dressings methods, with open techniques reporting a 0% to 1% infection rate [126,128]. It is thought that occlusive dressings promotes the growth of bacteria and fungi [125]. Regarding topical antibiotic use, a systematic review of randomized, controlled trials comparing

Surgical Site Infections in Cosmetic Surgery postoperative topical antibiotic ointment with petroleum ointment found no difference in the infection rate, but a higher incidence of contact dermatitis in the antibiotic group [129]. Reports are variable regarding the effect of systemic antibiotics on SSI rates [124,125,130,131]. In 1 study, a significantly higher rate of infection was found in patients receiving systemic antibiotics, most frequently growing Enterobacter and Pseudomonas on wound culture [131]. Thus, there is no consistent evidence for the use of antibiotic prophylaxis in skin resurfacing procedures.

Other dermatologic procedures Studies of Mohs surgeries have found infection rates varying from 2% to 4% [132,133]. Infection rates are low, because most of these procedures are classified as a clean wound class and performed in the outpatient or clinical setting [132,133]. One analysis of antibiotic prophylaxis found that 18.5% of patients received antibiotics, with an overall infection rate of 3.4%, and although higher rates of SSI were found in those given antibiotics, multivariable analysis reduced this effect to be nonstatistically significant (adjusted odds ratio, 1.47; 95% confidence interval, 0.29–7.39) [132]. Data from other prospective studies indicate a greater risk of SSI in skin procedures if performed on the lower extremities, groin, wedge excision of the lip and ear, skin flaps of the nose, and skin grafts, and in patients with extensive inflammatory skin disease [134,135].

RISK FACTORS Large multicenter studies established factors affecting SSI rates in clean surgery to be age, BMI, preoperative shaving, surgical drains, perioperative antibiotic use, preoperative skin decolonization, perioperative hypothermia, and nicotine use [38,39]. Regarding age, it has been thought that, with advancing age, there is a decrease in both the innate and adaptive immune systems, resulting in a higher incidence of SSI and an inability of the body to respond adequately to postoperative stress [136–139]. In some studies, females have been found to be at greater risk for SSI than males; however, they also comprise a majority of plastic surgery patients [32]. Although traditionally males have had higher overall complication rates, such as hematoma, this finding does not seem to translate to increased wound infection rates [32]. BMI has shown to be a risk factor for many cosmetic procedures, especially in breast reduction, liposuction, and abdominoplasty [14–17,26,140–146]. There is thought to be less perfusion to the skin owing to excess subcutaneous


adipose tissue, thus making infection more likely [32]. Tobacco use has been associated with higher rates of infection in multiple studies, with one showing a 12fold increase in the SSI rate for abdominoplasty [66,147,148]. There is some evidence that SSI risk is decrease after at least 4 weeks of tobacco abstinence, although some effects may be irreversible [147,148]. Diabetes has shown varying results; it was an independent risk factor in both a large database study, as well as another large study of 2860 patients undergoing plastic surgery procedures; however, other studies, particularly of breast surgery, have shown no association [9,12,32,149]. Regardless, the CDC and World Health Organization guidelines recommend maintaining glucose control intraoperatively to less than 200 mg/ dL [5,6]. The type of facility has also been associated with higher rates of infections at higher levels of care; however, this factor may be related to patients with higher American Society of Anesthesiologists classification undergoing procedures in these settings [32,60,78]. Wound classification also presents an increased risk of infection. As one might expect, increased infection rates are associated with advancing wound class [150,151]. This finding is also reflected in the different antibiotic recommendations from a systematic review previously discussed for plastic surgery procedures, wherein systemic antibiotic prophylaxis was recommended for clean breast surgery, and contaminated surgery of the hand or head and neck, but not recommended to decrease infection in clean surgical cases of the hand, skin, head and neck, or abdominoplasty [40]. The body region where surgery is performed also influences SSI rate, because procedures performed on the trunk and extremities are associated with higher SSI rates than the face and breast [32,40,134,135]. Additionally, a longer procedure duration or performance of combined procedures are also associated with increased rate of SSI [32,60,78,151]. The presence of drains is also a potential factor influencing infection occurrence in cosmetic surgery patients. In a study of 54 patients undergoing plastic surgery procedures with 101 drains, all patients received perioperative antibiotics; however, only 39 patients received postoperative antibiotics. Although about two-thirds of the drains were found to be colonized with bacteria, only 2 cases, or 5.6% were infected, despite many of these drains being in the presence of prosthetic material [152]. Other studies have found variable results regarding infections rates with surgical drain use [11,59]. According to the evidence summarized in the CDC guidelines, however, perioperative antibiotics should not be continued to the postoperative



period in the presence of a wound drain for the purpose of preventing an SSI [5].

SUMMARY Despite the trend toward using antibiotics more frequently in cosmetic surgery, because SSI is often viewed as an unacceptable complication, there is a strong push toward implementing evidenced-based measures to decrease adverse side effects, such as antibiotic resistance and superinfection [114]. Through the implementation of institutional measures to improve patient safety, track SSI rates, provide feedback, and use evidenced-based SSI prevention guidelines, SSIs can be greatly reduced, as in the Agency for Healthcare Research and Quality initiative [4]. Owing to the heterogeneity of cosmetic surgery procedures, different recommendations based on surgical procedure performed, as well as patient and procedural factors need to be taken into account. Thus, cosmetic surgeons should be familiar with the current literature and clinical practice guidelines for each procedure they routinely perform.

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[108] Cabouli JL, Guerrissi JO, Mileto A. Local infection following aesthetic rhinoplasty. Ann Plast Surg 1986; 17:306–9. [109] Yoder MG, Weimert TA. Antibiotics and topical surgical preparation solution in septal surgery. Otolaryngol Head Neck Surg 1992;106:243–4. [110] Abuzeid WM, Brandt MG, Moyer JS, et al. Methicillinresistant Staphylococcus aureus-associated infections following septorhinoplasty. Facial Plast Surg 2012;28: 354–7. [111] Nicholas BD, Bhargave G, Hatipoglu A, et al. Preoperative prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization in patients undergoing intranasal surgery. Med Sci Monit 2010;16:CR365–8. [112] Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty. Otolaryngol Head Neck Surg 2017; 156(2Supp):S1–30. [113] Constantinides MS, Galli SKD, Miller PJ, et al. Malar, submalar and midfacial implants. Facial Plast Surg 2000;16:35–44. [114] Kridel RWH, Patel S. Cheek and chin implants to enhance facelift results. Facial Plast Surg 2017;33(3): 279–84. [115] Hasson O, Levi G, Conley R. Late infections associated with alloplastic facial implants. J Oral Maxillofac Surg 2007;65(02):321–3. [116] Niamtu J. Alloplastic chin augmentation. Oral Maxillofac Surg Clin North Am 2000;12:765. [117] Ivy JE, Lorenc PZ, Aston SJ. Malar augmentation with silicone implants. Plast Reconstr Surg 1995;96:63. [118] Eppley BL. Alloplastic implantation. Plast Reconstr Surg 1999;104(6):1751–83. [119] Strauss RA, Abubaker OA. Genioplasty: a case for advancement osteotomy. J Oral Maxillofac Surg 2000; 58:783. [120] Rubin JP, Yaremchuk MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg 1997; 100:1336. [121] Whitaker LA. Aesthetic augmentation of the malarmidface structures. Plast Reconstr Surg 1987;80:337. [122] Peled ZM, Warren Ag, Johnston P, et al. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg 2008;121(3):85e–92e. [123] Alster TS. Against antibiotic prophylaxis for cutaneous laser resurfacing. Dermatol Surg 2000;26(7): 697–8. [124] Menuskiatti W, Fitzpatrick RE, Goldman MP, et al. Prophylactic antibiotic in patients undergoing laser resurfacing of the skin. J Am Acad Dermatol 1999;40(1): 77–84. [125] Sriprachya-Anunt S, Fitzpatrick RE, Goldman MP, et al. Infections complicating pulsed carbon dioxide laser resurfacing for photoaged facial skin. Dermatol Surg 1997;23(7):527–35.



[126] Bernstein LJ, Kauvar AN, Grossman MC, et al. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997;23(7):519–25. [127] Gilbert S, McBurney E. Use of valacyclovir for herpes simplex virus-1 (HSV-1) prophylaxis after facial resurfacing: a randomized clinical trial of dosing regimens. Dermatol Surg 2000;26(1):50–4. [128] Nanni CA, Alster TS. Complication of carbon dioxide laser resurfacing: an evaluation of 500 patients. Dermatol Surg 1998;24:315–20. [129] Saco M, Howe N, Nathoo R, et al. Topical antibiotic prophylaxis for prevention of surgical wound infection from dermatologic procedures: a systematic review and meta-analysis. J Dermatolog Treat 2015;26(2):151–8. [130] Ross EV, Amesbury EC, Barile A, et al. Incidence of postoperative infection or positive culture after facial laser resurfacing: a pilot study, a case report, and a proposal for a rational approach to antibiotic prophylaxis. J Am Acad Dermatol 1998;39(6):975–81. [131] Walia S, Alster TS. Cutaneous CO2 laser resurfacing infection rate with and without prophylactic antibiotics. Dermatol Surg 1999;25(11):857–61. [132] Levin EC, Chow C, Makhzoumi Z, et al. Association of postoperative antibiotics with surgical site infection in Mohs micrographic surgery. Dermatol Surg 2018;00: 1–6. [133] Smith H, Borchard K, Cherian P, et al. Randomized controlled trial of preoperative topical decolonization to reduce surgical site infection for staphylococcus aureus nasal swab-negative Mohs micrographic surgery patients. Dermatol Surg 2019;45(2):229–33. [134] Dixon AJ, Dixon MP, Askew DA, et al. Prospective study of wound infections in dermatologic surgery in absence of prophylactic antibiotics. Dermatol Surg 2006;32: 819–26. [135] Wahie S, Lawrence CM. Wound complications following diagnostic skin biopsies in dermatology inpatients. Arch Dermatol 2007;143:1267–71. [136] Graham JE, Christian LM, Kiecolt-Glaser JK. Stress, age, and immune function: toward a lifespan approach. J Behav Med 2006;29(4):389–400. [137] Kiecolt-Glaser JK, Page GG, Marucha PT, et al. Psychological influences on surgical recovery. Perspectives from psychoneuroimmunology. Am Psychol 1998; 53(11):1209–18. [138] Roubenoff R, Harris TB, Abad LW, et al. Monocyte cytokine production in an elderly population: effect of age and inflammation. J Gerontol A Biol Sci Med Sci 1998;53(1):M20–6.

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Advances in Cosmetic Surgery 2 (2019) 41–46


Pain Control in the Age of an Opioid Epidemic Rachel C. Baker, BS, Jennifer F. Waljee, MD, MPH, MS* Section of Plastic Surgery, University of Michigan, North Campus Research Complex (NCRC), 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA


 Opioid  Pain management  Surgery  Nonpharmacologic  Analgesia KEY POINTS

 Acute pain is common following surgery, and important to effectively manage to ensure optimal outcomes.  Opioid analgesics are commonly prescribed for acute postoperative pain and are highly effective; however, it is critical to prescribe according to clinical guidelines and encourage safe storage and disposal.  Multiple pharmacologic and nonpharmacologic opioid alternatives are available for postoperative pain control and are often highly effective in managing acute pain following surgery.

INTRODUCTION The US Department of Health and Human Services recently released data indicating that more than 130 Americans died each day in 2017 from an opioidrelated overdose [1]. Opioid analgesics are frequently used to treat acute and chronic pain, but current evidence suggests that opioid exposure can yield prolonged use and dependence among some patients. For example, among patients undergoing major and minor elective surgery, roughly 5% of previously opioid-naïve patients continued to fill opioid prescriptions well beyond the usual postoperative period [2]. In addition to the risk of opioid dependence, prescription opioids are commonly overprescribed during procedural care. Prior research demonstrates that most pills prescribed to patients undergoing common surgical procedures remain unused and undisposed, increasing the potential of diversion into the community. Prescription opioids are now the primary pathway for transition to heroin use,

and nearly 80% of heroin users report their first opioid exposure includes misused prescription opioids [3,4]. In 2017, the number of deaths due to drug overdoses was estimated to have reached 72,000 [5]. Unfortunately, deaths related to opioids now exceed annual deaths related to motor vehicle collisions and gun violence and has been implicated in changes in life expectancy in the United States. The escalation of morbidity and mortality related to opioids in recent decades is due to a confluence of factors. First, in 2001, professional organizations charged with ensuring the safety of health care increasingly considered pain as a “fifth” vital sign and emphasized the eradication of pain as a top priority in health care quality [6]. In addition to this, aggressive marketing strategies by the pharmaceutical companies fueled the belief that opioids could be used effectively without concern for developing long-term dependence [7]. Finally, evidence-based guidelines for prescribing, particularly in surgical care, have been lacking, further fueling

Disclosure Statement: The authors have nothing to disclose. *Corresponding author. Department of Surgery, University of Michigan Medical School, 1500 E Medical Center Drive, 2130 Taubman Center, Ann Arbor, MI 48103. E-mail address: [email protected] 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.



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excess prescribing in the absence of data. Taken together, these factors have contributed to the rising incidence of opioid use, misuse, abuse, and associated mortality in the United States in recent decades.

PAIN CONTROL: OPIOIDS The sensation of pain is the body’s biological protective measure when subject to damaging stimuli [8]. Opioids and their derivatives remain highly effective analgesics, despite the growing knowledge regarding their risks. As shown in Table 1, natural opioids, derived entirely from the opium poppy plant, include opiates such as morphine, thebaine, and codeine [9]. The semisynthetic opioids, inclusive of hydromorphone, hydrocodone, and oxycodone, are derivatives of natural opioids designed to increase potency and efficacy. Last, fully synthetic opioids include fentanyl, methadone, and tramadol, and the highly potent opioid derivatives have gained increasing attention due to their high risk of associated overdose. All naturally occurring, semisynthetic, and completely synthetic opioids produce an effect by binding to central nervous system receptors [9]. Although opioids are nonselective and have the opportunity to act on any of the body’s opioid receptors (mu


Categories of opioids based on their chemical synthesis Classification

Opioid Name


Morphine Codeine Thebaine


Hydromorphone Oxycodone Buprenorphine Oxymorphone Hydrocodone (Vicodin)


Pentazocine Meperidine Propoxyphene Tapentadol Tramadol Transdermal systems with fentanyl Methadone Levacetylmethadol Levorphanol

Opioid antagonists

Naloxone Naltrexone

[MOP], delta [DOP], kappa [KOP]), most clinically relevant opioids act as agonists and bind to the mu receptor [9]. These receptors are all coupled to G-proteins, which, when activated, increase outward movement of potassium and decrease calcium entry into the presynaptic cell [9]. When the receptor becomes occupied, it inhibits neurotransmitters (ie, substance P) from being released from the dorsal horn in the presynapse [10]. This binding impedes the body’s ability to transmit nociception signals to the brain. Clinically, opioids produce analgesia, euphoria, sedation, and respiratory depression, as well as constipation, nausea and vomiting, and cognitive impairment.

OPIOID PRESCRIBING FOR SURGICAL CARE Although guidelines for the management of long-term opioid therapy and chronic pain have been released [11], much less is known regarding pain management in the context of procedural care. Recent evidence suggests that there is wide variation in opioid prescribing for common surgical procedures, and high-risk prescribing is common. For example, among patients undergoing common upper extremity procedures, most patients filled an opioid prescription, and high daily doses and overlapping prescriptions were common [12]. In addition, there is growing evidence that the risk of prolonged use among opioid-naïve patients is increased with earlier opioid prescribing (ie, before surgery) as well as greater amounts prescribed in the initial postoperative prescription and throughout the postoperative period. Therefore, identifying opportunities to standardize prescribing practices and use opioid alternatives is critical to enhance the safety and effectiveness of postoperative pain management. Recent evidence suggests that most patients consume fewer pills than prescribed after surgery [13], and that adherence to lower guidelines for opioid prescribing is acceptable to patients and providers. For example, recent guidelines introduced to reduce opioid prescribing following laparoscopic cholecystectomy not only reduced prescribing but was not associated with an increase in patient-reported pain, a decrease in patientreported satisfaction, or the need for additional refills. Moreover, guidelines to reduce prescribing for this procedure yielded reductions in other related procedures without explicit guidelines, producing positive spillover effects [14]. In an effort to curb excess prescribing, recent legislation has included efforts to ensure patients receive education about their risk of prescription opioids,

Pain Control in the Age of an Opioid Epidemic


prescribing limits on the duration of opioid therapy for acute pain, mandatory review of prescription drug monitoring programs, and referral for care for patients who suffer an opioid overdose. For example, limiting prescribing for acute pain to 3-day, 5-day, or 7-day limits is increasingly common. However, their effect on prescribing practices remains unclear, particularly for surgical care. Taken together, these findings suggest that engaging health care systems and professional societies to build clinical guidelines for opioid prescribing and postoperative pain management based on patient-reported opioid use and pain outcomes is an important opportunity to minimize excess pills prescribed while meeting patient needs after surgery.

This binding inhibits sodium from entering the channel and subsequently inhibits the conduction of neural impulses. Liposomal bupivacaine is associated with a significant reduction in opioid analgesic use in the 24 hours following surgery, as compared with those treated with bupivacaine HCl [19]. Moreover, most patients reported lower pain scores compared with placebo [19,20]. Nonetheless, more evidence is needed regarding the rate of adverse events by formulations, the cost-effectiveness of these local anesthetic options, and their effect on long-term opioid use [21].


Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory, analgesic, and antipyretic functions. Due to the role of prostaglandins in the body’s inflammation process, NSAIDs are actively able to suppress pain through the inhibition of prostaglandin synthesis [22]. To successfully inhibit the cyclo-oxygenase enzyme, NSAIDs are a competitive antagonist with arachidonic acid [23]. With the anti-inflammatory properties of high lipophilicity and strong acidity, NSAIDs are able to lessen inflammation in areas where tissue has been damaged and an immune response has been initiated. Common adverse effects associated with NSAIDs include gastrointestinal bleeding, heart attack or stroke, acute renal failure, skin reactions, and anaphylaxis. Specific to surgery, changes in platelet function have diminished enthusiasm for the use of NSAIDs due to the possibility of an increased risk of surgical site bleeding. However, a recent review suggests that NSAIDs are not associated with postoperative hematoma formation [24], and the American Society of Anesthesiologists recommends that NSAIDs should be highly considered when implementing a multimodal, perioperative pain treatment plan [25].

In addition to opioids, multiple other pharmacologic and nonpharmacologic strategies have been shown to be effective in managing acute postoperative pain, including nerve blocks, nonsteroidal antiinflammatory agents, acetaminophen, gabapentinoids, and behavioral-based techniques. For example, local and regional nerve blocks are widely used and highly effective in providing intraoperative and postoperative analgesia. All local anesthetics contain a common chemical structure, inclusive of a lipophilic aromatic ring, an ester or an amide, and a tertiary amine [15]. Whether the local anesthetic contains an ester, or an amide, determines its pathway for metabolism. Directly engaging with a cell’s voltage-gated sodium channels, local anesthetics are able to block conduction and the rate of action potentials decreases [15]. Greater hydrophobicity of a local anesthetic increases the potency and the duration of action of the drug [15]. By desensitizing the surgical site, lidocaine inhibits the conductance of neural impulses and is used to decrease both inflammation and pain following surgery [16]. In addition to short-acting anesthetics, there is increasing enthusiasm for innovations in long-acting local anesthetics to enhance postoperative recovery and pain control. For example, liposomal bupivacaine was approved by the US Food and Drug Administration (FDA) in October of 2011 [17]. This formulation allows for the extended release of bupivacaine over the course of approximately 72 hours [18]. This mechanism also takes advantage of the cell membranes’ voltage-gated sodium channels. As the injected bupivacaine slowly leaks from its liposome in the extracellular space, some of it is able to pass through the membrane and attach to sodium channels in the intracellular space.


ALTERNATIVE ANALGESIC TREATMENTS: ACETAMINOPHEN Acetaminophen is an antipyretic and analgesic commonly prescribed in conjunction with NSAIDs. Acetaminophen has relatively weak lipophilic and acidic properties [23], but its mechanism of action remains poorly understood. Nonetheless, acetaminophen is effective for acute postoperative pain, particularly for patients who are unable to use NSAIDs, and intravenous (IV) acetaminophen was approved by the FDA


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in 2010 [26,27]. Multiple studies demonstrate that IV acetaminophen alleviates pain effectively in the immediate postoperative period and is associated with enhanced patient satisfaction [28]. Although the risks of acetaminophen include anaphylaxis and liver toxicity, acetaminophen is safe in small doses and easily combined with multimodal analgesia protocols using NSAIDs and in conjunction with opioids, given its different mechanism of action.


Pharmacologic versus nonpharmacologic pain management methods Pharmacologic Opiates Local blocks (lidocaine) Regional blocks Nonsteroidal anti-inflammatory drugs (Intravenous) Acetaminophen

ALTERNATIVE ANALGESIC TREATMENTS: BEHAVIORAL TECHNIQUES Behavioral-based strategies are important nonpharmacologic techniques that are highly effective for managing both acute and chronic pain. Such strategies include heat and cold applications, massage therapy, exercise therapy, yoga, acupuncture and acupressure therapy, and mindfulness-based stress reduction techniques. Most of these techniques are directed toward reducing state and trait anxiety [29,30]. These selfregulatory techniques have been shown to improve anxiety symptoms in both psychiatric and medical patient populations and are the cornerstones of behavioral and cognitive-behavioral therapy for anxiety [29,31,32]. Many of the most effective techniques teach patients how to induce the relaxation response. Examples include paced breathing, guided imagery, and guided imagery plus suggestion and exposure therapy [31]. The relaxation response is activated, and patients are subsequently exposed to anxiety-provoking stimuli in a graded manner (from the least to most threatening). Over time, the fear-inducing stimuli lose their potency, and individuals habituate to what was once anxiety provoking [29,33]. In practice, such techniques are provided by trained practitioners through group or individual therapy sessions held over time. In a meta-analysis evaluating 20 randomized controlled trials (RCTs), both relaxation-based (eg, breathing practice, guided imagery) and audiovisual interventions (eg, videos, video games, music) were effective for pain and anxiety management for surgery performed under local anesthesia [34]. This review found that relaxation-based interventions were more effective than audiovisual interventions for managing anxiety. In another meta-analysis of RCTs assessing behavioral interventions conducted before orthopedic procedures, these techniques significantly reduced both preoperative and postoperative anxiety, improved postoperative pain control, and enhanced overall recovery. This robust evidence underscores the potential of psychosocial interventions, particularly patient

Nonpharmacologic Mindfulness-based stress reduction Exercise therapy Massage Heat/Cold applications Acupuncture Acupressure

education and relaxation techniques, to improve surgical care [30]. To improve scalability, recorded versions of guided imagery have been tested. For example, the Presurgical Guided Imagery Program examined preoperative anxiety and utilization outcomes among 905 patients [35]. In this cohort, 74% of patients adopted guided imagery, which resulted in higher levels of patient satisfaction. Further, 47% of patients in the usual care group reported “high” or “very high” preoperative anxiety, compared with 1.6% of patients reporting “high” or “very high” anxiety after listening to the guided imagery recordings. The greatest relief was reported by the patients who reported the highest levels of preoperative anxiety. Last, guided imagery was associated with shorter hospital stays and a 14% reduction in mean total charges billed per procedure, yielding an average savings of $2003 per procedure. Overall, these behavioral techniques have been shown to significantly decrease preoperative anxiety and result in better surgical outcomes in multiple types of surgery [34–38]. See Box 1 for pain management methods, both pharmacologic and nonpharmacologic.

SUMMARY Opioids are commonly prescribed for acute pain, and are highly effective [39]. However, these analgesics are associated with a risk of respiratory depression, gastrointestinal effects, and long-term dependence, and unsafe prescribing practices increase the risk of diversion

Pain Control in the Age of an Opioid Epidemic of unused medication into communities. As such, the creation and adherence to evidence-based prescribing guidelines and use alternative forms of analgesia in conjunction with or instead of opioids is important to avoid additional morbidity and mortality.

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[14] Howard R, Alameddine M, Klueh M, et al. Spillover effect of evidence-based postoperative opioid prescribing. J Am Coll Surg 2018;227(3):374–81. [15] Catterall WA, Mackie K. Goodman & Gilman’s: the pharmacological basis of therapeutics [Chapter 20]. Local Anesthetics. 12th edition. New York: McGraw-Hill; 2007. Available at: http://accessmedicine.mhmedical. com/content.aspx?bookid=1613§ionid=102159230. [16] Li J, Wang G, Xu W, et al. Efficacy of intravenous lidocaine on pain relief in patients undergoing laparoscopic cholecystectomy: a meta-analysis from randomized controlled trials. Int J Surg 2018;50: 137–45. [17] Noviasky J, Pierce D, Whalen K, et al. Bupivacaine liposomal versus bupivacaine: comparative review. Hosp Pharm 2014;49(6):539–43. [18] Malik O, Kaye A, Kaye A, et al. Emerging roles of liposomal bupivacaine in anesthesia practice. J Anaesthesiol Clin Pharmacol 2017;33(2):151–6. [19] Smoot J, Bergese S, Onel E, et al. The efficacy and safety of DepoFoam bupivacaine in patients undergoing bilateral, cosmetic, submuscular augmentation mammaplasty: a randomized, doubleblind, active-control study. Aesthet Surg J 2011;32(1):69–76. [20] Candiotti K, Gorfine S, Bramlett K, et al. Efficacy profile of liposome bupivacaine, a novel formulation of bupivacaine for postsurgical analgesia. J Pain Res 2012;2012:107–16. [21] Lambrechts M, O’Brien M, Savoie F, et al. Liposomal extended-release bupivacaine for postsurgical analgesia. Patient Prefer Adherence 2013;2013:885–90. [22] Calatayud S, Esplugues JV. NSAIDs and aspirin. Switzerland: Springer International Publishing; 2016. [23] Mehanna AS. NSAIDs: chemistry and pharmacological actions. American Journal of Pharmaceutical Education 2003;67(2):1–7. [24] Kelley BP, Bennett KG, Chung KC, et al. Ibuprofen may not increase bleeding risk in plastic surgery: a systematic review and meta-analysis. Plast Reconstr Surg 2016; 137(4):1309–16. [25] American Society of Anesthesiologists. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004;100(6):1573–81. [26] FDA. OFIRMEV package insert 2010. Available at: http:// 022450lbl.pdf. Accessed July 10, 2018. [27] Groudine S, Fossum S. Use of intravenous acetaminophen in the treatment of postoperative pain. J Perianesth Nurs 2011;26(2):74–80. [28] Wininger SJ, Miller H, Minkowitz HS, et al. A randomized, double-blind, placebo-controlled, multicenter, repeat-dose study of two intravenous acetaminophen dosing regimens for the treatment of pain after abdominal laparoscopic surgery. Clin Ther 2010; 32(14):2348–69.


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[29] Tolin DF. Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clin Psychol Rev 2010;30(6):710–20. [30] Szeverenyi C, Kekecs Z, Johnson A, et al. The use of adjunct psychosocial interventions can decrease postoperative pain and improve the quality of clinical care in orthopedic surgery. A systematic review and metaanalysis of randomized controlled trials. J Pain 2018; 19(11):1231–52. [31] Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo-controlled trials. Depress Anxiety 2018;35(6):502–14. [32] Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry 2008;69(4): 621–32. [33] Hofmann SG. Cognitive processes during fear acquisition and extinction in animals and humans: implications for exposure therapy of anxiety disorders. Clin Psychol Rev 2008;28(2):199–210.

[34] Hudson BF, Ogden J. Exploring the impact of intraoperative interventions for pain and anxiety management during local anesthetic surgery—a systematic review and meta-analysis. J Perianesth Nurs 2016;31(2): 118–33. [35] Schwab D, Davies D, Bodtker T, et al. A study of efficacy and cost-effectiveness of guided imagery as a portable, self-administered, presurgical intervention delivered by a health plan. Adv Mind Body Med 2007;22(1):814. [36] Akgul A, Guner B, Cirak M, et al. The beneficial effect of hypnosis in elective cardiac surgery: a preliminary study. Thorac Cardiovasc Surg 2016;64(7):581–8. [37] Schnur JB, Bovbjerg DH, David D, et al. Hypnosis decreases presurgical distress in excisional breast biopsy patients. Anesth Analg 2008;106(2):440–4, table of contents. [38] Hizli F, Ozcan O, Selvi I, et al. The effects of hypnotherapy during transrectal ultrasound-guided prostate needle biopsy for pain and anxiety. Int Urol Nephrol 2015; 47(11):1773–7. [39] Peponis T, Kaafarani HMA. What is the proper use of opioids in the postoperative patient? Adv Surg 2017; 51(1):77–87.

Advances in Cosmetic Surgery 2 (2019) 47–53


Microneedling Shilpi Khetarpal, MDa,*, Jonathan Soh, MDb, Mara Weinstein Velez, MDb, Adele Haimovic, MDc a

Cleveland Clinic Foundation, 9500 Euclid Avenue, A61, Cleveland, OH 44195, USA; bUniversity of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA; cThe Ronald O. Perelman Department of Dermatology, New York University Langone Health, 530 First Avenue, Suite 7R, New York City, NY, 10016, USA


 Microneedling  Scars  Facial rejuvenation  Percutaneous collagen induction KEY POINTS

 Microneedling is safe in all skin types given it does not use heat, therefore does not have a chromophore.  Microneedling can be used to treat scars and facial rejuvenation and as a transdermal drug delivery system.  Microneedling is an effective procedure with a low side-effect profile and minimal downtime and is well tolerated.

Video content accompanies this article at

BACKGROUND Microneedling, also referred to as percutaneous collagen induction (PCI) therapy, has gained significant popularity in dermatology. With a wide array of applications, including scar treatment, improvement of pigmentary alteration, skin rejuvenation, and as a transdermal drug delivery system, microneedling is a valuable therapeutic option. Microneedling is an effective procedure with a low side-effect profile and minimal downtime and is well tolerated. The concept was first described by Orentreich and Orentreich in 1995 [1], who described subcision for the treatment of scars and wrinkles. In their article, they hypothesize that in addition to releasing fibrous attachments, controlled trauma from a hypodermic needle triggers a wound healing response and connective tissue production and subsequently improves depressed sites [1]. A few years later, Camirand and

Doucet [2] used a tattoo gun without ink to puncture wounds with 9 needles or 12 needles at high speed They reported significant improvement in achromic, hypertrophic, and undesirable scars.

MECHANISM OF ACTION Microneedling is believed to stimulate the wound healing cascade and promote new collagen deposition without significant damage to the overlying epidermis. Physical trauma from the penetration of the needle through the stratum corneum creates microchannels with minimal damage to the epidermis. This controlled skin injury induces dermal regeneration. The wound healing cascade in the dermis is triggered, and multiple growth factors are released, including fibroblast growth factor, platelet-derived growth factor, and transforming growth factor (TGF)-a and TGF-b [3], leading to the

Disclosure statement: The authors have nothing to disclose. *Corresponding author. Cleveland Clinic Foundation, 9500 Euclid Avenue, A61, Cleveland, OH 44195. E-mail address: [email protected] 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.



Khetarpal et al

proliferation and migration of fibroblasts [4]. Neovascularization and neocollagenesis ensue. Tissue remodeling occurs over the subsequent weeks to months [4]. Initially a fibronectin matrix forms and allows for the deposition of collagen type III. The type III collagen is eventually replaced by type I collagen [5]. This remodeling process results in skin tightening and scar reduction. Aust and colleagues [6] performed histologic examination of 20 patients treated with microneedling and reported normal stratum corneum, thickened epidermis (stratum granulosum), and normal rete ridges. Elastica staining demonstrated an increase in elastic fiber deposition and van Gieson staining demonstrated an increase in collagen deposition at 6 months postoperatively [6]. Aust and colleagues [7] went on to show that PCI can lead to skin regeneration without scar formation. TGF-b is essential for fibrotic scar formation. TGF-b1 and TGF-b2 promote a fibrotic response whereas TGF-b3 is believed to promote scarless wound healing [8]. They reported an initial increase in TGF-b1 and TGF-b2 after PCI followed by a significant downregulation. This contrasts with TGF-b3, which was upregulated 2 weeks after PCI and did not down-regulate at weeks 4 and 8 [7]. This may partially explain why microneedling can promote skin rejuvenation and improve texture without triggering scar formation.

MICRONEEDLING INSTRUMENTS The first microneedling device described in the literature was by Fernandes [9]. Fernandes created a cylindricalshaped tool with many needles that was designed to be rolled back and forth on the skin until pinpoint bleeding was achieved [9]. This device is similar to the modernday dermaroller. Today, there are numerous microneedling devices commercially available varying based on needle length, needle number, and automation. More superficial devices, with needle lengths less than 0.15 mm, can be purchased for home use whereas deeper devices, with needle lengths ranging from 0.1 mm to 3.5 mm, are designed to be used in a medical facility. The automated devices are pen-shaped and allow needle penetration depths to be easily adjusted. Choice of needle length varies depending on the location treated. Another advantage of electronic pens is their disposable needle tips, which decrease risk of infection and allow for the treatment of small areas [5]. Many dermarollers, in contrast to the automated devices, need to be disposed of after each use and are difficult to use in small areas, such as the upper lip and around the eyes [3]. In addition to traditional microneedling devices, companies are now combining microneedling with

radiofrequency and light-emitting diodes to treat scarring, wrinkles, and skin laxity. With fractional radiofrequency microneedling, there are insulated needles that on skin penetration release radiofrequency currents that lead to dermal remodeling and neocollagenesis [3]. Microneedling devices also have been shown an effective method of drug delivery. In some scenarios, the needles pierce the skin and then a drug is applied topically to the skin and is able to penetrate through the broken skin barrier. There also are microneedling pens with hollow needles that allow the medication to be delivered directly into the dermis [10]. Care must be taken when choosing which topical agents are used because certain medications are not designed to be delivered directly into the skin because hypersensitivity reactions have been reported [11].

PROCEDURE Microneedling is an office-based procedure. Prior to the procedure, the skin should be washed with a gentle cleanser. A topical anesthetic, such as eutectic mixture of lidocaine and prilocaine or 30% lidocaine, is applied to the skin for approximately 30 minutes prior to the procedure. After removing the topical anesthetic with a dry gauze, the skin should be cleansed thoroughly with alcohol to decrease the risk of any infection. The treatment area often is divided into zones and the needle depth varies depending on the location treated. A lubricant, such as a hyaluronic acid gel or platelet-rich plasma (PRP), is used to allow the device to gently glide over the skin. Each zone is treated with a combination of a circular motions, linear horizontal, or vertical strokes. For deeper scars and rhytids, a stamping technique may be used. It is important not to dwell in 1 spot for too long and avoid using excessive pressure [12]. Once the procedure is completed, the skin is cleansed with a wet gauze, and hyaluronic acid gel is applied. Frequent moisturization and sunscreen application is important for the days after the procedure (Video 1).

CONTRAINDICATIONS AND TREATMENT CONSIDERATIONS Contraindications to microneedling include  Active infection, such as herpes labialis, warts, or bacterial infections  Significant keloid predisposition  Immunosuppression  Blood dyscrasias

Microneedling Individuals with a history of herpes labialis should be treated with prophylactic oral antivirals. Although not a contraindication, the authors do not recommend performing microneedling and botulinum toxin in the same area on the same day to decrease risk of unwanted toxin diffusion [5]. The authors also do not recommend treatment of individuals with a suntan due to increased risk of postinflammatory hyperpigmentation (PIH).

ADVERSE EVENTS Microneedling is associated with a low rate of adverse events Expected side effects include post-treatment erythema, edema, and mild peeling. These usually resolve within 2 days to 3 days. Less common adverse events include reactivation of herpes, hypersensitivity reactions [13], and worsening of acne. Although PIH has been reported [14], it is uncommon. Microneedling is believed a safe treatment of patients with skin of color [15]. Permanent tram-track scarring has been reported but it has been suggested that this was due to improper technique and excessive pressure [16].

MICRONEEDLING AND REJUVENATION Microneedling has proved a targeted and safe option for facial rejuvenation [12,17,18]. Skin aging is the manifestation of dyspigmentation, rhytids, loss of elasticity, and collagen. Cumulative intrinsic and extrinsic pressures remodel the extracellular and cellular components of the skin. The microneedling ability to mechanically stimulate the dermis while sparing trauma to the epidermis allows for the neogenesis of collagen and elastin. This reorganization of dermal architecture is what is clinically perceived as skin rejuvenation. Rejuvenation has been characterized by both subjective and objective measures. Subjective scales, such as the Wrinkle Severity Rating Scale, Global Aesthetic Improvement Scale, and patient satisfaction scales, help quantify changes in skin quality [19]. Objective measures of rejuvenation include histologic examination (collagen, elastin, tropoelastin, fibroblasts, fibrillin, and epidermal thickness), ultrasound measurements, silicone relief impressions, and anatomic structural measurements. Microneedling triggers a proinflammatory and subsequent collagen and elastin remodeling cascade by disrupting dermal collagen and scar tethering. Adjustable needle lengths (0.5–3 mm) can deliver a drug or induce a mechanical injury anywhere from the stratum corneum down to the papillary dermis. In addition to depth control, microneedling minimally disrupts the epidermal barrier and melanocyte density along the


dermal-epidermal junction [20]. By preserving native epidermis and dermal-epidermal melanocytes, microneedling mitigates the risk of PIH, hypopigmentation, infection, scarring, and milia. Microneedling is a useful alternative to traditional skin resurfacing procedures in patients with darker skin types (Fitzpatrick IV–VI). Dermabrasion, chemical peels, and lasers have been associated with prolonged recovery periods and adverse events in patients with darker skin [15]. In preclinical models, Aust and colleagues [21] showed a decrease in melanocytestimulating hormone (MC1R) expression and no change in melanocyte quantity after PCI therapy. Microneedling has been examined for wrinkle reduction of the face and neck. Fabbroccini and colleagues [22] studied the effect of 2 microneedling sessions on perioral upper lip rhytids in 10 female subjects. Using photography (wrinkle depth) and silicon microrelief impressions, they demonstrated a 2.3-fold reduction in wrinkle severity (Wrinkle Severity Rating Scale) and a 33% decrease in skin irregularity (silicone impressions). In 2011, Fabbroccini and colleagues [23] used microneedling to treat aging neck skin in 8 patients over a span of 2 treatments. The group showed a 90% improvement in lesion severity using the Global Aesthetic Improvement Scale, Wrinkle Severity Rating Scale, photographic and ultrasound imaging, and silicone rubber impressions. Ultrasound demonstrated a 24% average reduction in rhytid depth and an average 0.45-mm increase in skin thickness (Fig. 1). Histologic changes associated with rejuvenation also have been described after microneedling. Aust and colleagues [21] demonstrated an increase of collagen and elastin deposition in 20 patients, 6 months after a microneedling procedure. At 1 year, patients were noted to have 40% thickening of the stratum spinosum [22]. El-Domyati and colleagues [24] treated 10 patients (Fitzpatrick III, Fitzpatrick IV, Glogau classes II–III) with 6 microneedling sessions at 2-week intervals. Patients were evaluated with standard photographs and skin biopsy (at baseline, 1 month, and 3 months after first treatment). The investigators reported noticeable clinical improvement of photoaged skin. Histometery was used to quantify levels of collagen types I, III, IV, elastin, and tropoelastin within the skin biopsies. The group noted a significant increase in collagen (I, III, and VII) and tropoelastin compared with baseline. Elastin was significantly decreased from baseline. These findings indicate that it can take 6 weeks to 8 weeks from initiation of treatment to achieve clinically apparent results from dermal collagen production.


Khetarpal et al

FIG. 1 Before (left) and after (right) 2 microneedling treatments for perioral rhytids done 2 weeks apart at a

depth of 2 mm.

Therefore, microneedling skin rejuvenation should be performed in a series of 3 to 6 biweekly sessions to achieve optimal improvement [5]. Microneedling can promote rejuvenation through transdermal drug delivery. Pre-procedural and concurrent treatment regimens include microneedling with topical agents like vitamins A and C, PRP, hyaluronic acid, and embryonic stem cells. In cases of exogenous supplementation, side effects like granuloma formation secondary to allergic hypersensitivity have been reported and should be considered [11]. Patients should be counseled to use only what is recommended by the physician as a postprocedural regimen. Lee and colleagues [25] conducted a randomized controlled, split-face study with 25 patients using microneedling (0.25 mm) with and without human embryonic stem cells–endothelial precursor cells (hESCs-EPCs). After 5 treatments at 2-week intervals, physician global assessments for pigment and wrinkle improvement were significantly higher in those with the hESCsEPCs and microneedling versus those with microneedling alone. Patient satisfaction scores also were reported higher in the hESCs-EPCs with microneedling group. In a split-face study, Sundaram and colleagues [26] found that patients treated with microneedling followed by a topical cross-linked hyaluronic acid formulation had improvement in skin moisture, tone, radiance, texture, uniformity, and global appearance. These were quantified by standardized topographic imaging and biometrical measures. Patients were more satisfied with the appearance of the treated versus untreated hemiface 28 days after the procedure. Microneedling has also shown effective when combined with other treatment modalities to improve facial rhytids and skin laxity. Clementoni and Munavalli [27] used high-intensity focused radiofrequency with

microneedling to treat 33 patients with skin laxity of the lower face and neck. Six months after treatment (3 treatments once per month, 3 passes per treatment), there was a significant decrease in the cervicomental and gnathion angles (primary endpoint); 81.8% of patients had moderate or higher improvement based on blinded global assessments and 87% of patients selfreported that they were very satisfied with the results. Although most of the research on microneedling has been conducted with respect to improving acne scars, microneedling with chemical peels has also proved to rejuvenate light and dark skin. Sharad [28] demonstrated significant improvement in superficial and deep acne scars as well as improvement in skin texture and PIH after microneedling with glycolic acid. Sixty patients with atrophic box scars or rolling acne scars with PIH were randomized to either microneedling alone or microneedling with 35% glycolic acid once every 6 weeks for 5 total sessions. Those with combination therapy had significant improvement in skin texture and postacne pigmentation [28]. In a similar study, patients undergoing microneedling (weeks 0, 6, and 12) with 70% glycolic acid peels (weeks 3, 9, and 15) had a larger improvement in skin texture (based on visual analog scale) than patients undergoing microneedling alone [29]. Improvements in atrophic acne scars also have been found after combination therapy with 15% trichloroacetic acid (TCA) [30]. EL-Domyati and colleagues [31] found significant increases in epidermal thickness, collagen bundle organization, and neogenesis after microneedling with 15% TCA. Kontochristopoulos and colleagues [32] performed microneedling with 10% TCA on 13 patients with periorbital hyperpigmentation (melanosis). After 1 treatment of microneedling followed by TCA application to the infraorbital area, nearly all patients had

Microneedling significant improvement (fair, good, or excellent) by physician and patient global assessments. There was no recurrence at 4-month follow-up. Combination microneedling therapy with PRP also has led to improvement of atrophic acne scars [33–35]. Extrapolation from this and similar studies suggests that combination therapy with PRP may be a useful tool for rejuvenation. Microneedling has shown promising results with respect to facial rejuvenation. Studies thus far have documented clinical and histologic changes that help improve wrinkles and skin laxity. Its minimal invasiveness lends itself to a favorable safety profile. Microneedling can be considered a useful tool for rejuvenation and one that mitigates risk of hyperpigmentation and patient down time. Microneedling can be used safely and effectively alone or in combination with additional agents or treatment modalities.

MICRONEEDLING AND SCARS Microneedling is an alternative therapy that can be used to improve the appearance of scars. It initially was used for skin rejuvenation, and it is now used for a wide variety of indications, but most of the literature focuses on acne scarring. The extent of acne scarring is related to the severity of preceding inflammation, stage and nature of treatment, extent of local manipulation, and individual predisposition to scarring. Although most of the literature has focused on acne scars, microneedling has been using in other types of scarring, including varicella, burns, and striae, and post-surgical scars. Microneedling is a minimally invasive procedure involving superficial and controlled puncturing of the skin by rolling with fine needles [3]. The microinjuries cause a wound healing cascade with release of various growth factors, including platelet-derived growth factor, TGF-a and TGF-b, connective tissue growth factor, and fibroblast growth factor. This process helps breakdown old hardened scar tissue and allows tissue to revascularize. Neovascularization and neocollagenesis are initiated by migration and growth of fibroblasts. After 5 days of injury, a fibronectin matrix forms that determines the deposition of collagen. Histologic examination of skin treated with 4 microneedling sessions 4 weeks apart shows up to 400% increase in collagen and elastin 6 months after the last treatment. Additionally, collagen bundles have a normal lattice pattern rather than the parallel pattern seen in scar tissue [35]. Results after each treatment are not seen immediately, because new collagen continues to be produced for 3 months to 6 months after each treatment; the final outcome of


each treatment is seen after 6 months. It is recommended that 4 sessions to 6 sessions are done for a significant improvement when treating all types of scars. Microneedling can be combined with other techniques to yield better results. These include transdermal drug delivery, chemical peels, and energy devices. There are various commercially available devices that have small microneedles (0.5–3 mm long and 0.1–0.25 mm in diameter) that break collagen bundles in the superficial layer of the dermis that contribute to scars. This leads to induction of more collagen beneath the epidermis [36]. The microneedles create small wounds in the epidermis, which enhance the delivery of drugs across the skin barrier because it bypasses the stratum corneum and delivers the drug directly in the vascularized dermis. Laser-assisted drug delivery, however, seems more effective. An advantage of microneedling over laser is a lower risk of PIH. Other techniques that damage the epidermis have a high risk of PIH, but microneedling is an exception. Microneedling also has been combined with PRP to enhance outcomes when treating acne scars. PRP is an autologous concentration of platelets in a small volume of plasma. The plasma is rich in platelets, stem cells, and growth factors, which stimulate skin to produce more collagen. These platelets also enhance tissue regeneration and promote healing by the release of numerous growth factors from their a-granules. One study compared 35 subjects with atrophic acne scars who received 4 monthly microneedling sessions with and without PRP for facial acne scarring. The right face received microneedling alone, whereas the left side of the face received microneedling followed by the topical application of PRP [34]. A dermaroller was used with 192 titanium needles at a depth of 1.5 mm until an endpoint of uniform pinpoint bleeding was achieved. Assessments were done at 6 months after the last treatment using the Goodman and Baron global acne scarring scale. There was significant improvement on both sides of the face, but the side treated with microneedling and PRP had higher patient satisfaction compared with the side treated with microneedling alone. Additionally, there was significantly less erythema and edema postmicroneedling on the side treated with PRP, leading to less downtime overall. A split-face study of 50 patients with acne scars were treated with microneedling of the full face, followed by topical and intradermal injection of PRP or distilled water [37]. The side treated with PRP had greater improvement, faster healing shown by decreased edema and erythema after


Khetarpal et al

2 days, and increased collagen and epidermal thickness on histology. Another study by Chawla [38] using microneedling with either vitamin C or PRP for acne scarring showed patients were more satisfied with PRP than vitamin C. A study comparing microneedling to nonablative fractional erbium 1340-nm laser for acne scarring showed no statistical difference between the 2 groups 6 months after 3 monthly sessions [39]. There was, however, a higher rate of PIH (13.6%) in the laser group. Other studies have examined microneedling with other topical agents, including glycolic acid and TCA, which enhanced microneedling results, leading to greater improvement in acne scars compared with microneedling alone. It is believed that these topical agents are delivered directly to the dermis, given the microneedles facilitated deeper penetration into the skin, bypassing epidermal damage to stimulate collagen and elastin formation [40]. Microneedling has gained popularity in treating striae distensae. Several studies have compared microneedling to other modalities, including fractional ablative CO2 laser resurfacing and microdermabrasion [41,42]. In both studies, patients were randomized to receive 3 monthly microneedling sessions. Patient satisfaction was higher in the microneedling group, and increased collagen, fibroblasts, and epidermal thickness was seen in all the microneedling treated specimens. Side effects of the areas treated with microneedling included mild pain, erythema, and spotty bleeding. As for burn scars, mouse models have shown that 4 monthly microneedling session lead to an increase in type III collagen and increased mean epidermal thickness up to 140% [43]. The results continued to improve with repeated treatments. Mouse models who had second-degree burns showed improvement in epidermal thickening and normalization of dermal collagen and elastin up to 12 months after each microneedling session. Microneedling has recently gained popularity given it is simple, inexpensive, safe, and effective technique. Given it lacks heat and a chromophore target, microneedling has an excellent safety profile in all skin types. It has a decreased risk of infection, photosensitivity, and postinflammatory dyspigmentation given it does not deliver heat to the skin. Providers should be cautious not to apply excess pressure during treatment, because reports of tram track scarring have been observed [16]. It can be used for a wide variety of indications, including transdermal drug delivery, facial rejeuvenation, and improvement in the appearance of scars.

SUPPLEMENTARY DATA Supplementary data related to this article can be found online at

REFERENCES [1] Orentreich D, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg 1995;21:543–9. [2] Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast Surg 1997;21:48–51. [3] Singh A, Yadav S. Microneedling: advances and widening horizons. Indian Dermatol Online J 2016;7:244–54. [4] Fabbrocini G, Fardella N, Monfrecola A, et al. Acne scarring treatment using skin needling. Clin Exp Dermatol 2009;34:874–9. [5] Alster T, Graham P. Microneedling: a review and practical guide. Dermatol Surg 2018;44:398–404. [6] Aust MC, Fernandes D, Kolokythas P, et al. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles,and skin laxity. Plast Reconstr Surg 2008;121:1421–9. [7] Aust M, Reimers K, Gohritz S, et al. Percutaneous collagen induction. Scarless skin rejuvenation: fact or fiction? Clin Exp Dermatol 2010;35:437–9. [8] Ferguson MW, O’Kane S. Scar-free healing: from embryonic mechanisms to adult therapeutic intervention. Philos Trans R Soc Lond B Biol Sci 2004;359:839–50. [9] Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofacial Surg Clin N Am 2005;17: 51–63. [10] Bariya SH, Gohel MC, Mehta TA, et al. Microneedles: An emerging transdermal drug delivery system. J Pharm Pharmacol 2012;64:11–29. [11] Soltani-Arabshahi R, Wong JW, Duffy KL, et al. Facial allergic granulomatous reaction and systemic hypersensitivity associated with microneedle therapy for skin rejuvenation. JAMA Dermatol 2014;150:68–72. [12] Hou A, Cohen B, Haimovic A, et al. Microneedling: a comprehensive review. Dermatol Surg 2017;43:321–39. [13] Pratsou P, Gach J. Severe systemic reaction associated with skin microneedling therapy in 2 sisters: a previously unrecognized potential for complications. J Am Acad Dermatol 2013;68:AB219. [14] Dogra S, Yadav S, Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J Cosmet Dermatol 2014;13(3):180–7. [15] Cohen BE, Elbuluk N. Microneedling in skin of color: a review of uses and efficacy. J Am Acad Dermatol 2016; 74(2):348–55. [16] Pahwa M, Pahwa P, Zaheer A. ‘‘Tram track effect’’ after treatment of acne scars using a microneedling device. Dermatol Surg 2012;38(7 Pt 1):1107–8. [17] Ramaut L, Hoeksema H, Pirayesh A, et al. Microneedling: Where do we stand now? A systematic review of the literature. J Plast Reconstr Aesthet Surg 2018;71(1):1–14.

Microneedling [18] Bonati LM, Epstein GK, Strugar TL. Microneedling in all skin types: a review. J Drugs Dermatol 2017;16(4): 308–13. [19] Day DJ, Littler CM, Swift RW, et al. The wrinkle severity rating scale. Am J Clin Dermatol 2004;5(1):49–52. [20] Hogan S, Velez MW, Ibrahim O. Microneedling: a new approach for treating textural abnormalities and scars. Semin Cutan Med Surg 2017;36(4):155–63. [21] Aust MC, Reimers K, Repenning C, et al. Percutaneous collagen induction: minimally invasive skin rejuvenation without risk of hyperpigmentation-fact or fiction? Plast Reconstr Surg 2008;122(5):1553–63. [22] Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J Dermatolog Treat 2012;23(2):144–52. [23] Fabbrocini G, De Vita V, Di Costanzo L, et al. Skin needling in the treatment of the aging neck. Skinmed 2011;9(6):347–51. [24] El-Domyati M, Barakat M, Awad S, et al. Multiple microneedling sessions for minimally invasive facial rejuvenation: an objective assessment. Int J Dermatol 2015; 54(12):1361–9. [25] Lee HJ, Lee EG, Kang S, et al. Efficacy of microneedling plus human stem cell conditioned medium for skin rejuvenation: a randomized, controlled, blinded split-face study. Ann Dermatol 2014;26(5):584. [26] Sundaram H, Cegielska A, Wojciechowska A, et al. Prospective, randomized, investigator-blinded, split-face evaluation of a topical crosslinked hyaluronic acid serum for post-procedural improvement of skin quality and biomechanical attributes. J Drugs Dermatol 2018;17: 442–50. [27] Clementoni MT, Munavalli GS. Fractional high intensity focused radiofrequency in the treatment of mild to Moderate laxity of the lower face and neck: a pilot study. Lasers Surg Med 2016;48(5):461–70. [28] Sharad J. Combination of microneedling and glycolic acid peels for the treatment of acne scars in dark skin. J Cosmet Dermatol 2011;10(4):317–23. [29] Rana S, Mendiratta V, Chander R. Efficacy of microneedling with 70% glycolic acid peel vs microneedling alone in treatment of atrophic acne scars-A randomized controlled trial. J Cosmet Dermatol 2017;16(4):454–9. [30] Garg S, Baveja S. Combination therapy in the management of atrophic acne scars. J Cutan Aesthet Surg 2014; 7(1):18. [31] El-Domyati M, Abdel-Wahab H, Hossam A. Microneedling combined with platelet-rich plasma or trichloroacetic acid peeling for management of acne scarring: a split-face clinical and histologic comparison. J Cosmet Dermatol 2018;17(1):73–83.


[32] Kontochristopoulos G, Kouris A, Platsidaki E, et al. Combination of microneedling and 10% trichloroacetic acid peels in the management of infraorbital dark circles. J Cosmet Laser Ther 2016;18(5):289–92. [33] Ibrahim ZA, El-Ashmawy AA, Shora OA. Therapeutic effect of microneedling and autologous platelet-rich plasma in the treatment of atrophic scars: a randomized study. J Cosmet Dermatol 2017;16(3):388–99. [34] Ibrahim MK, Ibrahim SM, Salem AM. Skin microneedling plus platelet-rich plasma versus skin microneedling alone in the treatment of atrophic post acne scars: a split face comparative study. J Dermatolog Treat 2018;29(3): 281–6. [35] Nair PA, Arora TH. Microneedling using dermaroller: a means of collagen induction therapy. GMJ 2014;69: 24–7. [36] El-Domyati M, Barakat M, Awad S, et al. Microneedling therapy for atrophic acne scars: an objective evaluation. J Clin Aesthet Dermatol 2015;8:36–42. [37] Asif M, Kanodia S, Singh K. Combined autologous platelet rich plasma with microneedling with distilled water in the treatment of atrophic acne scars: a concurrent split-face study. J Cosmet Dermatol 2016;15(4): 434–43. [38] Chawla S. Split face comparative study of microneedling with PRP versus microneedling with vitamin C in treating atrophic post acne scars. J Cutan Aesthet Surg 2014; 7:209–12. [39] Cachaferio T, Escobar G, Maldonado G, et al. Comparison of nonablative fractional erbium laser 1,340 nm and microneedling for the treatment of atrophic acne scars: a randomized clinical trial. Dermatol Surg 2016; 42:232–41. [40] Leheta TM, Abdel Hay RM, El Garem YF. Deep Peeling using Phenol versus Percutaenous Collagen Induction Combined with Trichloroacetic Acid 20% show better results than each individual modality in the treatment of atrophic acne scars? A randomized controlled trial. J Dermatolog Treat 2014;25(2):137–41. [41] Park KY, Kim HK, Kim SE, et al. Treatment of striae distensae using needling therapy: a pilot study. Dermatol Surg 2012;38:1823–8. [42] Nassar A, Ghomey S, El Gohary Y, et al. Treatment of striae distensae with needling therapy versus CO2 fractional laser. J Cosmet Laser Ther 2016;18(6):330–4. [43] Zeitter S, Sikora Z, Jahn S, et al. Microneedling: matching the results of medical needling and repetitive treatments to maximize potential for skin regeneration. Burns 2014; 40(5):966–73.

Advances in Cosmetic Surgery 2 (2019) 55–67


New Synergistic Tricks Fillers 1 Neuromodulators 1 Technology 5 More than the Sum Ryan C. Kelm, BSa,1, Omer Ibrahim, MDb,* a

Univsersity of Oklahoma College of Medicine, Oklahoma City, OK, USA; bChicago Cosmetic Surgery and Dermatology, Chicago, IL, USA


 Neuromodulator  Filler  Neurotoxin  Laser  Combination treatment  Radiofrequency  Ultrasound KEY POINTS

 The aging process is multifactorial and thus necessitates a combination of treatments to globally treat the aging face.  Neuromodulators and soft tissue fillers have been safely and effectively combined to provide optimal correction of rhytides and improvement of facial contour.  Energy devices can be safely implemented with neuromodulators and fillers to enhance results and increase patient satisfaction.  Laser-assisted delivery of topical pharmaceuticals and medications can enhance percutaneous absorption and augment results.

INTRODUCTION Aesthetic surgery has developed and several pioneering techniques have been innovated to address the varied facets of cutaneous photoaging. Neuromodulators, soft tissue fillers, and energy-based devices are but a few noninvasive options available to clinicians for facial rejuvenation. Understanding that the skin ages due to a combination of extrinsic and intrinsic factors, such as the sun, stress, and skeletal and tissue changes, a more comprehensive approach that focuses on all aspects of aging has allowed for multimodal treatment plans to be developed. This multimodal, combination approach has optimized therapy for treating the different features of photoaging—lines and wrinkles, fine or deep, static or dynamic, skin texture, and pigmentary changes, as well as skin laxity. In this article the authors examine

and discuss the efficacy, safety, and applications of combining different treatment modalities in the management of the multidimensional process of skin aging.

COMBINING SOFT TISSUE FILLERS WITH NEUROMODULATORS The advent of injectable medications has completely transformed the approach and treatment of aging skin, providing an alternative to more invasive surgical techniques. Common, established modalities for dynamic facial rhytides are injections of neurotoxins, such as onabotulinum toxin A (onaBot), abobotulinum toxin A (aboBot), and incobotulinum toxin A (incoBot), which are primarily used for the upper face, with increasing uses in the perioral area, jawline, and neck.

The authors have no conflicts of interest to disclose. 1 Present address: 801 Northwest 10th Street, #302, Oklahoma City, OK 73106. *Corresponding author. 3533 North Wilton Avenue, #2, Chicago, IL 60657. E-mail address: [email protected]. com 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.



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These methods are often the first step patients take on the path to facial rejuvenation and frequently lead to more treatments with fillers and other devices. Many different variations of dermal fillers, in addition to the popular hyaluronic acid (HA) fillers, have come to market, which has led to the exploration of neuromodulator and filler combinations. These 2 facial rejuvenation techniques, in isolation, are effective and safe at treating dynamic and static lines, but a detailed understanding of combinations of neurotoxins and soft tissue fillers is crucial to enhanced techniques and superior results. Efficacy and safety of neurotoxin and soft tissue filler combinations have been explored since the early 2000s. Synergistic effects of coupling these 2 modalities have been described to enhance efficacy and patient satisfaction [1]. Botulinum toxin injection may improve skin texture, resulting in a softer appearance that may be augmented by dermal fillers [2,3]. A study examined the treatment with HA alone or with HA and onaBot for severe glabellar rhytides and found that the combination group demonstrated a more sustained response by an average of 14 weeks with an enhanced response, both at rest and maximum frown, with no differences in adverse events [4]. Similar to the aforementioned study, aboBot and HA demonstrated superior results to aboBot alone for glabellar and forehead rhytides exhibiting longer-lasting effects and greater reductions in dynamic and static wrinkles [5]. In addition to injecting combinations into one anatomic area, improvements have been demonstrated by strategically placing neurotoxin and filler in adjacent facial locations. HA soft tissue filler was injected into the glabella and temples with concurrent placement of aboBot into the glabella and crow’s feet, which significantly improved signs of aging in periorbital areas, temporal hollowing, crow’s feet, and glabellar wrinkles [6]. Furthermore, HA with onaBot showed greater improvement in the lower face and perioral region compared with either HA alone or onaBot alone (Fig. 1) [2]. Expert consensus recommends botulinum toxin injection to the procerus, corrugator, and lateral aspect of orbital orbicularis oculi muscles combined with HA filler injection to the retro-orbicularis oculi fat pat to lift the brow, restoring a more youthful appearance [7]. Soft tissue filler and toxin combinations have demonstrated rejuvenation in 13 facial zones and a high degree of patient satisfaction [8]. Expert consensus recommends that individual treatments be spaced 1 to 2 weeks apart to allow for resolution of local reactions and accurate evaluation of results [9]. If spacing is possible, neuromodulators should be

administered first to reduce the dynamic component of the marked rhytides, thus increasing filler implant longevity [9]. However, a study found no outcome differences with sequential use of onaBot/HA versus HA/ onaBot [10]. Spacing out treatments may not be possible because of patient convenience and scheduling difficulties. If same day treatment is necessary, sequential injection can be performed in any order [9]. However, in some facial areas such as the glabellar, perioral, and periorbital/temporal zones, experts have advised to administer filler first, with subsequent toxin injection [11]. They reason that this technique avoids tissue manipulation and distention caused by toxin injection, thus more precisely implanting the filler. These studies suggest that coupling neuromodulators and soft tissue fillers act synergistically in providing facial harmonization and rejuvenation. Synergy achieved by this combination is thought to be due to toxin-induced muscle relaxation, which slows the degeneration of the filler, possibly reducing the frequency of retreatment [11]. This combination has demonstrated efficacy and seems to be safe. Patients preferred combination treatments to toxin alone, and safety profiles of filler and toxin combinations were similar to individual therapies with no increased risk of adverse events [2,5,6,12]. Of note, most of the reports assessing combination safety were conducted using HA fillers. Consequently, physicians should take caution in extrapolating these results to other variations of fillers.

SOFT TISSUE FILLER COMBINATIONS The perpetual advancement of soft tissue fillers continues to provide physicians with an expanding inventory from which to choose. With a more thorough, comprehensive understanding of aging physiology and filler characteristics, new products have inevitably come to market. Soft tissue fillers differ by their constituent such as HA, poly-L-lactic acid (PLLA), or calcium hydroxyapatite (CaHA), among others, concentration of constituent, viscosity, particle size, and degree of cross-linking, which, taken together, allow for the subtle but important differences in facial restoration effects. Since the transition to a more global approach to facial aging, these minor differences in filler characteristics have allowed for more advanced and customized techniques using combinations of fillers for revolumizing hollows and correcting static wrinkles. It is recommended that when treating multiple facial areas the midface be the starting point because it may positively affect adjacent

New Synergistic Tricks


FIG. 1 Injections of botulinum toxin to the depressor anguli oris muscles and medium-weight hyaluronic acid filler to the marionettes upturned the corners of the mouth and softened irregularities in the lower face. (Ó 2019 Dr. Omer Ibrahim.)

areas reducing the overall quantity of filler needed [13,14] (Fig. 2). Generally, fillers can be divided by their primary use—ones that add volume, fill lines, offer lift, or provide support [15]. These fillers can be used at the same time at different anatomic subregions and in different facial planes to produce the desired result. More viscous fillers are generally injected into deeper facial planes whereas thinner fillers are typically used in more superficial planes. Many times, one type of filler is often indicated for multiple uses at multiple locations, allowing the clinician discretion on filler choice. Adding to the inherent complexity of fillers, many can be blended with an anesthetic such as lidocaine or xylocaine, which creates more versatile fillers,

reducing the viscosity and extrusion force while improving patient comfort. Therefore, highly viscous fillers can be blended for use at more superficial planes, such as in treating finer lines in the medial cheek [16,17]. The disappearance of the malar fat pad with subsequent midface drooping is often one of the most noticeable changes that occur with aging [18,19]. A common approach to address this drooping is injecting thick HA fillers or CaHA into the deep malar area to lift and create a more youthful projection. But neglecting adjacent facial regions can result in an unevenness of youthful restoration and aged appearance with hard transitions from the midface to lower face. Hence, thinner, less viscous fillers should be used in parallel for marionette, perioral, and superficial lip


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FIG. 2 Viscous hyaluronic acid filler placement into the midface in order to correct midfacial volume loss concurrently slimmed the jawline and reduced the amount of filler needed in the nasolabial folds and marionettes. (Ó 2019 Dr. Omer Ibrahim.)

rhytides to create a seamless blend of youthful appearance [15] (see Fig. 2). In addition to the malar region, heavier fillers can be used for temple, jawline, and cheek revolumization [20]. Different types of HA fillers have also been used simultaneously for facial rejuvenation. A double-blind clinical study found that combining a cross-linked HA filler with a non– cross-linked HA filler resulted in superior aesthetic improvement and patient satisfaction than 2 of the same cross-linked HA fillers for the nasolabial folds [21]. Subcutaneous injection of carbon dioxide (CO2) with HA filler has also demonstrated superior, longer-lasting results compared with HA filler alone for nasolabial folds [22]. Another characteristic of fillers is their duration of effect. This feature allows for fillers to be combined not

only geographically but also temporally. Shorter acting fillers can be used as a method to determine patient response and satisfaction, thereby allowing the patient and physician to have more confidence in using fillers with longer-lasting effects while maintaining the same degree of response [15].

COMBINATIONS WITH ENERGY-BASED DEVICES The number of energy-based devices available for aesthetic treatment has exploded in the last decade. Energy-based treatments—ablative and nonablative lasers, focused ultrasound, radiofrequency (RF), intense pulsed light (IPL)—are becoming more and more popular as noninvasive methods for restoring a

New Synergistic Tricks youthful face. Investigators have demonstrated that these techniques are effective with high rates of patient satisfaction for rejuvenation while having a low adverse event profile. As the paradigm has shifted to a more 3-dimensional, global approach to aging, investigators examined if coupling these different devices with other treatment modalities, such as soft tissue fillers, would be as safe and effective as each treatment alone for revitalizing the nuances of agerelated facial changes. In this article, the authors discuss current literature and consensus with combinations of the following:  IPL  Lasers  Nonablative  Ablative  Microfocused ultrasound  RF  RF with microneedling

INTENSE PULSED LIGHT IPL is a device primarily used for the treatment of pigmentation and vascular changes, targeting melanin and hemoglobin in sun-damaged skin. One study examined the efficacy and safety of combining IPL directly before or soon after PLLA injection and found that 86.7% of patients reported photorejuvenation without significant adverse effects such as nodule formation [23]. Fabi and Goldman [23] determined that using these 2 treatments in concert was effective and did not lead to an increase in complications than with each treatment method in isolation. Aging hands can be treated with IPL for dyschromia, rhytides, and solar lentigines in combination with soft tissue fillers that can address dermal thinning, uneven texture, and the increased noticeability of underlying hand structures [24], without adverse events [25]. In addition to coupling IPL with soft tissue fillers, combinations with neurotoxins have been explored. A randomized, double-blind, split-face study demonstrated that IPL combined with botulinum toxin significantly improved small wrinkles and fine lines of the cheeks compared with IPL alone [26]. Another clinical study assessed the safety and efficacy of panfacial IPL with botulinum toxin versus panfacial IPL alone for lateral canthal crow’s feet [27]. The investigators found a greater response, at rest and maximum smile, and greater improvement in skin texture with combination panfacial IPL and botulinum toxin than with light treatment. Furthermore, IPL has demonstrated synergistic effects with nonablative fractional lasers (NAFL). It is


thought that the increased edema induced by IPL allows for better absorption of NAFL energy by water, leading to superior results in the improvement of discoloration, acne scars, and rhytides [28,29]. The investigators recommend same day IPL treatment followed immediately by NAFL.

LASERS The quantity of laser options for photorejuvenation is vast with each type—ablative versus nonablative or fractionated versus nonfractionated—providing different advantages regarding efficacy, side-effect profile, and patient satisfaction, based on the fundamental characteristics of the laser. The choice of laser subtype is often centered on the desired outcome, patient characteristics and preferences, and which aspect of aging is being targeted. Considering manifestations of aging are multifaceted, laser therapy has been studied to determine if its use affects other treatment modalities when used in concert.

NONABLATIVE LASERS The 1320-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, fractional 1440-nm Nd:YAG laser, 1450-nm diode laser, and the 1550-nm erbium-glass laser are but a few available nonablative options for cutaneous revitalization. Their effects are thought to be due to induction of neocollagenesis in the dermis without compromising the superficial epidermal layer. NAFL therapy has been safely and successfully combined with dermal fillers to improve skin texture, quality, and laxity (Fig. 3). A randomized clinical trial examined the effects of the 1320nm Nd:YAG and 1450-nm diode laser on HA injections administered immediately before the laser and found that the combination did not affect the efficacy or safety of HA treatment, suggesting that these combinations are feasible approaches [30]. Another study assessed the interaction of HA fillers with different energy-based devices on porcine models [25]. The investigators found no effects of nonablative lasers or superficially ablative lasers on the HA filler. In another study, same day treatment with the fractional 1440-nm Nd:YAG laser combined with HA injections has been shown to improve neck skin texture [31]. They found that this coupling provided clinical and histologic evidence of improvement in skin tension, fine lines, and texture. RF with microneedling (RFM) combined with the 1550-nm erbium glass laser has also demonstrated synergistic effects. This


Kelm & Ibrahim

FIG. 3 Nonablative fractional 1927 nm laser combined with hyaluronic acid filler in the malar cheeks improved facial contour, cheek projection, and overall texture and pigmentation, without an increased risk profile. (Ó 2019 Dr. Omer Ibrahim.)

combination treatment exhibited greater efficacy and quicker acne scar improvement compared with the laser alone without increases in recovery time [32]. In addition to coupling with HA fillers, the implementation of NAFL treatments along with regular botulinum toxin therapy can simultaneously improve dynamic and static rhytides, resulting in superior aesthetic improvement than with each treatment alone (Fig. 4).

ABLATIVE LASERS The 10,600-nm CO2 and the 2940-nm erbium:yttrium aluminum garnet (Er:YAG) lasers are 2 ablative lasers used for cutaneous rejuvenation and tightening by way of increased collagen and elastin production.

Although ablative lasers are more efficacious, they have longer recovery times and higher side-effect profiles than nonablative lasers. Ablative lasers have been studied in combination with other treatment modalities—neurotoxins, fillers, and other devices such as microfocused ultrasound (MFUS). OnabotA injection into dynamic facial rhytides 1 week before or 1 month following CO2 laser resurfacing demonstrated superior and prolonged improvement in wrinkles [33]. Another study assessing the effects of energy-based devices on soft tissue fillers revealed that deep ablative treatments could influence the final placement of HA fillers, promoting unwanted migration into ablated areas [25]. The investigators propose that if ablative therapies are required for deeper resurfacing, they should be done before HA filler

New Synergistic Tricks


FIG. 4 Nonablative fractional 1550 nm laser treatment coupled with regular botulinum toxin injections safely and synergistically improved dynamic and static wrinkles, yielding optimal results. (Ó 2019 Dr. Omer Ibrahim.)

injections or weeks after HA filler injections in order to minimize interactions and provide the optimal effect. Combination therapy with MFUS immediately followed by CO2 laser facial and neck resurfacing has also been explored. Significant improvement of skin laxity and sun-damaged skin, without changes to individual safety profiles, was seen with CO2 laser and MFUS combination treatment [34]. Within the last decade, newer novel applications for ablative fractional lasers (AFL) have come to clinical practice. The concept of AFL augmenting topical drug penetration through the epidermis was introduced [35]. Since its inception, laser-assisted drug delivery (LADD) has been shown to increase penetration of numerous topical agents treating neoplasia, melasma, scars, and photoaging, among many other indications [36].

Although the most studies on LADD investigate the enhanced treatment of actinic keratoses and superficial skin cancers, this technique has been increasingly used in the aesthetic realm. Taking advantage of the small channels created by the AFL, topical agents are more readily absorbed into the skin allowing for a more robust response. One study examined Er:YAGassisted drug delivery of topical antiaging agents [37]. The investigators noted an improvement in rhytide severity and cutaneous discoloration in patients with melasma, wrinkles, and acne scarring. Similar studies have demonstrated the utility and applicability of LADD, suggesting enhanced response to topical cosmeceutical and vitamin formulations for cutaneous rejuvenation and quicker post-AFL resurfacing healing [38,39].


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In addition, LADD has amplified the effects of neurotoxins and dermal fillers/biostimulators. A study compared the efficacy of AFL-assisted topical onaBot delivery verses LADD with topical normal saline for periorbital wrinkles and found superior clinical results with the LADD/onaBot group [40]. Furthermore, LADD with topical PLLA has been demonstrated to improve the appearance of atrophic scars and perioral rhytides [41,42]. In the treatment of upper lip rhytides, 3 treatments of low-density fractional CO2 laser followed by topical PLLA application resulted in approximately 50% improvement in upper lip wrinkles as measured by objective and subjective assessments without unexpected adverse events (Fig. 5) [42]. Of note, as LADD is a newer concept in the dermatologic and surgical fields, optimal treatment parameters and the ideal topical agents have yet to be solidified.

Therefore, LADD should be approached with caution, in order to minimize adverse events such as unwanted local and systemic reactions.

MICROFOCUSED ULTRASOUND MFUS is another tool that is used for the treatment of skin laxity. Combination treatments with MFUS have been suggested to provide superior results to individual modalities alone. Such combinations include MFUS with fillers, energy-based devices, and neurotoxins. The literature suggests that PLLA and MFUS together act synergistically in reducing rhytides, lines, and crevices in the décolletage [28,43]. To increase aesthetic outcome, IPL is often added to this combination to treat other aspects of photoaging such as dyschromia and

FIG. 5 Three treatments of laser-assisted delivery of topical poly-L-lactic acid significantly improved upper lip

rhytides. (Ó 2019 Dr. Omer Ibrahim.)

New Synergistic Tricks telangiectasias [28,43,44]. It has been demonstrated that MFUS combined with PLLA and IPL is a safe, single treatment option for photorejuvenation [44]. The investigators recommend that MFUS and IPL devices should be used before soft tissue filler injection to avoid risk of contaminating the devices with blood [44]. Further sequential recommendations are to use IPL first, followed by MFUS, because initial MFUS use may cause erythema that increases undesired absorption by the IPL [7,28,43]. Clinical efficacy and safety has also been established by combining MFUS, HA fillers, and incoBot for neck rhytides [45]. The investigators report that a single treatment session with the aforementioned multimodal combination produces synergistic effects resulting in long-lasting favorable results. Another study evaluated the safety and efficacy of combining 1:1 dilution of CaHA with lidocaine with MFUS and showed that patients had a significant improvement in neck and décolletage lines and wrinkles with a high degree of patient satisfaction [46]. Expert consensus recommends adding a low viscosity HA filler or diluted CaHA filler to MFUS treatment for deeper décolletage wrinkles to improve tone, hydration, and texture [24]. MFUS has also been combined with botulinum toxins to address the different facets of the aging neck—platysmal banding, horizontal wrinkles, and skin laxity—without increased adverse effects or toxin spread [47]. MFUS is performed first, followed by botulinum toxin injection [24]. A retrospective chart review examined the safety of using HA fillers, CaHA fillers, and/or incoBot injections within 6 months of MFUS treatment on the face and/or neck [48]. The investigators found that no additional safety signals emerged from combining these different injectables, suggesting that their use, together, can be safely performed.

RADIOFREQUENCY RF instruments are used for their ability to reduce skin laxity and finesse the contours of the skin. However, similar to the light and energy-based devices, RF devices are poor choices for restoring volume in areas where lipoatrophy has occurred, prompting investigators to explore the possible applications of combining RF treatment with soft tissue augmentation [47]. Initial studies investigating this concept found that filler duration or side-effect profiles were not affected by RF treatment when administered 2 weeks following injections [49] but did find histologic evidence of increased inflammatory and fibrotic response [50]. In an attempt to further


ascertain the utility of RF and filler combinations, another study found that using RF following HA or CaHA filler treatment did not demonstrate any appreciable histopathologic changes [51]. In addition to the sequential use of RF after filler treatment, same day therapy has been suggested to improve overall results with RF and fillers acting synergistically [52]. Choi and colleagues [53] compared the use of intradermal RF immediately before HA filler versus HA filler alone for nasolabial fold treatment. The investigators demonstrated that preceding treatment with RF resulted in significant, synergistic, longer-lasting effects for the improvement of nasolabial rhytides and suggest that this technique may be applied to other facial areas.

RADIOFREQUENCY WITH MICRONEEDLING An additional synergistic concept is RFM. These combination devices, using the consistent depth and arrangement of microneedles, allow deeper, more targeted RF administration, while leaving most of the epidermis intact [54]. RFM has been explored in the improvement of photoaged skin. Studies have demonstrated that using this modality on the lower face, neck, and décolletage has resulted in significant improvement in skin texture, laxity, and wrinkles [55,56]. Multiple other studies have substantiated these results with RFM, reporting significant improvements in facial and neck skin laxity and wrinkles, which were maintained at 6month follow-up after a single treatment session [57– 59]. Another study demonstrated similar facial rejuvenation with RFM, but patients received 3 treatments at 4-week intervals [60]. RFM has also been shown to be effective at treating acne scars and expanded facial pores with one treatment session [61].

SOFT TISSUE FILLER AND SYNTHETIC DEOXYCHOLIC ACID Dermal filler combined with synthetic deoxycholic acid (SDA) is another option for facial rejuvenation and skin tightening. A case report presented the use of botulinum toxin, HA filler, and SDA for lower face restoration [62]. The investigator administered toxin into each depressor anguli oris muscle, followed by HA filler injection into marionette lines, and completing the treatment with SDA into the jowls. This 3-pronged approach demonstrated marked improvement in lower facial laxity and was well tolerated. In addition, SDA and filler can be combined in the same location, to reduce the appearance of jowls, create a more well-defined jawline, and improve lower facial laxity (Fig. 6).


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FIG. 6 Injections of synthetic deoxycholic acid to the jowls combined with calcium hydroxyapatite filler to the

mandible improved laxity and restored the contour of the jaw. (Ó 2019 Dr. Omer Ibrahim.)

SUMMARY The advent of neuromodulators, soft tissue fillers, and energy-based devices has revolutionized the management of photoaged skin. Knowing that the aging process is multifaceted and that certain therapy modalities treat specific aging manifestations, combination therapy is many times necessary for optimal results. Coupling neuromodulators, soft tissue fillers, and energy-based devices together is a safe and effective technique for skin rejuvenation and often demonstrates synergism with enhanced patient satisfaction.

REFERENCES [1] Pavicic T, Few JW, Huber-Vorlander J. A novel, multistep, combination facial rejuvenation procedure for treatment of the whole face with incobotulinumtoxinA, and two dermal fillers- calcium hydroxylapatite and a

monophasic, polydensified hyaluronic acid filler. J Drugs Dermatol 2013;12(9):978–84. [2] Carruthers J, Carruthers A, Monheit GD, et al. Multicenter, randomized, parallel-group study of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation: satisfaction and patient-reported outcomes. Dermatol Surg 2010;36(Suppl 4):2135–45. [3] Dessy LA, Mazzocchi M, Rubino C, et al. An objective assessment of botulinum toxin A effect on superficial skin texture. Ann Plast Surg 2007;58(5):469–73. [4] Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg 2003;29(8):802–9.

New Synergistic Tricks [5] Dubina M, Tung R, Bolotin D, et al. Treatment of forehead/ glabellar rhytide complex with combination botulinum toxin a and hyaluronic acid versus botulinum toxin A injection alone: a split-face, rater-blinded, randomized control trial. J Cosmet Dermatol 2013;12(4):261–6. [6] Beer KR, Julius H, Dunn M, et al. Remodeling of periorbital, temporal, glabellar, and crow’s feet areas with hyaluronic acid and botulinum toxin. J Cosmet Dermatol 2014;13(2):143–50. [7] Langelier N, Beleznay K, Woodward J. Rejuvenation of the upper face and periocular region: combining neuromodulator, facial filler, laser, light, and energy-based therapies for optimal results. Dermatol Surg 2016; 42(Suppl 2):S77–82. [8] Molina B, David M, Jain R, et al. Patient satisfaction and efficacy of full-facial rejuvenation using a combination of botulinum toxin type a and hyaluronic acid filler. Dermatol Surg 2015;41(Suppl 1):S325–32. [9] Carruthers J, Burgess C, Day D, et al. Consensus recommendations for combined aesthetic interventions in the face using botulinum toxin, fillers, and energy-based devices. Dermatol Surg 2016;42(5):586–97. [10] Cohen JL, Swift A, Solish N, et al. OnabotulinumtoxinA and hyaluronic acid in facial wrinkles and folds: a prospective, open-label comparison. Aesthet Surg J 2019; 39(2):187–200. [11] Sundaram H, Liew S, Signorini M, et al. Global aesthetics consensus: hyaluronic acid fillers and botulinum toxin type a-recommendations for combined treatment and optimizing outcomes in diverse patient populations. Plast Reconstr Surg 2016;137(5):1410–23. [12] Carruthers A, Carruthers J, Monheit GD, et al. Multicenter, randomized, parallel-group study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation. Dermatol Surg 2010;36(Suppl 4):2121–34. [13] Narurkar VA, Cohen JL, Dayan S, et al. A Comprehensive approach to multimodal facial aesthetic treatment: injection techniques and treatment characteristics from the HARMONY study. Dermatol Surg 2016;42(Suppl 2): S177–91. [14] Wollina U. Facial rejuvenation starts in the midface: three-dimensional volumetric facial rejuvenation has beneficial effects on nontreated neighboring esthetic units. J Cosmet Dermatol 2016;15(1):82–8. [15] Beer K. Dermal fillers and combinations of fillers for facial rejuvenation. Dermatol Clin 2009;27(4):427–32, v. [16] Fagien S. Variable reconstitution of injectable hyaluronic acid with local anesthetic for expanded applications in facial aesthetic enhancement. Dermatol Surg 2010; 36(s1):815–21. [17] Fagien S, Cassuto D. Reconstituted injectable hyaluronic acid: expanded applications in facial aesthetics and additional thoughts on the mechanism of action in cosmetic medicine. Plast Reconstr Surg 2012;130(1): 208–17.


[18] Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–27 [discussion: 2228–31]. [19] Shaw RB Jr, Kahn DM. Aging of the midface bony elements: a three-dimensional computed tomographic study. Plast Reconstr Surg 2007;119(2):675–81 [discussion: 682–73]. [20] Sadick NS, Manhas-Bhutani S, Krueger N. A novel approach to structural facial volume replacement. Aesthetic Plast Surg 2013;37(2):266–76. [21] Iannitti T, Morales-Medina JC, Coacci A, et al. Experimental and clinical efficacy of two hyaluronic acidbased compounds of different cross-linkage and composition in the rejuvenation of the skin. Pharm Res 2016; 33(12):2879–90. [22] Nisi G, Cuomo R, Brandi C, et al. Carbon dioxide therapy and hyaluronic acid for cosmetic correction of the nasolabial folds. J Cosmet Dermatol 2016;15(2): 169–75. [23] Fabi SG, Goldman MP. The safety and efficacy of combining poly-L-lactic acid with intense pulsed light in facial rejuvenation: a retrospective study of 90 patients. Dermatol Surg 2012;38(7 Pt 2):1208–16. [24] Fabi SG, Burgess C, Carruthers A, et al. Consensus recommendations for combined aesthetic interventions using botulinum toxin, fillers, and microfocused ultrasound in the neck, decolletage, hands, and other areas of the body. Dermatol Surg 2016;42(10):1199–208. [25] Farkas JP, Richardson JA, Brown S, et al. Effects of common laser treatments on hyaluronic acid fillers in a porcine model. Aesthet Surg J 2008;28(5):503–11. [26] Khoury JG, Saluja R, Goldman MP. The effect of botulinum toxin type A on full-face intense pulsed light treatment: a randomized, double-blind, split-face study. Dermatol Surg 2008;34(8):1062–9. [27] Carruthers J, Carruthers A. The effect of full-face broadband light treatments alone and in combination with bilateral crow’s feet Botulinum toxin type A chemodenervation. Dermatol Surg 2004;30(3):355–66 [discussion: 366]. [28] Peterson JD, Kilmer SL. Three-dimensional rejuvenation of the decolletage. Dermatol Surg 2016;42(Suppl 2): S101–7. [29] Kearney C, Brew D. Single-session combination treatment with intense pulsed light and nonablative fractional photothermolysis: a split-face study. Dermatol Surg 2012;38(7 Pt 1):1002–9. [30] Goldman MP, Alster TS, Weiss R. A randomized trial to determine the influence of laser therapy, monopolar radiofrequency treatment, and intense pulsed light therapy administered immediately after hyaluronic acid gel implantation. Dermatol Surg 2007;33(5): 535–42. [31] Ribe A, Ribe N. Neck skin rejuvenation: histological and clinical changes after combined therapy with a fractional non-ablative laser and stabilized hyaluronic acid-based














Kelm & Ibrahim gel of non-animal origin. J Cosmet Laser Ther 2011; 13(4):154–61. Kwon HH, Park HY, Choi SC, et al. Combined fractional treatment of acne scars involving non-ablative 1,550-nm Erbium-glass laser and micro-needling radiofrequency: a 16-week prospective, randomized split-face study. Acta Derm Venereol 2017;97(8):947–51. West TB, Alster TS. Effect of botulinum toxin type A on movement-associated rhytides following CO2 laser resurfacing. Dermatol Surg 1999;25(4):259–61. Woodward JA, Fabi SG, Alster T, et al. Safety and efficacy of combining microfocused ultrasound with fractional CO2 laser resurfacing for lifting and tightening the face and neck. Dermatol Surg 2014;40(Suppl 12): S190–3. Haedersdal M, Sakamoto FH, Farinelli WA, et al. Fractional CO(2) laser-assisted drug delivery. Lasers Surg Med 2010;42(2):113–22. Haedersdal M, Erlendsson AM, Paasch U, et al. Translational medicine in the field of ablative fractional laser (AFXL)-assisted drug delivery: a critical review from basics to current clinical status. J Am Acad Dermatol 2016;74(5):981–1004. Alexiades M. Randomized, double-blind, split-face study evaluating fractional ablative erbium:YAG lasermediated trans-epidermal delivery of cosmetic actives and a novel acoustic pressure wave ultrasound technology for the treatment of skin aging, melasma, and acne scars. J Drugs Dermatol 2015;14(11):1191–8. Trelles MA, Leclere FM, Martinez-Carpio PA. Fractional carbon dioxide laser and acoustic-pressure ultrasound for transepidermal delivery of cosmeceuticals: a novel method of facial rejuvenation. Aesthetic Plast Surg 2013;37(5):965–72. Waibel JS, Mi QS, Ozog D, et al. Laser-assisted delivery of vitamin C, vitamin E, and ferulic acid formula serum decreases fractional laser postoperative recovery by increased beta fibroblast growth factor expression. Lasers Surg Med 2016;48(3):238–44. Mahmoud BH, Burnett C, Ozog D. Prospective randomized controlled study to determine the effect of topical application of botulinum toxin A for crow’s feet after treatment with ablative fractional CO2 laser. Dermatol Surg 2015;41(Suppl 1):S75–81. Rkein A, Ozog D, Waibel JS. Treatment of atrophic scars with fractionated CO2 laser facilitating delivery of topically applied poly-L-lactic acid. Dermatol Surg 2014; 40(6):624–31. Ibrahim O, Ionta S, Depina J, et al. Safety of laser-assisted delivery of topical poly-L-lactic acid in the treatment of upper lip rhytides: a prospective, rater-blinded study. Dermatol Surg 2019. [Epub ahead of print]. Hart DR, Fabi SG, White WM, et al. Current concepts in the use of PLLA: clinical synergy noted with combined use of microfocused ultrasound and poly-L-lactic acid on the face, neck, and decolletage. Plast Reconstr Surg 2015;136(5 Suppl):180s–7s.

[44] Friedmann DP, Fabi SG, Goldman MP. Combination of intense pulsed light, Sculptra, and Ultherapy for treatment of the aging face. J Cosmet Dermatol 2014;13(2): 109–18. [45] Jeon H, Kim T, Kim H, et al. Multimodal approach for treating horizontal neck wrinkles using intensity focused ultrasound, cohesive polydensified matrix hyaluronic acid, and incobotulinumtoxinA. Dermatol Surg 2018; 44(3):421–31. [46] Casabona G, Nogueira Teixeira D. Microfocused ultrasound in combination with diluted calcium hydroxylapatite for improving skin laxity and the appearance of lines in the neck and decolletage. J Cosmet Dermatol 2018;17(1):66–72. [47] Cuerda-Galindo E, Palomar-Gallego MA, LinaresGarciavaldecasas R. Are combined same-day treatments the future for photorejuvenation? Review of the literature on combined treatments with lasers, intense pulsed light, radiofrequency, botulinum toxin, and fillers for rejuvenation. J Cosmet Laser Ther 2015;17(1):49–54. [48] Fabi SG, Goldman MP, Mills DC, et al. Combining microfocused ultrasound with botulinum toxin and temporary and semi-permanent dermal fillers: safety and current use. Dermatol Surg 2016;42(Suppl 2):S168–76. [49] England LJ, Tan MH, Shumaker PR, et al. Effects of monopolar radiofrequency treatment over soft-tissue fillers in an animal model. Lasers Surg Med 2005;37(5): 356–65. [50] Shumaker PR, England LJ, Dover JS, et al. Effect of monopolar radiofrequency treatment over soft-tissue fillers in an animal model: part 2. Lasers Surg Med 2006; 38(3):211–7. [51] Alam M, Levy R, Pajvani U, et al. Safety of radiofrequency treatment over human skin previously injected with medium-term injectable soft-tissue augmentation materials: a controlled pilot trial. Lasers Surg Med 2006; 38(3):205–10. [52] Ko EJ, Kim H, Park WS, et al. Correction of midface volume deficiency using hyaluronic acid filler and intradermal radiofrequency. J Cosmet Laser Ther 2015;17(1): 46–8. [53] Choi SY, Lee YH, Kim H, et al. A combination trial of intradermal radiofrequency and hyaluronic acid filler for the treatment of nasolabial fold wrinkles: a pilot study. J Cosmet Laser Ther 2014;16(1):37–42. [54] Hogan S, Velez MW, Ibrahim O. Microneedling: a new approach for treating textural abnormalities and scars. Semin Cutan Med Surg 2017;36(4):155–63. [55] Lyons A, Roy J, Herrmann J, et al. Treatment of decolletage photoaging with fractional microneedling radiofrequency. J Drugs Dermatol 2018;17(1):74–6. [56] Clementoni MT, Munavalli GS. Fractional high intensity focused radiofrequency in the treatment of mild to Moderate laxity of the lower face and neck: a pilot study. Lasers Surg Med 2016;48(5):461–70. [57] Tanaka Y. Long-term three-dimensional volumetric assessment of skin tightening using a sharply tapered

New Synergistic Tricks non-insulated microneedle radiofrequency applicator with novel fractionated pulse mode in asians. Lasers Surg Med 2015;47(8):626–33. [58] Alexiades-Armenakas M, Newman J, Willey A, et al. Prospective multicenter clinical trial of a minimally invasive temperature-controlled bipolar fractional radiofrequency system for rhytid and laxity treatment. Dermatol Surg 2013;39(2):263–73. [59] Alexiades-Armenakas M, Rosenberg D, Renton B, et al. Blinded, randomized, quantitative grading comparison of minimally invasive, fractional radiofrequency and surgical face-lift to treat skin laxity. Arch Dermatol 2010; 146(4):396–405.


[60] Zhang M, Fang J, Wu Q, et al. A prospective study of the safety and efficacy of a microneedle fractional radiofrequency system for global facial photoaging in chinese patients. Dermatol Surg 2018;44(7): 964–70. [61] Cho SI, Chung BY, Choi MG, et al. Evaluation of the clinical efficacy of fractional radiofrequency microneedle treatment in acne scars and large facial pores. Dermatol Surg 2012;38(7 Pt 1):1017–24. [62] Mess SA. Lower face rejuvenation with injections: botox, juvederm, and kybella for marionette lines and jowls. Plast Reconstr Surg Glob Open 2017;5(11): e1551.

Advances in Cosmetic Surgery 2 (2019) 69–74


Facial Rejuvenation Fat Transfer Versus Fillers Ali A. Qureshi, MDa,*, Marissa M.J. Tenenbaum, MDb,1 a

Marina Plastic Surgery, Marina del Rey, CA, USA; bDivision of Plastic Surgery, Washington University in St. Louis, St. Louis, MO, USA


 Soft tissue filler  Fat transfer  Filler  Facial rejuvenation  Nonsurgical  Injectables KEY POINTS

 Aging of the face is a complex, multidimensional process that includes volume deflation.  Autologous fat transfer and fillers are both popular ways to restore volume to the face.  Fat transfer uses an individual’s own fat as a soft tissue filler but involves fat harvest and can have unpredictable viability with lasting results.  Filler uses manufactured product to augment the face but is temporary and often requires repeat treatments to maintain results in the long term.  Customized facial rejuvenation plans require an assessment of the pros and cons of fat transfer versus filler for each patient.

THE AGING FACE The complexity of facial aging should not be underestimated because it is multidimensional and affects the underlying bony skeleton, overlying skin, and the musculoaponeurotic system and fat compartments in-between. More than 50 years ago, Gonzales-Ulloa and Flores described the role of facial volume loss as a component of facial aging [1]. More recent studies by Lambros with longitudinal photographic studies have highlighted the central role of volume loss rather than ptosis of tissues in facial aging [2]. Anatomic studies by Rohrich and Pessa [3] have described different fat compartments of the face, helping explain how differential volume loss can lead to telltale signs of aging. Autologous fat and soft tissue fillers can be used to restore lost volume. But they can also be used to improve contour and changes seen after trauma,

congenital defects, oncologic surgery and other diseases processes that affect the face. It is critical to understand that restoration of volume in a poor skin envelope can only do so much. Many times, the outer lamella, the skin needs to be treated with nonsurgical modalities like laser or energy-based devices or surgical management of excess skin.

AUTOLOGOUS FAT INJECTION Autologous fat can be used for volume restoration of the face. There are several advantages to fat as a soft tissue filler of choice. 1. Fat is often readily available from expendable donor sites in patients with normal or high body mass indices. Finding sufficient fat for grafting can be challenging in patients with low body fat

Disclosure Statement: The authors have nothing to disclose. 1 Present address: 1020 North Mason Road, Suite 110, Creve Couer, MO 63141. *Corresponding author. 4644 Lincoln Boulevard #552, Marina Del Rey, CA 90292. E-mail address: [email protected] 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.



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percentages, low body weight, or history of previous liposuction and/or fat harvesting. 2. Fat can be obtained easily with liposuction, a common cosmetic procedure with a proved safety record in the hands of well-trained, licensed physicians. There is low donor-site morbidity when performed safely and properly. 3. Fat grafting can be repeated and done until a desired effect is achieved. 4. Fat grafting uses a patient’s own tissue for augmentation. There are benefits beyond volume restoration associated with fat grafting. It has been reported to lead to improved skin quality, reduced wrinkles and pore size, and improvements in pigments and dyschromias [4]. Reports of fat grafting in irradiated breast cancer patients have reported improved skin quality as well [4]. There are shortcomings and disadvantages associated with fat grafting: 1. Not all volume of fat grafted in a session survives in the long term. There are varied estimations of fat graft take, or survival, between 25% and 70% [4]. The durability of fat is hard to predict and this can be frustrating for patients who see a loss in volume with time. Adequate patient counseling and education are important for setting of expectations (Fig. 1). 2. Fat necrosis can occur and lead to palpable nodules that may require further intervention for resolution. 3. Superficial injection of fat in areas of thin skin like the lower eyelid can be difficult to treat.

4. Fluctuations in total body weight can affect the appearance of a fat-grafted face, because the fat continues to respond metabolically the way it would have at the donor site. Grafted fat can be thought of surviving in 3 zones: outer, intermediate, and central (Box 1) [4,5]. 1. The outer zone consists of grafted fat that comes in direct contact with the recipient bed. This fat tends to be most likely to survive because it is closest to the recipient vascular bed. 2. The intermediate zone is the regenerating zone, where there are adipose-derived stromal cells that have the ability to become adipocytes and replace the ones lost in the central necrotic zone. 3. The central necrotic zone is furthest from the vascular bed and does not survive long term.

Surgical technique for fat grafting Much controversy and debate exist on the best methods for fat grafting. The best outcome with fat grafting would be adequate and predictable volume with little or no donor-site morbidity. Regardless of the techniques used, there are 3 key components of fat grafting surgery [4]: 1. Harvest 2. Processing 3. Injection Harvest of fat involves liposuction of some sort. Methods include but are not limited to suction-assisted liposuction, power-assisted liposuction, and ultrasoundassisted liposuction, with no definitive evidence to suggest

FIG. 1 A 55-year-old woman desired improvement in her facial volume and overall appearance of her face.

She had autologous fat transfer to her face, specifically the malar and cheek areas.

Facial Rejuvenation


1. Outer

or suction-assisted liposuction alone can be performed for the harvest (Fig. 2). The authors prefer simple decanting prior to injection.

2. Intermediate 3. Central



that 1 method is superior to others. Other possible variables include the size of cannula used to harvest fat, amount of negative pressure used in liposuction, optimum particle size, and type of tumescence used. Processing of fat aims to minimize debris being injected and attempting to improve total volume of fat retained in the recipient site. There is a wide range of philosophies about the importance of processing fat. Anecdotally, some investigators argue that the fat does not need to be processed at all and that, by not doing so, cellular factors that would promote retention are not removed. Other investigators argue that processing of fat would lead to improved total retention of fat by removing debris and factors that could promote inflammation. Common methods for fat processing include centrifugation, washing, decanting, and sedimentation. The authors prefer to use suction-assisted lipectomy with the tumescent technique when done under local anesthetic in the office. If done under general anesthesia and combined with another procedure, power-assisted

Fat injection typically is performed using small cannulas with small aliquots fanned at various depths over the area to be revolumized. Smaller cannulas also reduce the amount of trauma in the recipient bed. Bolus injection of fat is not recommended because this can lead to fat necrosis and other complications. For the first 48 hours, the grafts survive primarily through absorption of nutrients from the surrounding bed. Neovascularization occurs at 1 mm a day and it is recommended that grafts not be greater than 2 mm to avoid central necrosis [6]. If fat injection is not done with a general anesthetic, the authors prefer using topical anesthetics in the area to be injected.

Common side effects After fat grafting, there typically is a loss in volume because some of the injected fat resorbs. This can lead to asymmetry or incomplete correction of the targeted areas. Fat necrosis can occur and be palpable and bothersome to patients and may require breaking up with a large-bore needle or excision with surgery. Superficial

FIG. 2 A 62-year-old woman desired a secondary facelift. She wanted improvement in facial volume and autologous fat transfer was performed at the same time as her secondary facelift.


Qureshi & Tenenbaum


1. HA 2. CaHA 3. PLLA 4. PMMA

placement of fat grafts in areas of thin skin can lead to visibility of injected fat. Imprecise harvest technique at the donor site can lead to contour irregularities and patient dissatisfaction.

FILLER Soft tissue fillers most often are made of hyaluronic acid (HA), calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), and polymethyl methacrylate (PMMA) (Box 2). In the past, bovine collagen and even liquid silicone were used but, because they are no longer firstline soft tissue fillers, they are not reviewed. Fillers have different properties, including [7] 1. G* (hardness) 2. G’ (elasticity) 3. G’’ (viscosity) HA occurs naturally in the skin and there is a wide range of fillers that differ in their properties but still are made from HA. Anatomy, location, degree of volume loss, and depth of rhytides all influence specific filler choice. In general, a harder filler or one with a greater G* is usually placed at a deep level in the face, just above the periosteum (Box 3, Fig. 3). Cohesivity is how the filler resists deformation and spreading and measures the internal adhesive forces in the gel. More cohesive HAs are better suited for areas that need to maintain their contour shape and projection, as in cases of malar augmentation or the chin. Less cohesive fillers, which spread more and soften with muscle motion, are better suited for areas of motion like the lips or nasolabial folds. In general, fillers are administered with a fine 27-gauge or 30gauge needle although blunt tip cannulas can also be used.


Areas with greater motion like the lips tend to see less longevity of correction than the cheekbones or tear troughs, where there is less motion.

FIG. 3 A 44-year-old woman desired improvement in

her lower face. She did not want surgery and had Utherapy to the lower face and injection of CaHA filler to the lower face.

Hyaluronidase is an enzyme that can be injected that dissolves injected HA by depolymerizing the HA. There is also some effect, however, on native hyaluronan present in the recipient bed. Native hyaluronan is quickly regenerated by the body. Injection of hyaluronidase is a key step for the management of inadvertent intravascular injection or tamponading of a vessel from too much filler. It also can be used to correct asymmetry or over-injection. CaHA is found in bone mineral and can be combined with a neutral gel that dissolves after injection. It is a thicker filler typically injected deep to the subcutaneous tissue (Fig. 4). The CaHA degrades over a year and can be visible on radiologic imaging. Overtreatment with CaHA can be challenging to correct. Usually multiple stab incisions with a large-bore needle can allow for manual extraction. Nodules can form and may be amenable to corticosteroid injection. PLLA works by stimulating fibrosis and inducing neocollagenesis [7]. The powder is reconstituted in water and injected into the deep subcutaneous plane.

Facial Rejuvenation


FIG. 4 A 68-year-old man wanted improvement in his lower face and jawline definition without surgery. He

did not have enough fat for autologous fat grafting and had HA and CaHA injected to the nasolabial folds and jawline areas.

Water is resorbed and the dispersed spherules induce neocollagenesis. Multiple injections are required because injection does not lead to immediate correction. Typically, 1 month to 3 months are needed before the volume effects of neocollagenesis are visible [7]. Some investigators recommend postinjection massage to reduce the occurrence of nodules. Results tend to last 18 months to 2 years. PMMA was approved by the Food and Drug Administration in 2006 and is permanent filler. It contains bovine collagen in addition to the PMMA, which is why allergy testing is usually recommended a month prior to planned injection. Injection plane is deep to the dermis at the dermal subcutaneous junction. The collagen acts as a carrier for the PMMA beads and is slowly resorbed. Fibrosis that follows leads to volume augmentation. Commonly, granulomas can occur [8].

Anesthesia and pain management Like any cosmetic procedure, soft tissue filler injection should be comfortable and as pain-free as possible. Patients typically are awake and may have had prior experiences that shape the way they view a new encounter. Although many fillers have lidocaine mixed into

them, topical anesthetics can make the injection process more comfortable for patients. Topical ice packs also can serve to distract during injections and lead to vasoconstriction of underlying blood vessels, theoretically reducing the risk of trauma to a blood vessel and subsequent bruising. Another option is blocking infraorbital nerve and mental nerves, which can provide adequate anesthesia for malar, nasolabial fold, and lip augmentation (Box 4). There can be, however, diffusion of the anesthetic and it can block the muscles of facial expression. Patients should be forewarned that they may have asymmetric expression postinjection that may be due to residual effects of the block and not necessarily the filler. Direct injection of local anesthetic into areas of planned soft tissue augmentation usually is not recommended and is not the authors’ choice for anesthetic. BOX 4

Making fat and/or filler injection as painless as possible is critical to ensuring a positive experience for patients seeking volume restoration.


Qureshi & Tenenbaum


The Tyndall effect occurs with superficial injection of HA, where bluish striae can appear on the skin and can occur in the tear trough areas.

The volume of local anesthetic given can alter the tissue and actually augment it until it diffuses out; this makes correction of asymmetries and the desired goal difficult to achieve.

Common side effects After injection, it is common to have injection-site sensitivity. Redness and swelling are common. Often, the authors tell patients that swelling gets worse before it gets better and improves after 72 hours after injection. Patients can feel lump and bumps for a few days after injection, depending on where it is injected, and gentle massage can help as the filler incorporates. Asymmetry is difficult to assess once swelling has begun and, therefore, any touch-up procedures should be deferred until it appears that swelling has subsided. Less common things that can occur include intravascular injection that presents with severe pain at the time of injection and delayed reticulated erythema or violaceous discoloration (Box 5). Too much filler in an area of a blood vessel also can lead to a tamponade effect on the vessel, leading to tissue compromise. Retrograde movement of filler in the retinal artery has been reported to lead to blindness and is a rare but devastating complication. This presents with sudden, sharp pain and loss of unilateral vision [7]. Fillers that contain bovine collagen can lead to immunologic and allergic responses, and spot testing prior to full correction with such fillers is recommended. Rarely, HAs can cause erythema, itching, or swelling that self-resolves or can improve with antihistamines. Rarely, granulomas also can form, depending on the filler used.

Management of vasoocclusion In the unlikely but possible event of vasoocclusion after filler injection, several steps immediately should be taken [9,10]. If it is an HA, injection of hyaluronidase in the area of the HA placement should be performed. The hyaluronidase breaks up the HA polymers, which in turn allows for easier dissolution and elimination. Nitropaste, warm compresses, and aspirin administration can help as well. Hyperbaric oxygen can help with tissue perfusion. The most important thing is close

and continued follow-up with patients after such an event, to monitor for changes and progression and to maintain the doctor-patient relationship.

AUTHORS’ THOUGHTS ON FAT VERSUS FILLER Fat and filler injections both have revolutionized the ability to correct and restore volume and contour irregularities of the face. Like any procedure, there are pros and cons associated with both. In patients who are naive to soft tissue injection of any kind, filler may be an easy, low-risk way to introduce patients to what kind of results are possible. They lead to an immediate effect and have no donor-site morbidity. Additionally, some results are reversible, and results are temporary for the most part. Fat grafting is suitable in patients who have fat grafting donor sites, have previously had filler, and want a potentially more durable, lasting result. In the authors’ experience, fat injection also leads to improvement in skin quality, texture, and dyschromias.

REFERENCES [1] Gerth DJ. Structural and volumetric changes in the aging face. Facial Plast Surg 2015;31(1):3–9. [2] Fitzgerald R, Graivier MH, Kane M, et al. Update on facial aging. Aesthet Surg J 2010;30(Suppl):11S–24S. [3] Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–27. [4] Bellini E, Grieco MP, Raposio E. The science behind autologous fat grafting. Ann Med Surg (Lond) 2017;24:65–73. [5] Eto H, Kato H, Suga H, et al. The fate of adipocytes after nonvascularized fat grafting: evidence of early death and replacement of adipocytes. Plast Reconstr Surg 2012;129: 1081–92. [6] Simonacci F, Bertozzi N, Grieco MP, et al. Procedure, applications,and outcomes of autologous fat grafting. Ann Med Surg (Lond) 2017;20:49–60. [7] Alam M, Tung R. Injection technique in neurotoxins and fillers: Indications, products, and outcomes. J Am Acad Dermatol 2018;79(3):423–35. [8] Fallacara A, Manfredini S, Durini E, et al. Hyaluronic acid fillers in soft tissue regeneration. Facial Plast Surg 2017; 33(1):87–96. [9] Cavallini M, Gazzola R, Metalla M, et al. The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers. Aesthet Surg J 2013;33(8): 1167–74. [10] DeLorenzi C. New high dose pulsed hyaluronidase protocol for hyaluronic acid filler vascular adverse events. Aesthet Surg J 2017;37(7):814–25.

Advances in Cosmetic Surgery 2 (2019) 75–87


Submental Fat Contouring A Comparison of Deoxycholic Acid, Cryolipolysis, and Liposuction Sara Hogan, MD, MPHa,*, Prasanthi Kandula, MDa, Daniel J. Callaghan, MDa, Jeffrey S. Dover, MD, FRCPCb,c a

SkinCare Physicians, 1244 Boylston Street, Chestnut Hill, MA 02467, USA; bYale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA; cBrown Medical School, 222 Richmond Street, Providence, RI 02912, USA


 Submental contouring  Submental fullness  Cryolipolysis  Deoxycholic acid  Liposuction KEY POINTS

 Noninvasive nonsurgical treatments have simplified the approach to submental fullness and have lowered the threshold for many potential patients to pursue treatment.  Deoxycholic acid and cryolipolysis are most appropriate for patients who have moderate submental fullness and minimal platysmal banding.  Submental liposuction is most beneficial in younger patients with excess preplatsymal fat and good skin elasticity.  Skin laxity and platysmal banding may be uncovered with the removal of submental adipose.

INTRODUCTION The jawline and chin give definition to the beauty of the face. This anatomic site does not respond easily to diet or exercise and thus is of particular cosmetic interest to patients. In the 2017 Consumer Survey by the American Society for Dermatologic Surgery, nearly 73% of 7322 respondents reported being “somewhat to extremely bothered” by excess fat under the chin or neck [1]. For younger patients, excess submental fullness may give the unwanted impression of obesity in the setting of a normal body weight or premature aging. In older patients, a loss of mandibular definition and an increase in submental adiposity is often observed. Additional factors affecting the development of submental fullness include genetic susceptibility, poor hard tissue structural support (eg, microgenia, micrognathia, retrogenia), smoking, dyschromia, skin laxity, and platysmal weakness [2]. With the development of noninvasive cosmetic treatments targeting the submental area,

physicians are now armed with more options to offer patients presenting with submental fullness. Here, the authors compare and review 3 modalities for submental contouring: deoxycholic acid (DCA), cryolipolysis, and liposuction.

ANATOMY OF THE SUBMENTAL AREA The cervicomental area lies within boundaries formed by the inferior mandible, antegonial notch, anterior sternocleidomastoid muscle, submental crease, and hyoid bone. Within this, the cervicomental angle is formed at the intersection of the horizontal plane of the submental region and the vertical plane of the neck. The ideal cervicomental angle is between 90 and 120 , and any angle greater than 120 can give the appearance of a “double chin” [3] (Box 1). The hyoid bone is preferably positioned at the C3-C4 cervical spine level, higher than the level of the menton [4].

*Corresponding author, E-mail address: [email protected] 2542-4327/19/ © 2019 Elsevier Inc. All rights reserved.



Hogan et al


Ideal features of the submental region 

Cervicomental angle between 90 and 120

Absence of jowls

Sharp anterior border of the sternocleidomastoid muscles


Hyoid bone positioned higher than the menton Visible thyroid cartilage

Inserting laterally onto either side of the hyoid are the digastric muscles, separated into anterior and posterior bellies, which also contribute to submental volume [4]. Patients with a lowered hyoid have a displaced anterior digastric belly that can blunt the cervicomental angle (Fig. 1). Submandibular gland hypertrophy and ptosis can additionally contribute to submental fullness. The sternocleidomastoid muscles divide the cervicomental area into anterior and posterior triangles, and the hyoid bone further divides the anterior triangle into submandibular, carotid, muscular, and submental triangles [5]. It is the submental triangle that most determines submental contour and is particularly affected by adiposity. The structure of the platysma muscle itself helps shape of the anterior neck, with superficial fibers inserting on anterior mandible and coursing inferiorly to create different decussation patterns that separate adipose compartments. Patients with platysmal decussation exhibit redundancy in the upper neck, whereas patients without decussation demonstrate prominent platysma banding. Submental adipose covers this entire area, regardless of decussation pattern, and is divided into 2 compartments: superficial or preplatysmal adipose beneath the dermis and above the platysma, and deep or postplatysmal adipose lying deep to the muscle. Variability exists in preplatysmal and postplatysmal adipose distribution [5]. Preplatysmal adipose weighs an average 15 g in men and 14.3 g in women, whereas postplatysmal adipose weighs an average 5.5 g in men and 3.7 g in women [6]. It is preplatysmal adipose that is the primary target of submental contouring. Postplatysmal adipose, which is less commonly targeted, is divided into 3 compartments: central, medial, and lateral, distinguished by their relationship to the platysmal, digastric, and mylohyoid muscles [6]. Aggressive removal of these areas could result in neck concavity. There are no clinically significant blood vessels or nerves superficial to the platysma, making this area amenable to liposuction, although the muscle itself is thin and can be penetrated by a needle or liposuction

cannula [4,7]. The marginal mandibular branch of the facial nerve courses beneath the platysma within the submandibular gland fascia, 1 to 2 cm inferior to the mandibular ramus, although with anatomic variation and skin laxity this can be up to 4 cm inferiorly [8]. The facial nerve transverses the inferior mandible at the antegonial notch, along with the facial artery and vein. Anterior to the antegonial notch, the marginal mandibular nerve is always above the inferior mandibular border [8]. Other important anatomic structures include the external jugular vein and greater auricular nerve, which course superficially to the sternocleidomastoid [4].

EVALUATION OF THE PATIENT WITH SUBMENTAL FULLNESS Patients presenting with submental fullness must be evaluated for central neck laxity, jowl formation, and extent of platysma banding. Instructing a patient to press their tongue upward against the hard palate produces contraction of the suprahyoid and platysmal muscles to give an accurate assessment of preplatysmal adipose [2]. The presence of submandibular gland ptosis, and cervical lymphadenopathy should also be ruled out, because these can incorrectly be identified as adiposities [5].

DEOXYCHOLIC ACID DCA, previously known as ATX-101 (Kybella in United States and Belkyra in Canada; Allergan Biopharmaceuticals, Inc, Westlake Village, CA, USA) is a nonhuman exogenous bile acid that selectively causes adipocyte lysis via cell membrane disruption. DCA is chemically identical to endogenous deoxycholic acid, a secondary bile acid located in the small intestine that emulsifies dietary fat [9]. The plasma concentration of DCA increases rapidly after injection and returns to endogenous levels by 12 hours, whereas the systemic concentrations of total cholesterol, total triglycerides, or free fatty acids remain unchanged [10,11]. For several weeks following DCA injection, macrophages clear lipid cellular debris [11]. In 2015, DCA was approved by the Food and Drug Administration (FDA) as a first-in-class injectable drug to address moderate to severe submental fullness.

DEOXYCHOLIC ACID PATIENT EVALUATION Patients should be asked about a history of dysphagia or facial nerve paresis, recent infection within proposed

Submental Fat Contouring


FIG. 1 The cervicomental angle with aging. (A) Youthful patient with sharp cervicomental angle. (B) Early stage of aging process. (C) Late stage of aging process. (From DeFatta R, Ducic Y. Liposuction of the face and neck. Oper Tech Otolaryng 2007;18:262; with permission.)

treatment areas, and other cosmetic procedures in the submental area [6]. The patient should be examined from frontal and side views. Asking patients to contract their platysma while palpating the submental area enables a physician to examine the patient for prominent

platysmal banding, skin laxity, and smile asymmetry [6] (Box 2). The amount of submental fullness and convexity can be measured using the Clinician-Reported Submental Fat Rating Scale, by grading the patient in 1 of 5 points (0 5 absent, 1 5 mild, 2 5 moderate,


Hogan et al


Appropriate patients for deoxycholic acid injection 

Mild to moderate amount of preplatysmal adipose

Little to no skin laxity

Minimal platysmal banding

No history of dysphagia or facial nerve paresis

3 5 severe, and 4 5 extreme) with the assistance of a photonumeric guide [12] (Fig. 2). Patient expectations should be established before treatment. Several treatment sessions, spaced at least 4 to 6 weeks apart, may be required until satisfactory results are noted. Expected side effects include discomfort, erythema, edema, bruising, focal areas of induration, and pruritus. The most clinically relevant and bothersome side effects are bruising, which is relatively common, and swelling, which on average lasts about 2 weeks. Given the mean cost of a 2-mL vial of Kybella in the United States ranges between $300 and $691 and that often more than 1 vial is needed per treatment, the procedure may be cost-prohibitive to some patients [13].


1. It is recommended that medications and supplements (eg, aspirin, ginkgo biloba, St. John’s wort,



4. 5.


garlic) that increase the risk of bruising be discontinued by the patient 7 to 14 days before treatment. To fully document the submental area and neck, baseline photographs of the patient are taken from frontal, 45 and 90 views at baseline. The patient is seated in the upright position, with their head slightly reclined and resting against the chair. The treatment area is cleaned with alcohol. Anatomic landmarks are identified and marked with a surgical pen. A line is drawn 2 cm below the inferior mandibular border and to mark the antegonial notch bilaterally, because these areas fall within the path of the marginal mandibular nerve. The thyroid cartilage is marked, because it is to be avoided by at least 2 cm. An injection grid, consisting of 1-cm spacing between injection site markings, is applied to the treatment area. The grid design is based on the known 1.0- to 1.5-cm radius of cell lysis caused by DCA in subcutaneous adipose for each 0.2 mL of injection volume (data on file; Kythera Biopharmaceuticals, Inc) [7]. In the authors’ opinion, the use of the injection grid ensures accurate distribution of DCA. Grid sites located outside of the desired treatment area are removed with alcohol.

FIG. 2 Clinical-reported submental fat rating scale (CR-SMFRS). (Adapted from McDiarmid J, Ruiz JB, Lee D, et al. Results from a pooled analysis of two European, randomized, placebo-controlled, phase 3 studies of ATX-101 for the pharmacologic reduction of excess submental fat. Aesthetic Plast Surg 2014;38:851; with permission.)

Submental Fat Contouring


1. Starting at the inferior portion of the preplatysmal adipose and moving across in rows upward to the submental area, the patient is treated with subcutaneous injections [7]. The number of injections administered depends the amount and distribution of submental and preplatysmal fat present in each patient. 2. Fat is pinched between the thumb and index finger of the noninjecting hand, and injections are perpendicular to the skin surface until the needle is midway into preplatysmal adipose [7]. Injections that are too shallow into the dermis increase the risk of skin ulceration. 3. The amount of DCA injection varies depending on the thickness of submental and preplatysmal adipose and treatment area. A single-center, open-label, doseescalation study found that an injection volume of 0.1 to 0.2 mg/cm2 is ideal, with 0.2 mg/cm2 resulting in greater efficacy relative to 0.1 mg/cm2 [14,15]. 4. In patients with widely distributed submental adipose, injections that are lateral or inferior to the treatment grid are beneficial. This, however, must be approached with caution given the increased risk of injury to the facial artery and vein, marginal mandibular nerve, and submandibular gland.


1. Patients can experience transient pain after treatment. Ice is applied for 5 to 20 minutes after treatment. 2. Patients must be counseled on edema, delayed bruising, and induration that may occur in the days following treatment. 3. Physicians can monitor the patient for smile asymmetry and difficulty swallowing, which would develop hours to days later [7,16].

ADVERSE EFFECTS DCA injection causes a localized inflammatory response wherein adipocyte cellular debris is phagocytized [11]. This inflammation is responsible for most adverse effects experienced by patients [17]. Patients may experience burning and discomfort, which peaks at 5 minutes after treatment, substantially decreases within 15 minutes, and resolves by 24 hours [16,18]. Periprocedure practices to minimize patient discomfort vary and are listed in later discussion (Table 1). The combination of topical lidocaine 4%/injectable lidocaine 1% with epinephrine, ice, ibuprofen 600 mg/dose, and loratadine 10mg/day were studied in the lessening of side effects with DCA



Management of patient experience with deoxycholic acid injection Oral analgesics (acetaminophine 325 mg or ibuprofen 600 mg)

60 min before treatment

Topical anesthetics (Lidocaine 4%)

45 min before treatment

Injectable anesthetics (Lidocaine 2%)

15 min before treatment -orMixed with DCA before treatment

Injectable steroid (Kenalog 2.5 mg/ml)

Mixed with DCA before treatment

Ice or cold packs

5 min before treatment -and/orImmediately following treatment

Compression (chin strap 15 min/day  3 days)

Immediately following treatment

injection. Compared with ice alone, treatment with topical and injectable lidocaine reduced median peak pain by 17%; the addition of ibuprofen and loratadine resulted in a total reduction in pain by 40% [18]. Edema may develop in treated areas and persist for up to 2 weeks after the procedure. Studies have shown that edema is not substantially mitigated by nonsteroidal antiinflammatory drugs, antihistamines, or compression with a chin strap [18,19]. Edema after initial treatment is usually more significant than that which is experienced with subsequent treatments, although patients who undergo multiple treatments can experience edema for longer periods than those who receive a single treatment [16,19]. Delayed bruising can occur 24 to 48 hours after treatment. Lidocaine 1% or 2% with epinephrine can be injected in the treatment site or mixed with DCA before treatment to lessen the risk of bruising, because of the vasoconstrictive effect of epinephrine [18].

COMPLICATIONS Complications from DCA injection are infrequent. Dysphagia has been reported secondary to edema, but is transient and resolves within 3 days [20]. Across clinical trials, the incidence of marginal mandibular nerve paresis was rare, affecting between 2% and 4% of treated patients, with a recovery time of up to 3 weeks


Hogan et al

to several months [19]. The risk of this side effect is much less frequent in clinical practice, likely because less product is being used and smaller areas are being treated, as well as avoidance of injecting in the vicinity of the marginal mandibular nerve. Ischemia and skin necrosis have infrequently been reported with injections of DCA into submental fat and are thought to occur after inadvertent intravascular injection causes, either vasospasm and endothelial wall swelling to the point of occlusion, or direct cytolysis of endothelial cells [21,22]. Persistent focal areas of alopecia, notable in the beards of men, are a rare complication and thought to occur in areas with thin subcutaneous adipose where peribulbar adipose has increased exposure to DCA [23]. One case of submental cellulitis and abscess formation after DCA injection has been reported [24].

CLINICAL RESULTS In 4 phase 3 clinical trials, DCA has demonstrated statistically significant reductions in submental fullness by objective clinical measurements (eg, calipers, MRI) and by subjective assessments by both physicians and patients [17,25–27] (Table 2). In these trials, an average of 4.1 treatment sessions was performed, more than the average of 2.6 treatment sessions reported in a 2017 survey of facial plastic and reconstructive surgeons, which is perhaps more reflective of current clinical practices [13]. Available data suggest that this reduction is maintained in most patients up to at least 4 years after the last treatment [28]. Long-term follow-up studies are ongoing. When submental adipose is removed, a subsequent increase in skin laxity is a concern. Data support maintenance or improvement of skin laxity among patients treated with DCA [17,25,27]. Histology of tissue treated with DCA demonstrates neocollagenesis and the thickening of fibrous septae [11]. Nonetheless, this is not the case for all patients. In instances of unveiled prominent platysmal bands, botulinum toxin injection or cervicoplasty may need to be considered [29].

CRYOLIPOLYSIS Cryolipolysis is a noninvasive modality that uses cold ischemic injury to induce marked inflammatory response within 72 hours, adipocyte apoptosis, and removal of adipose from treatment sites within 14 days, and based on histologic studies, macrophage removal of dead adipocytes and replacement with fibrous septae within 3 months [30,31]. Serum lipid

levels remain unchanged during the periprocedure period [32]. CoolSculpting (Zeltiq Aesthetics/Allergan, Pleasanton, CA, USA) received FDA approval in 2010 for the treatment of excess adipose on the abdomen and flank and was FDA cleared in 2015 for treatment of the submental area. The CoolMini applicator, measuring 2.5 cm  7.5 cm, was designed to match the submental area with a concave shape.

CRYOLIPOLYSIS PATIENT EVALUATION Patients with a history of cold urticaria, cryoglobulinemia, or paroxysmal cold hemoglobinuria are not candidates for cryolipolysis. Physical examination includes the assessment of the degree adiposity, submental contour, and skin laxity (Box 3). Patients with prominent platysmal bands at baseline are not ideal candidates for treatment. At the time of consultation, patient expectations should be set that although submental contour may improve after the first treatment, a second or even third treatment may be necessary, and that full treatment response may not be noted for up to 4 months afterward. Expected side effects include temporary numbness and/ or tingling, erythema, and edema of the treated areas.


1. Baseline photographs of the patient are taken from frontal, 45 , and 90 views at baseline to fully document the submental area and neck. Patient positioning is the key for cryolipolysis to be effective. The patient is seated comfortably, with the chin at a slightly upward angle. Use of cell phone or laptop during treatment may result in loss of contact with the applicator and is thus discouraged [33]. 2. The treatment area is cleaned with alcohol and marked with the CoolMini applicator template. Patients with central submental adiposity may benefit from partial overlapping of 2 CoolMini applicators. If applicators are overlapped, then central overlap is drawn. For patients with diffuse or predominately lateral submental adiposity, only 1 applicator is used to avoid irregular contours [34]. If lateral areas are treated, care is taken to place the applicator away from the course of the marginal mandibular nerve. 3. A pretreatment skin wipe is applied for 60 seconds. 4. Gel is applied to treatment area. An applicator liner and gel trap is placed in the CoolMini applicator or applicators. 5. The CoolMini applicator or applicators are applied to treatment area. Patients should not feel pressure on the throat and be able to swallow comfortably.


Clinical results of deoxycholic acid for submental fullness % with 1 or greater improvement on Level of CR-SMFRS Secondary findings evidence



No. of Concentration Treatment frequency, patients (mg/cm2) follow-up period

Shridharani [19], 2017

Single-center, open-label



1-mo intervals, 12-wk follow-up


Multicenter, randomized, Humphrey double-blind, placeboet al [27], 2016 controlled



28-d intervals, 44-wk follow-up

66.5% (P