Body Rejuvenation

Murad Alam
Marisa Pongprutthipan
Editors
Body
Rejuvenation
Body Rejuvenation
Murad Alam Marisa Pongprutthipan
●
Editors
Body Rejuvenation
Editors
Murad Alam, MD, MSCI Marisa Pongprutthipan, MD
Associate Professor, Departments Visiting Instructor,
of Dermatology, Otolaryngology-Head Department of Dermatology,
and Neck Surgery, and Surgery Northwestern University, Feinberg
Chief, Section of Cutaneous and Aesthetic School of Medicine
Surgery Chicago, IL
Northwestern University, Feinberg USA
School of Medicine and
Chicago, IL Clinical Instructor, Division of
USA Dermatology, Department of Medicine
Chulalongkorn University
Bangkok
Thailand
ISBN 978-1-4419-1092-9 e-ISBN 978-1-4419-1093-6

DOI 10.1007/978-1-4419-1093-6
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2009942274
© Springer Science+Business Media, LLC 2010

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Contents
Part I Neck and Upper Chest
1 Treatment of Platysmal Bands with Botulinum Toxin........................... 3

Kenneth R. Beer
2 Treatment of Neck Laxity with Radiofrequency

and Infrared Light..................................................................................... 9
Macrene Alexiades-Armenakas
3 Treatment of Neck Laxity with Therapeutic Ultrasound....................... 17

Lucile E. White, Mark Villa and Natalie A. Kim
4 Treatment of Neck Fat with Injectable Adipolytic Therapy.................. 23

Adam M. Rotunda
5 Treatment of Poikiloderma with Fractional Resurfacing...................... 31

Zakia Rahman
6 Treatment of Poikiloderma with Chemical Peeling................................ 39

Luciana Molina de Medeiros, Arlene Ruiz de Luzuriaga,
and Rebecca Tung
7 Treatment of Poikiloderma by Pigment and Vascular Lasers............... 47

Mohamed Lotfy Elsaie, Voraphol Vejjabhinanta, Angela C. Martins,
and Keyvan Nouri
Part II Back and Chest
8 Treatment of Truncal Acne Scarring........................................................ 55

Emmy M. Graber and Kenneth A. Arndt
9 Truncal Hair Removal............................................................................... 61

David J. Goldberg
10 Revision of Disfiguring Surgical Scars of the Back................................. 65

Matthew J. Mahlberg, Julie K. Karen, and Vicki J. Levine
v
vi Contents
Part III Breast
11 Breast Reduction Through Liposuction................................................... 73

Michael S. Kaminer
12 Botulinum Toxin A for Upper Thoracic Posture

and the Appearance of a “Breast Lift”..................................................... 77
Kevin C. Smith
Part IV Hands (and Feet)
13 Treatment of Keratoses and Lentigines with Peels and PDT................. 85

John Strasswimmer
14 Off-Face Laser Treatment of Keratoses and Lentigines......................... 89

Paul M. Friedman and Brenda Chrastil-LaTowsky
15 Treatment of Hand Veins with Sclerotherapy......................................... 99

Neil S. Sadick
16 Treatment of Hand Atrophy with Fat Transplantation.......................... 105

Samuel M. Lam
Part V Arms (and Legs)
17 Reduction of Arm Fat by Liposuction...................................................... 111

Hayes B. Gladstone
18 Reduction of Excess Arm Skin via Surgical Excision............................. 117

John Y.S. Kim, Robert D. Galiano, and Donald W. Buck
19 Skin Tightening of the Arms and Legs with Radiofrequency

and Broadband Light................................................................................ 121
Matthew J. Mahlberg, Julie K. Karen, and Elizabeth K. Hale
20 Sclerotherapy of Leg Veins........................................................................ 127

Mary Martini and Katherine K. Brown
21 Ambulatory Phlebectomy.......................................................................... 135

Marisa Pongprutthipan, Girish Munavalli, and Simon Yoo
22 Endovenous Laser and Radiofrequency Treatment

of Leg Veins................................................................................................. 145
Marisa Pongprutthipan and Jeffrey T.S. Hsu
Part VI Abdomen, Thighs, Hips, and Buttocks
23 Noninvasive Body Rejuvenation............................................................... 155

Amy Forman Taub
Contents vii
24 Reduction of Cellulite with Subcision®.................................................... 167

Doris Hexsel, Taciana Dal’ Forno, Mariana Soirefmann,
and Camile Luiza Hexsel
25 Body Contouring with Tumescent Liposuction....................................... 173

Carolyn I. Jacob
26 Skin Tightening Off the Face with Radiofrequency

and Broadband Light................................................................................ 193
Douglas Fife and Anthony Petelin
27 Female Genital Surgery............................................................................. 201

Francesca De Lorenzi, Elena Mascolo, Francesca Albani,
and Mario Sideri
28 Reduction of Excess Abdominal Skin via Liposuction

and Surgical Excision................................................................................ 207
Emil Bisaccia, Liliana Saap, and Dwight Scarborough
Part VII Advanced and General Topics
29 Ablative Laser Resurfacing Off the Face................................................. 215

Richard Fitzpatrick and William Groff
30 Prepackaged Injectable Soft-Tissue Rejuvenation

of the Hand and Other Nonfacial Areas.................................................. 221
William Philip Werschler and Mariano Busso
31 Cosmeceuticals Off the Face..................................................................... 227

Zoe Diana Draelos
32 Special Considerations in Asian Patients................................................. 233

Sherry Shieh and Henry H.L. Chan
33 Treatment and Prevention of Dyspigmentation in Patients

with Ethnic Skin......................................................................................... 239
Smita S. Joshi and Roopal V. Kundu
Index.................................................................................................................... 245
Contributors
Murad Alam, MD
Departments of Dermatology, Otolaryngology—Head and Neck Surgery, and
Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
Francesca Albani, MD
Gynecological Endocrinology and Menopause Unit, IRCCS Maugeri Foundation,
Pavia, Italy
Macrene Alexiades-Armenakas, MD, PhD
Department of Dermatology, Yale University School of Medicine,
New Haven, CT, USA
Kenneth A. Arndt, MD
Department of Dermatology, Harvard Medical School, Boston, MA, USA
SkinCare Physicians, Chestnut Hill, MA, USA
Kenneth R. Beer, MD
Esthetic, Surgical and General Dermatology Center, West Palm Beach, FL, USA
Department of Dermatology and Cutaneous Surgery, University of Miami, Miller
School of Medicine, Miami, FL, USA
Emil Bisaccia, MD
Department of Dermatology, Columbia University, College of Physicians
and Surgeons, New York, NY, USA
Katherine K. Brown, MD
Department of Dermatology, Northwestern University, Feinberg School
of Medicine, Chicago, IL, USA
Donald W. Buck II, MD
Division of Plastic and Reconstructive Surgery, Northwestern University,
Feinberg School of Medicine, Chicago, IL, USA
Mariano Busso, MD
Private Practice, Coconut Grove, FL, USA
ix
x Contributors
Henry H.L. Chan, MD, FRCP

Division of Dermatology, Department of Medicine, University of Hong Kong;
Division of Dermatology, Department of Pediatrics; Department of Medicine
and Therapeutics, Chinese University of Hong Kong, Hong Kong
Department of Dermatology, Fudan University, Shanghai, China
Brenda Chrastil-LaTowsky, MD
North Valley Dermatology, Peoria, AZ, USA
Taciana Dal’Forno, MD, PhD
Research Department, Brazilian Center for Studies in Dermatology, Porto,
Alegre, Brazil
Francesca De Lorenzi, MD
Division of Plastic Surgery, Preventative Gynecology Unit,
European Institute of Oncology, Milan, Italy
Zoe Diana Draelos, MD
Department of Dermatology, Duke University School of Medicine,
Durham, NC, USA
Mohamed Lotfy Elsaie, MD, MBA
Department of Dermatology and Cutaneous Surgery,
National Research Center, Cairo, Egypt
Douglas Fife, MD
Surgical Dermatology and Laser Center, Las Vegas, NV, USA
Richard Fitzpatrick, MD
La Jolla Cosmetic Surgery Centre, La Jolla, CA, USA
Paul M. Friedman, MD
DermSurgery Assocaites, Houston, TX, USA
Robert D. Galiano, MD
Division of Plastic Surgery, Department of Surgery, Northwestern University,
Hayes B. Gladstone, MD
Department of Dermatology, Stanford University School of Medicine,
Redwood City, CA, USA
David J. Goldberg, MD
Skin Laser & Surgery Specialists of NY/NJ; Department of Dermatology, Mount
Sinai School of Medicine, New York, NY, USA
Sanctuary Medical Aesthetic Center, Boca Raton, FL, USA
Emmy M. Graber, MD
William Groff, DO
La Jolla Cosmetic Surgery Centre, La Jolla, CA, USA
Contributors xi
Elizabeth K. Hale, MD
Ronald O. Perelman Department of Dermatology, New York University
School of Medicine, New York, NY, USA
Camile L. Hexsel, MD
Department of Dermatology, Henry Ford Hospital, Detroit, MI, USA
Doris Hexsel, MD
Department of Dermatology, University of Passo Fundo School of Medicine,
Porto Alegre, Brazil
Jeffrey T.S. Hsu, MD
The Dermatology Institute, Dupage Medical Group, Naperville, IL, USA
Carolyn I. Jacob, MD
Department of Dermatology, Northwestern University, Feinberg School of
Medicine, Chicago, IL, USA
Smita S. Joshi, BAS
Department of Dermatology, Northwestern University, Feinberg
School of Medicine, Chicago, IL, USA
Michael S. Kaminer, MD
Julie K. Karen, MD
John Y.S. Kim, MD
Division of Plastic and Reconstructive Surgery, Northwestern University,
Natalie A. Kim, BA
Roopal V. Kundu, MD
Samuel M. Lam, MD, FACS
Lam Facial Plastic Surgery Center, Plano, TX, USA
Vicki J. Levine, MD
Matthew J. Mahlberg, MD
Mary Martini, MD
xii Contributors
Angela C. Martins, MD
Department of Dermatology and Cutaneous Surgery, University of Miami,
Miller School of Medicine, Miami, FL, USA
Elena Mascolo, MD
Preventative Gynecology Unit, European Institute of Oncology, Milan, Italy
Luciana Molina de Medeiros, MD
Department of Dermatology, University of São Paulo, Sao Paulo, Brazil
Girish Munavalli, MD, MHS
Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
Dermatology, Laser and Vein Specialists of the Carolinas, Charlotte, NC, USA
Keyvan Nouri, MD, FAAD
Department of Dermatology and Cutaneous Surgery, and
Department of Otolaryngology, University of Miami,
Anthony Petelin, MD
Department of Dermatology, University of California at Irvine,
College of Medicine, Irvine, CA, USA
Marisa Pongprutthipan, MD
Department of Dermatology, Northwestern University,
Division of Dermatology, Department of Medicine,
Chulalongkorn University, Bangkok, Thailand
Zakia Rahman, MD
Department of Dermatology, Stanford University School of Medicine,
Redwood City, CA, USA
Adam M. Rotunda, MD
Division of Dermatology, Department of Medicine, University of California
at Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
Arlene Ruiz de Luzuriaga, MD, MPH
Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA
Liliana Saap, MD
Department of Dermatology and Skin Surgery, Roger Williams Medical
Center, Providence, RI, USA
Neil S. Sadick, MD
Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
Dwight Scarborough, MD
Division of Dermatology, Department of Medicine, Ohio State University
College of Medicine, Columbus, OH, USA
Sherry Shieh MD
Department of Dermatology, Columbia University College of Physicians
and Surgeons, New York, NY, USA
Contributors xiii
Mario Sideri, MD
Preventative Gynecology Unit, European Institute of Oncology, Milano, Italy
Kevin C. Smith, MD
Niagara Falls Dermatology & Skin Care Centre, Niagara Falls, ON, Canada
Mariana Soirefmann, MD, MPH
Research Department, Brazilian Center for Studies in Dermatology, Porto,
Alegre, Brazil
John M. Strasswimmer, MD, PhD
Dermatology Associates of the Palm Beaches, Delray Beach, FL, USA
Amy Forman Taub, MD
Advanced Dermatology, SkinQRI and Skinfo, Lincolnshire, IL, USA
Department of Dermatology, Northwestern University, Feinberg School
of Medicine, Chicago, IL, USA
Rebecca Tung, MD
Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA
Voraphol Vejjabhinanta, MD
Department of Dermatology and Cutaneous Surgery, University of Miami,
Department of Dermatology, Mahidol University, Bankok, Thailand
Mark Villa, MD
Department of Plastic Surgery, University of Texas,
M.D. Anderson Cancer Center, Houston, TX, USA
William Philip Werschler, MD
Department of Dermatology, University of Washington School of Medicine,
Seattle, WA, USA
Spokane Dermatology Clinic, Spokane, WA, USA
Lucile E. White, MD
Pearland Dermatology, Pearland, TX, USA
Simon Yoo, MD
Department of Dermatology, Northwestern University,
Part I
Neck and Upper Chest
Chapter 1
Treatment of Platysmal Bands with Botulinum Toxin
Kenneth R. Beer
Introduction tend to neutralize the downward pull from this muscle

and also to affect the appearance of the muscle, which
has a dramatic result in many individuals.
The use of Botulinum toxins for the upper third of the
As with the rest of the body, platysmal bands change
face has been a well-ensconced facet of dermatologic sur-
over time. During the first few decades of life, the plat-
gery for over a decade. With greater experience with this
ysma is camouflaged by a thin layer of subcutaneous fat.
toxin, additional areas have been treated with varying
In addition, the anatomy of the muscle is that of a diffuse
degrees of success. The middle third of the face as well as
band rather than a group of strings. With age, the layer of
the lower thirds of the face may be injected by physicians
fat disappears and there is no barrier between the muscle
with advanced technical abilities and knowledge of the
and the skin. Thus, each string of the muscle can be visual-
relevant anatomy. Within the lower third of the face, the
ized. Concurrently, the muscle becomes a series of fibrous
mentalis and platysma are easily treated with Botulinum
bands rather than a homogenous layer. The combination
toxins. Despite the fact that the platysma is not techni-
of the loss of a barrier layer and development of discrete
cally part of the lower third of the face, the muscle func-
bands lends itself to treatment with Botulinum toxins.
tions as a depressor of this region and its treatment greatly
The platysma is a superficial and diffuse muscle. Its
impacts the overall aesthetic of the entire face. Its treat-
insertion is onto the chin and its origin is on the sternum.
ment with Botulinum toxins is a relatively simple tech-
It may be best visualized by asking the patient to gri-
nique that can be mastered by those with experience in
mace or make a monster face (Fig. 1.1). Variations in
the upper third of the face and it can be extremely reward-
individual anatomy are common and each patient should
ing for both patient and physician. Newer modalities of
be assessed and treated according to their anatomy.
radiofrequency, fractional resurfacing, and laser are able
One caveat that bears mention is that injections into
to change the texture and color of the neck. Combining
patients without dynamic contributions from the plat-
these with injections of botulinum toxins offers the oppor-
ysma (e.g., those with flaccid necks that require liposuc-
tunity to dramatically improve an area that has tradition-
tion or that have redundant skin for which surgery is the
ally been recalcitrant to rejuvenation.
only solution) will result in patients who are dissatisfied.
As with other Botulinum toxin treatments, proper patient
selection is important when injecting the neck.
Clinical Examination
The lower third of the face has several depressors that Treatment Indications
serve to pull it in a caudal direction. These include the
depressor anguli oris, depressor labii, the mentalis and,
to an extent, the platysma. Inactivation of the depres- Setting Selection
sors will tend to enable the elevator muscles to lift the
lower third of the face. When used in conjunction with In comparison with upper facial injections, the dilution
fillers for this area, the results of these treatments can of Botulinum toxin for this area may be more diffuse
be dramatic and synergistic. Injections of the platysma as the muscle itself is diffuse rather than discrete.
M. Alam and M. Pongprutthipan (eds.), Body Rejuvenation, 3

DOI 10.1007/978-1-4419-1093-6_1, © Springer Science+Business Media, LLC 2010
4 K.R. Beer
Fig. 1.1 Well defined platysma

bands are evident in this
6-year-old girl
When injecting Botox, dilutions between 2 and 4 mL drapes out over the span of the neck. Other individuals
per 100 units, is appropriate. For Dysport, the dilution have vertical muscles that are typically 2–4 bands that
should be between 2 and 4 mL per 300 units. Dilution can be easily grasped.
with more saline than these amounts may be beneficial For patients with broad diffuse muscles of the neck,
for this area since diffusion may help to deactivate this injections should be diffuse and should be spaced out
diffuse muscle. across the area that moves with contraction (Fig. 1.2).
Each injection should be approximately 1.5–2 cm apart
and it is helpful to inject in a horizontal manner.
Treatment Technique Subcutaneous injections should be made with the nee-
dle in the superficial dermis. Raising a bleb, each area
Anatomic considerations when injecting the neck are should be injected with about 2.5 units of toxin for
paramount to patient safety. The strap muscles of the Botox or 7.5 units for Dysport. When beginning to
neck are adjacent to the thyroid cartilage and errant treat this area, women may be treated with between 25
injection of toxin may potentially interfere with their and 50 units of Botox or 50-120 units of Dysport
functions. This may impair the ability to swallow and, depending on their muscle mass. Men require more
in rare instances, necessitate a feeding tube (a subopti- than this and may be treated with between 30 and 75
mal outcome for a cosmetic patient). If a patient treated units of Botox or 60-180 units of Dysport.
in the neck with Botulinum toxin reports difficulty Discrete muscle bands are best injected by grabbing
swallowing, immediate consultation with an otorhi- the band and injecting it by putting the needle into the
nolaryngologist for a swallowing study is indicated. muscle (in contrast with the subcutaneous injections for
Fortunately, this complication is extremely rare. diffuse platysma) (Fig. 1.3). Injections of 2.5 units of
Injection techniques depend on the anatomy being Botox or about 6-8 units of Dysport are made about 1–1.5
treated. To visualize the platysma and observe the cm apart. Total amount of Botox or Dysport injected into
function of the muscle, one needs to activate it by asking patients with discrete bands is about what is used for
the patient to grimace or to show you their lower teeth. patients with diffuse bands but many injectors find it help-
In some individuals, the platysma muscle is broad and ful to use slightly higher doses directly into the muscles.
1 Treatment of Platysmal Bands with Botulinum Toxin 5
Fig. 1.2 Injection pattern

for patients with broad diffuse
muscle patterns. Courtesy
of Sarah Weitzul, MD
Fig. 1.3 Injection pattern for

patients with discrete muscle
bands. Courtesy of Sarah
Weitzul, MD
Carruthers and Carruthers have provided an excel- appeal for patients with this type of anatomy and the
lent description for the treatment of the platysmal area referenced article recommends injecting no more than
with Botulinum toxins.1 They describe the horizontal 15–20 units.
neck lines that may be seen in younger patients with The platysma, as it invests the inferior sternum,
thick necks. These, they believe, are caused by the also gives rise to wrinkles of the décolleté. This area
superficial musculoaponeurotic bands. In their article, is one of the most frequently cited for cosmetic
they recommend “dancing” along the neck, injecting enhancement. Botulinum toxins have been success-
1–2 units of Botox in the deep dermis at intervals fully used to smooth this area.2 As with other areas,
of about 1 cm apart. This technique has significant patient selection is paramount. For patients who have
6 K.R. Beer
significant rippling when asked to show their lower Straying superior or diffusion into the musculature of
teeth or to grimace, the activity of the inferior plat- the lower third of the face can cause asymmetry of the
ysma may be dampened with injections of Botulinum mouth.
toxins. Suggested doses range from 25 to 75 units,
depending on the length and breadth of the muscle.
Injections should be made approximately 1–1.5 cm
apart (Fig. 1.4). The décolleté, when combined with Alternative Treatment Methods
modalities such as fractional resurfacing and photody-
namic light treatment, can produce dramatic and grat- Alternatives to Botulinum treatments for the neck
ifying results. include minimally invasive surgical approaches, tradi-
There are several caveats about Botulinum toxin tional surgery, and laser treatments. Perhaps the treat-
treatments of the platysma. Obviously, there are numerous ment best suited for those who are not candidates for
vascular structures in this area and they should be avoided. treatment with toxin because they have loose bands
Fig. 1.4 (a) Prior to treatment, patient presents with V-shaped wrinkles of the décolleté. (b) Schematic of horizontal injection sites to
treat vertical wrinkles. (c) Patient 1 week after horizontal injections. However, patient still presents with horizontal wrinkles of the
décolleté. (d) Schematic of vertical injection sites to treat horizontal wrinkles. (e) Patient 1 week after vertical injections
1 Treatment of Platysmal Bands with Botulinum Toxin 7
that no longer contract is a modified platysma banding Botulinum toxins improves the results from laser
such as that described by Kaminer et al. If this mini- resurfacing and it is likely that it will also enhance the
mally invasive technique is not adequate, traditional outcomes from fractional resurfacing since the mecha-
rhytidectomy may be performed. nism of action is similar.3
Liposuction is a minimally invasive technique to
reduce the fat in the neck. Following this procedure,
the muscular bands may become more prominent.
Combinations of Botulinum Toxins
Botulinum toxin may be injected in this scenario to
with Other Modalities minimize the appearance of these bands, which may
have been camouflaged by the adipose. It is likely that
Treatment of the platysma area may obtain optimal many patients undergoing liposuction of the neck will
results when combined with other modalities. As want to have this area treated with Botulinum toxins
lasers and other energy devices become more effec- for optimal outcomes.
tive, they may be used to enhance patient outcomes.
Among the devices that are potential, synergistic
opportunities for treatment with Botulinum toxins are Conclusion
radiofrequency, fractional resurfacing, infrared, and
liposuction.
Radiofrequency has been utilized for cosmetic Treatments of the lower third of the face and neck with
enhancement of the neck with varying degrees of suc- Botulinum toxins may produce significant cosmetic
cess. Recent advances in the settings used for this improvements in these areas. Injections of Botulinum
treatment and improvements in the tips have enhanced toxins into the platysma bands are relatively simple
the ability of these devices to treat the neck success- from a technical perspective. Newer modalities, such
fully. When used in conjunction with Botulinum tox- as radiofrequency and fractional resurfacing, may be
ins, they may help to create a smoother contour of the used with these injections to produce a more compre-
neck as the toxins reduce the bands formed by the hensive rejuvenation of the neck. For patients with
platysma. This area seems ripe for further exploration dynamic platysmal bands and physicians with experi-
as the radiofrequency technology improves and con- ence, injections of Botulinum toxins into the lower
trolled trials in this area would be worthwhile. face and neck can be one of the most gratifying treat-
A second energy device used in conjunction with ments performed.
Botulinum toxins in the neck is fractional resurfacing.
There are several variations of this technology (dis-
cussed elsewhere in the book) but each removes small References
areas of the skin and stimulates collagen formation.
They may enhance the appearance of the neck by 1. Carruthers A, Carruthers J. Aesthetic Botulinum toxin in the mid
removing many of the signs of aging from the skin. In and lower face and neck. Dermatol Surg. 2003;29:468-476.
conjunction with toxins, this affords the neck a more 2. Becker-Wegerich PM, Rauch L, Ruzicka T. Botulinum toxin
A: Successful décolleté rejuvenation. Dermatol Surg.
youthful appearance and the synergy between these 2002;28(2):168-171.
techniques is likely to result in increased patient satis- 3. West T, Alster T. Effect of Botulinum toxin on following
faction. There is documentation that treatments with resurfacing. Dermatol Surg. 1999;25(4):259-261.
Chapter 2
Treatment of Neck Laxity with Radiofrequency
and Infrared Light
Macrene Alexiades-Armenakas
Introduction contraindicated. In addition, patients with rheumatologic

or connective tissue diseases, such as fibromyalgia
rheumatica, lupus erythematosus, scleroderma, derma
Neck rejuvenation predominantly targets skin laxity,
tomyositis, or other autoimmune skin diseases, are
with a lesser emphasis on rhytides and photoaging.
also contraindicated. Baseline and follow-up photog-
Neck laxity may increase with age due to progressive
raphy from both sides is exceedingly important, as the
prominence of platysmal bands, loss of bony mass along
degree of improvement in neck laxity is often best
the mandible and mental region, increased subcutane-
appreciated by side views. It is recommended that the
ous fat, and loosening of the connective tissue frame-
baseline and first set of follow-up photographs be
work. Additionally, photoaging may result in progressive
reviewed with the patient if the level of efficacy is in
solar elastosis, which may contribute to rhytides, laxity,
question. Patients are cautioned that in the vast majority
and poor texture. Important limitations to treatment
of cases, a minimum of three treatments are required to
include the anterior location of the thyroid and parathy-
achieve significant tightening, though some patients opt
roid glands, which must be shielded from deeply pene-
to pursue as many as five treatment sessions. Managing
trating wavelengths. The increased scarring risk on chest
patient expectations at the outset are very important: it is
secondary to pulsed light indicates a potential increased
best to explicitly elicit from the patient that they have
scarring risk on the inferior aspect of the neck as com-
ruled out the option of a neck lift and are willing to
pared to face, thus necessitating greater care and lower
invest the time, effort, and funds toward three tightening
fluences in this region. Overall, neck rejuvenation tar-
sessions before determining whether the treatment
gets skin laxity bringing skin tightening technologies to
was a success. The level of patient satisfaction has var-
the forefront in this category.
ied depending on the technology and protocol used
between 30 and 70%.
Clinical Examination and Patient History
The classification of neck laxity, rhytides, and photoa- Method of Device or Treatment
ging into quantitative grades has been previously pub- Application
lished and evaluated in clinical trials of laser and
light-based treatments of laxity and rhytides (Table 2.1).
A patient presenting with a grading score of two or Radiofrequency
higher may experience less utility from treatment of
neck laxity with radiofrequency and infrared light. Dose/Settings
Patients aged over 65 are less likely to respond to
radiofrequency treatment for reasons that remain to be 1. Monopolar RF (Thermage, ThermaCool system,
elucidated and therefore, should be strongly discour- Solta Medical Inc., Hayward, CA): The manufac-
aged from this form of treatment. Patients with a his- turer suggests avoiding the use of topical anesthetics
tory of thyroid or parathyroid disease or neoplasia are whenever possible, as it may mask discomfort and

10
Table 2.1 Quantitative grading and classification system of laxity, rhytides, and photoaging
Categories of skin aging and photodamage Patient
Erythema- satis-
Grading Descriptive Telangiectasia Overall faction
Scale parameter Rhytides Laxity Elastosis Dyschromia (E-T) Keratoses Texture score (Y/N)
0 None None None None None None None None
1 Mild Wrinkles in motion, Localized to Early, minimal Few (1–3) discrete Pink E or few T, Few Subtle irregularity
few, superficial nasolabial (nl) yellow hue small (<5 mm) localized to
folds lentigines single site
1.5 Mild Wrinkles in motion, Localized, nl and Yellow hue or early, Several (3–6), Pink E or several Several Mild irregularity
multiple, superficial early melolabial localized discrete small T localized in few areas
(ml) folds periorbital (po) lentigines two sites
elastotic beads
(eb)
2 Moderate Wrinkles at rest, few, Localized, nl/ml folds, Yellow hue, Multiple (7–10), Red E or multiple Multiple, Rough in few,
localized, superficial early jowls, early localized po eb small T localized to small localized
submental/ lentigines two sites sites
submandibular
(sm)
2.5 Moderate Wrinkles at rest, multiple, Localized, prominent Yellow hue, po Multiple, small Red E or multiple Multiple, Rough in several,
localized, superficial nl/ml folds, jowls and malar eb and few large T, localized large localized
and sm lentigines to three sites areas
3 Advanced Wrinkles at rest, multiple, Prominent nl/ml folds, Yellow hue, eb Many (10–20) Violaceous E or Many Rough in multiple,
forehead, periorbital jowls and sm, involving po, small and large many T, localized
and perioral sites, early neck malar and other lentigines multiple sites sites
superficial strands sites
3.5 Advanced Wrinkles at rest, Deep nl/ml folds, Deep yellow hue, Numerous (>20) Violaceous E, Little Mostly rough,
multiple, generalized, prominent jowls extensive eb with or multiple numerous T uninvolved little
superficial; few, and sm, prominent little uninvolved large with little little skin uninvolved
deep neck strands skin uninvolved uninvolved skin
skin skin
4 Severe Wrinkles throughout, Marked nl/ml folds, Deep yellow hue, Numerous, Deep, violaceous No uninvolved Rough throughout
numerous, extensively jowls and sm, eb throughout, extensive, E, numerous skin
distributed, deep neck redundancy comedones no uninvolved T throughout
and strands skin
M. Alexiades-Armenakas
2 Treatment of Neck Laxity with Radiofrequency and Infrared Light 11
result in local adverse events. However, for patient 2. Bipolar RF combined with diode (900 nm) laser
comfort, some practitioners do use topical anesthet- (Polaris and Galaxy, Syneron Inc.): Anesthesia in the
ics in concert with a safe low energy multi-pass form of topical EMLA is applied for 1 h. No ground-
treatment approach. Moisten skin with alcohol. ing pad is necessary. Aqueous gel is applied in a thin
Apply the 3.0-cm2 skin marking paper to the neck. 2–3 mm layer. For neck, commence the RF fluence at
Dab with alcohol then remove the marking paper. 80 J/cm2. Increase by 10 J/cm2 as tolerated to 100 J/
Commence initial treatment level at 362.0 for the cm2 maximum. For the initial treatment, employ mod-
3.0-cm2 ThermaTip TC. Apply coupling fluid and erate laser fluence, commencing at 20–22 J/cm2 and
deliver application of energy to assess pain toler- increasing by 2–4 J/cm2 per treatment session to a
ance. Titrate the setting based on patient’s heat sen- maximum of 36 J/cm2 in type I skin. Multiple passes
sation feedback. Continue to titrate setting until of 6–10 are administered with each treatment session.
patient reports heat sensation feedback of 2–2.5 The clinical endpoint is diffuse erythema and immedi-
based on a 0–4 point scale. Current recommenda- ate tightening. Key pearls during treatment include
tions are to perform several (4–6) passes at lower maintaining good contact with adequate aqueous gel
settings (352.0–354.0) within each treatment area to avoid arcing, and not stacking pulses to avoid
before treating the next area. See Fig. 2.1 for photo- ischemia.
graphic example of reduction of neck laxity with 3. Bipolar RF (ST ReFirme, Syneron Inc.): No topical
monopolar RF (Table 2.2). anesthetic is necessary. Aqueous gel is applied in a
Fig. 2.1 Treatment zones of the neck for radiofrequency protocols
Table 2.2 Treatment protocols of neck laxity with radiofrequency technologies. All technologies should be applied to submental,
submandibular, and lateral neck regions, strictly avoiding thyroid region
Device Fluence J/cm2 Pulses/Passes Target temp (Celcius) Rx # interval
Monopolar (thermage 3.0 cm 2
20–162 (352–364 4–6 passes NA 3–5 q month
tip, Solta Medical Inc.) treatment level)
Bipolar with diode 900 nm laser 90–100 6–10 passes NA 3–5 q month
(Polaris and Galaxy, Syneron Inc.)
Bipolar with Infrared light 100–120 200 pulses per 39 3–6 q 1–4 wk
(ST ReFirme, Syneron Inc.) target zone
Bipolar (Accent, Alma) 70, 60, 50, 40 1-3,1,1,1 (30-s) passes 40–43 3–5 q 1–4 wk
Unipolar (Accent, Alma) 90, 80, 70, 60 1-3,1,1,1 (30-s) passes 40–43 3–5 q 1–4 wk
12 M. Alexiades-Armenakas
2–3 mm film. RF fluence should be commenced at carotid system, which are present at the far lateral
100 J/cm2 increasing to 120 J/cm2 as tolerated at edges of the anterior neck. Figure 2.2 demonstrates
normal cooling. Apply a series of pulses numbering the degree of efficacy of unipolar and bipolar RF on
100–250 to each treatment zone, commencing with reduction of neck laxity, which is notable immedi-
each temporomandibular junction, followed by the ately postoperatively.
lateral submandibular and upper neck region, and
the submental region. If an infrared thermometer is
employed, a peak temperature of 40°C is the desired Postoperative Care
endpoint. A total of 750–1,000 pulses should be
administered to the neck. None of the skin tightening technologies require post-
4. Unipolar and Bipolar RF (Accent, Alma): No topical operative care. Postoperative erythema is expected and
anesthetic is necessary. Mineral oil is applied to the typically dissipates over minutes to hours.
skin. All passes with the unipolar followed by bipo-
lar handpiece should be administered to one side of
the neck followed by the other, avoiding the thyroid Management of Adverse Events
region. Unipolar RF is applied first with a starting
fluence of 90–100 J/cm2 for 1–2 20-second passes. In the case of monopolar radiofrequency, rare cases of
Once a target temperature of 40°C is achieved, three superficial burns, erythematous nodules, and atrophy
maintenance passes should be delivered at decre- have been reported. Nodules are best treated with
ments of 10 J/cm2 per pass. Bipolar RF is then admin- intralesional corticosteroids. Superficial burns are
istered with a starting fluence of 68–70 J/cm2 for 1–2 treated with topical silver sulfadiazine (e.g., Silvadene)
20-second passes followed by three maintenance or other wound dressing protocols. With the bipolar
passes at decrements of 10 J/cm2. Treatments may be RF device Polaris, vascular necrosis is possible if
administered weekly to monthly, totaling 3–5 treat- pulses are stacked and crusting is produced by inadver-
ment sessions. The key pearls include applying ade- tent arcing of the device if inadequate contact is made.
quate mineral oil so that the handpiece is kept mobile These should be treated with silvadene or other wound
and applied in a circular fashion, while avoiding care protocols. Rarely, superficial crusting may be
the large superficial and vascular structures of the observed with the ST as well. No adverse events were
Fig. 2.2 Degree of efficacy of unipolar and bipolar RF on reduction of neck laxity, which is notable immediately postoperatively
observed during the author’s experience with the focused pass that is applied to a targeted region.
Accent device, though the handpiece was kept mobile The pulses over bony areas (e.g., mandible) should
to avoid potential burns. be administered with a reduced fluence of 30–32 J/
cm2. The target number of pulses applied to the
anterior neck should number 100 following a total
of two passes. Pre-, parallel, and post-cooling of the
Infrared Wavelengths epidermis is applied to under 40°C through contin-
uous contact with a sapphire tip.
Infrared Light (1,100–1,800 nm, Titan, Cutera) 2. Treatment technique: A minimum of two passes are
required in order to achieve demonstrable results and
1. Dose/Settings: No topical anesthetic is needed for the three passes are typically recommended. The pulses
procedure. A thin 1-mm layer of cold 4°C aqueous should be administered in a linear fashion along the
ultrasound gel is applied. The treatment area on the jawline, along the upper neck and in the submental
neck is confined to midway up the neck to the man- area. Three passes are administered in succession to
dible, excluding the thyroid region. Energy may be each linear area before commencing in a new area. A
delivered in a stationary manner, applying adjacent total of 3 monthly treatment sessions are recom-
pulses without moving the handpiece, or in a mobile mended. Figure 2.3 demonstrates reduction of laxity
manner, making circular movements. The fluence is and rhytides on the anterior neck through application
commenced at 32 J/cm2 for the stationary protocol of passes to the lateral and submental regions.
and 40 J/cm2 for the mobile protocol and titrated as 3. Postoperative Care: Postoperative erythema
tolerated to a maximum of 36 J/cm2 for the majority resolves within minutes to hours and no postopera-
of stationary pulses and 44 J/cm2 for mobile admin- tive care is needed.
istration, while adjusting based on patient comfort 4. Management of Adverse Events: Vesiculation or
(range: 30–36 J/cm2 stationary; 40–44 J/cm2 blistering have been reported infrequent complica-
mobile). Three passes of adjacent nonoverlapping tions. During the procedure, this may be averted by
pulses are administered, each covering an area of utilizing the mobile technique and discontinuing
1.5 cm2. The clinical endpoints are warmth but no administration of a pulse when discomfort is height-
discomfort following the first pass, followed by ened. Wound care such as topical silvadene cream
pain tolerance to the end of the second “vector” or should be applied to facilitate healing. Post-
Fig. 2.3 Treatment of neck laxity with a broadband 1,100–1,800 nm infrared device. Patient prior to treatment (a) and 1 month
following two treatments (b)
14 M. Alexiades-Armenakas
inflammatory hyperpigmentation may be observed tion is improved with a reduction of joweling and
following healing which gradually fades. mandibular laxity following three treatments with
the 1,310 nm laser to the lower face and neck.
3. Postoperative Care: Minimal erythema lasting sev-
1,310 nm Diode Laser (Candela) eral minutes to one hour is expected. No postopera-
tive care is required.
1. Dose/Settings: No anesthesia is required for this 4. Management of Adverse Events: In clinical trials,
device. Aqueous ultrasound gel is applied in a thin rare instances of superficial burns were reported,
1–2 mm film. The variable depth device allows for which healed with silver sulfadiazine cream topi-
targeting of different depths (Table 2.3). cally twice daily.
2. Treatment Technique: A total of three passes are
administered in succession. Pressure needs to be
applied when delivering the pulses to the subman- Minimally-Invasive Radiofrequency (Miratone
dibular region in order to maintain good contact. System, Primaeva Medical, Inc., Pleasanton, CA)
The aqueous gel should be removed for the superfi-
cial targeting pass. The different depth targeting 1. Dose/Settings: Prior to treatment, the patient’s skin
parameters may be combined in a single treatment, was cleansed with Betadine® and treatments were
delivering one pass at deep, one pass at a medium delivered medial to lateral in rows following ana-
depth setting, and a final pass at the superficial set- tomical margins. Topical (EMLA) and/or local anes-
ting. Power may be titrated upward as tolerated, not thesia with dilute lidocaine (¼ % with 1:400,000
to exceed 30 W. In Fig. 2.4, the mandibular defini- epinephrine) is administered. A local anesthetic
Table 2.3 Variable depth 1310 nm laser parameters for treatment of facial and neck laxity
Laser pulse
Targeting Spot size (mm) Starting power (W) Precool (s) duration (s) Postcool (s) Cooling temp
Deep Dermis 12 24 1 1 1–3 2°C
Mid Dermis I 18 24 1 3 1 2°C
Mid Dermis II 18 17 1 5 1 2°C
Superficial Dermis 18 20 0.1 1 0.1 No cooling
Fig. 2.4 Treatment of neck laxity with a variable depth heating 1,310 nm laser. A patient prior to (a) and at 1 month (b), 3 months (c), and
6 months (d) following 3 monthly treatments. Note the progressive improvement in facial and neck laxity from 1 to 6 months follow-up
quantity of 18 cc of ¼ % lidocaine is used to infil- 4. Management of Adverse Events: Superficial place-

trate both cheeks, submental and lateral neck regions ment of electrodes may result in superficial thermal
per patient. Fractional radiofrequency (FRF) energy burns and pinpoint scar-formation in rare instances.
is delivered through five micro-needle electrode Application of silver sulfadiazidine cream twice
pairs deployed into the reticular dermis at an angle daily topically will facilitate healing.
of 20º to the skin surface with the exposed electrode
length extending from 0.75 to 2 mm below the skin
surface. The intra-dermal location of the electrode
tips is determined by real-time impedance measure-
Conclusion
ments, such that impedance measurements of
between 300 and 2000 Ohms are used to define ideal Radiofrequency therapy applied to the skin is limited by
intra-dermal placement. Software built into the penetration depth and protection of epidermis from ther-
device preclude energy delivery if impedance mal injury by surface cooling. Infrared lasers provide
between an electrode pair measured below 300 or the option of variable depth targeting, which will require
over 3000 Ohms, thereby restricting energy delivery further investigation to determine the optimal depth or
to proper intra-dermally placed electrodes. Software range of depths needed in order to achieve demonstrable
is programmed to delivery energy until a pre-selected tightening. It is not possible to definitively distinguish
intradermal target temperature is attained, and for a between these tightening modalities regarding degree of
specified duration in seconds. treatment efficacy. The impact of differences in treat-
2. Treatment Technique: Conservative treatment ment parameters and patient-specific anatomic features
parameters of 62°C and 3 seconds may be selected can outweigh the impact of mechanical differences
for initial cases. More aggressive treatment para across devices. Overall, efficiency may vary from 0 to
meters of 68-75°C and 5 seconds may be selected. approaching 50% improvement in skin laxity.
Epidermal cooling is achieved by positioning a Most recently, a minimally-invasive fractional radio
cooling device maintained at a temperature of 15ºC, frequency device completed FDA trials and has been
directly on the skin surface above the exposed elec- FDA-approved for the treatment of rhytides. Efficacy
trode length. The spacing of the bipolar needle pairs rates determined by blinded, randomized grading using
and the spacing of successive applications of the the validated laxity grading scale demonstrated higher
device are selected to give 15% to 35% fractional efficacy rates that skin surface technologies.
skin coverage by surface projection. Future aims include improving the degree of
3. Post-operative Care: The patient’s skin is cleansed contracture and degree of accuracy of targeting to
with normal saline, and a thin coat of white petrola- various depths of the tissue. It will be determined
tum is applied. Patients are allowed to resume nor- whether different penetration depths are needed for
mal activities immediately, and instructed to wash different body sites and tissues. Newer devices are being
the skin with mild cleansers, to avoid makeup for 24 developed, which will greatly improve the level of
hours, and to minimize sun exposure for 14 days. targeting and temperature regulation at these depths.
Chapter 3
Treatment of Neck Laxity with Therapeutic Ultrasound
Lucile E. White, Mark Villa, and Natalie A. Kim
Introduction can administer ultrasound at 7 MHz on the neck to

target the mid-to-deep reticular layer of dermis and
subdermis, sparing the overlying papillary dermis
Ultrasound represents sound waves above the capacity
and epidermis. This device is specifically designed
for human hearing (16 kHz). Generally, the ultrasound
for the treatment of the dermis in comparison to
used in clinical practice utilizes a spectrum of frequen-
previously available HIFU devices, which facilitates
cies between 1 and 20 MHz. When applied diffusely,
fat reduction. Based on the biophysical properties of
these waves have broad applicability as a diagnostic
the skin tissue, rapid heating of this focal zone to
imaging modality.
greater than 60°C results in rapid denaturation of
Ultrasound may also be applied by a variety of
collagen, producing controlled regions of coagulative
means including curved transducers or phased arrays
necrosis with an approximate volume of 1 mm3.3,4
that enable focusing of the waves. This method of
The ensuing wound healing process will promote
application is known as High Intensity Focused
new collagen production. This chapter will focus on
Ultrasound (HIFU). Depending on how these waves
transcutaneous devices and not on ultrasound-
are focused, small, high-energy foci can be created at
assisted liposuction, which is outside the scope of
variable depths within tissues that result in coagulative
this chapter.
necrosis and cavitation (Fig. 3.1). This technique was
first described in the mid 20th century and has subse-
quently been used clinically for the ablation of various
Patient History and Clinical
types of tumors, including those of the liver, the uterus,
and the prostate. Examination
As high-energy sound waves propagate through tis-
sues, a certain amount is absorbed by the tissue. This Candidates for therapeutic ultrasound to the neck are
mechanical energy is converted into thermal energy patients who do not have active systemic or local infec-
causing selective tissue necrosis in a well-defined area, tions including labial HSV or folliculitis. Additionally,
at a specified distance from the transducer. This depth patients should not be on anticoagulants and should
depends on the size of the transducer, the frequency of have not taken isotretinoin within past 6 months. If
the waves, and their angle of incidence. The ability to patients report a past surgical history of carotid endar-
tailor the depth at which this coagulation occurs estab- terectomy or surgery to other anatomical structures of
lishes the basis for HIFU as a potential means of non- the neck, inquire about the possible presence of surgi-
invasive skin tightening. HIFU has been shown to cal clips or prosthetic materials in the neck, which
elevate the brow and cause clinically appreciable could interfere with treatment.
results for facial rejuvenation.1 As is standard practice with any elective, aesthetic
Generally, higher frequencies are used for more procedure, patient’s expectations must be addressed.
superficial effects compared to lower frequencies, The ideal candidates for this procedure are those with
which may penetrate tissues more deeply.2 One mild jowling, neck sagging, and rhytides (Fig. 3.2).
device, the Ulthera System (Ulthera Inc., Mesa, AZ), Given our clinical experience thus far, patients with

18 L.E. White et al.
Fig. 3.1 The effect of High Intensity Focused Ultrasound (HIFU) on subcutaneous tissues. Note: during skin tightening treatments, the
coagulative thermal zone are placed in the reticular dermis. However, since the underlying ultrasound technology permits these to be
placed arbitrarily deeply into tissues, for illustrative purposes, the above diagram shows these zones within the fibromuscular layer.
Fig. 3.2 (a) Lax neck skin appropriate for treatment and (b) a neck with a significant amount of subdermal fat
3 Treatment of Neck Laxity with Therapeutic Ultrasound 19
severe neck laxity should be counseled that the desired Then the transducer is placed firmly on the targeted
effect may be beyond the capacity of this modality and skin surface, and pressed firmly to the skin surface.
offered full disclosure of surgical and nonsurgical The therapeutic ultrasound function is used to image
options. Patients with obvious submental fat pads the skin and confirm that the transducer base is in full
should be considered for liposuction before undergo- contact with the skin without any air bubbles in the
ing ultrasound therapy. underlying gel. The image also is used to confirm that
the predicted target depth is in the mid-to-deep retic-
ular dermis.
Firing is then initiated. The device applies a 1-mm
Method of Device or Treatment linear array of 17 coagulative zones over 2.5 cm. It is
Application important to maintain full contact with the skin during
energy delivery to avoid the formation of whitish
wheal-like striations from superficial coagulation.
Dose/Setting Selection With the more superficial transducer, more erythema will
be observed in comparison to the deeper transducers.
The Ulthera System has adjustable parameters including However, much of this resolves in 20–40 min after the
depth and amount of energy delivered. The device procedure. The handpiece is moved approximately 2–3
energy can vary from 0.25 J up to 0.9 J. When used mm up the neck before firing it again. This is repeated
on the neck, the device is typically used at energies until the entire neck and submental areas have been
lower than those used on the face due to the often treated. Typically, two passes on either side of the tra-
thinner dermis on the neck and the dense anatomy of chea is sufficient. The submental area can be treated
the underlying structures. Also, the device is used with one pass over the center of the submental area or
with the more superficial probes that penetrate to a bilateral passes that merge as you move the hand piece
depth of 3 or 4.5 mm. It is recommended that the anteriorly (Fig. 3.3). If the external jugular vein is
neck be treated with a first pass using the 4.5-mm appreciated, this area is avoided. Patients report most
transducer, followed by a second pass using the 3-mm sensitivity when treating the mandible and when
transducer, both at the highest energy setting as toler-
ated by the patient. For each transducer, three energy
levels can be chosen. When delivering the first line,
the highest energy setting is used (for the 3-mm trans-
ducer, 0.45 J and for the 4.5-mm transducer, 0.9 J).
With the recommended settings, the patient may feel
tolerable pain. While the highest energy setting has
been shown to be safe, if a patient’s pain score is a 7
or above, on a scale of 1–10, the energy setting should
be adjusted.
Treatment Technique
Because the zones of thermal injury are delivered to

the mid-to-deep reticular dermis, patients are usually
treated without any topical anesthetic prior to performing
the procedure. Oral premedication with pain medications
or benzodiazepines is seldom necessary.
The patient should be in supine position to enable
access to the neck and submental regions. Cool ultra-
sound gel is applied onto the transducer hand piece. Fig. 3.3 How to apply the device to the neck
20 L.E. White et al.
Fig. 3.4 (a) Before and (b) after treatment of the neck
treating more laterally on the neck. It is important to have been present in the office after their treatment.
document how many lines were applied to each side of Patients may follow-up for additional treatments if
the neck to ensure an even application of the device they are desired.
and prevent asymmetry. As with other noninvasive devices that cause
This ultrasound device therapy can be repeated collagen remodeling, the patient should be coun-
every 30–45 days for up to three treatments. However, seled that changes to the collagen, and thus, clinical
to obtain optimal results from subsequent treatments, improvement in neck laxity may take up to 3 months to
patients may be recommended to wait at least 90 days observe (Fig. 3.4). This improvement may persist for
for new collagen to be formed. up to 10 months.
Alternative Treatment Methods Management of Adverse Events
Other options to maximize neck rejuvenation include Ultrasound can cause dermal and subdermal zones of
pretreatment liposuction of any focal fat pads that may necrosis; however, these zones of necrosis may rarely
be contributing to the appearance of neck laxity. A variety occur closer to the epidermis. In these rare instances,
of other modalities for treating neck laxity include erythematous lines may occur on the neck immedi-
radiofrequency, infrared, and fractional resurfacing. ately after treatment (Fig. 3.5). The linear arrays of
About 2 weeks after ultrasound device therapy, one of pink papules likely represent superficial changes of
these modalities can be used to supplement the treatment necrosis. When these occur, a high potency topical
of neck laxity. steroid such as clobetasol propionate can be pre-
scribed twice a day for 5 days and complete resolu-
tion usually occurs within 4 weeks. In early clinical
trials, these linear arrays have not resulted in skin
Postoperative Care sloughing, hyperpigmentation, scarring, or any other
permanent adverse effects. There has also been one
After treatment, patients should wash the treated reported case of folliculitis that may or may not have
area. The area may feel as if it has been sunburned. been a result of the treatment. These patients can be
Thus, patients should be told to practice gentle skin treated with a 2-week course of oral doxycycline and
care. Patients should be contacted one day posttreat- topical clindamycin solution. The folliculitis usually
ment to assess for any skin changes that may not resolves within 2 weeks.
3 Treatment of Neck Laxity with Therapeutic Ultrasound 21
Fig. 3.5 Linear lines on the neck immediately posttreatment and resolution of lines 1 month later
Conclusion References
The early experience looks promising for nonsurgi- 1. Alam M, White LE, Miller N, et al. Safety and efficacy of a
novel ultrasound device for skin tightening on the face and
cal neck rejuvenation. The treatment is well-tolerated neck. American Society for Dermatologic Surgery Meeting
with mild intraprocedural pain, and transient red- 2007, Oct. 11–14, 2007
ness and swelling. Ultrasound can be used to pene- 2. Kennedy JE, Ter Haar GR, Cranston D. High intensity focused
trate deeper into the skin without significantly ultrasound: surgery of the future? Br J Radiol. 2003;76:590-
599
injuring superficial skin layers. The safe and effec- 3. Laubach H-J, Makin IRS, Slayton MH, et al. Intense Ultrasound
tive treatment settings have been defined, but cer- (IUS) in Dermatology: An in-vitro evaluation of a new approach
tainly are not yet maximized. Further clinical for precise microsurgery of the skin. American Society for
experience will work to optimize treatment parame- Dermatologic Surgery Meeting 2005, Oct. 27–30, 2005
4. White WM, Laubauch H-J, Makin IRS, et al. Selective trans-
ters including intervals between treatments, optimal cutaneous delivery of energy to facial subdermal tissue using
number of treatments, and optimal numbers of the ultrasound therapy system. American Society for Lasers in
passes with this device. Med. and Surgery Meeting 2006, April 5–9, 2006
Chapter 4
Treatment of Neck Fat with Injectable Adipolytic Therapy
Adam M. Rotunda
Introduction experiences describe the use of adipolytic therapy on

the trunk and/or extremities. It is the author’s opinion
that these areas are generally too large to be effectively
Adipolytic therapy is a novel technique that uses
treated with injections, leaving the patient and physi-
subcutaneous injections of pharmacologically active,
cian unsatisfied with the number of treatments and
natural detergents to chemically ablate adipose tissue.
medication volume required for an adequate outcome.
The technique has been notoriously described as meso-
Furthermore, adverse effects (systemic and local) from
therapy or Lipodissolve®, and its popularity can be
the injected medication are more probable and pro-
attributed due in large part to direct consumer adver
nounced when dosage is increased in order to accom-
tising and controversy rather than rigorous scientific
modate large areas. Therefore, fat on the trunk and
investigation. However, the following chapter describes
extremities are best treated with liposuction unless
what is perhaps best described as adipolytic therapy
they are postliposuction contour defects or very mod-
or lipodissolution, which is increasingly recognized in
est fat collections too small for liposuction (i.e., bra-
the literature as a novel method to treat fat, using injec-
strap fat, posterior arm, small collection on the anterior
tions rather than surgery or energy devices. Phosphatidyl-
abdomen), which both can be adequately treated with
choline (PC), a phospholipid derived from lecithin, has
injections. Patients considered candidates for submen-
been historically incorporated with its solvent, the ionic
tal liposuction are not candidates for adipolytic therapy
detergent sodium deoxycholate (DC), as the two pri-
unless they have adamantly expressed interest in a
mary injected medications. Recently, numerous reports
noninvasive option.
attribute the fat ablation effects of this treatment to DC,
The treatment area should be approximately one
which is a bile salt possessing potent cell lytic activity,
inch in subcutaneous fat thickness upon pinching.
and so this chapter will describe primarily the author’s
Patients should not have any significant skin laxity,
experience with this compound. It is imperative to note
platysmal banding, significant photodamage, or his-
that as of this writing, DC is not approved by any regu-
tory of keloid formation. Patients at least 18 years of
latory authority and therefore must be obtained from
age to approximately 50 years of age are generally best
compounding pharmacies. Physicians are advised to
candidates. The patient should have maintained a sta-
inquire about the status of this procedure with their
ble body weight for the last 6 months (i.e., plus or
malpractice carrier, and become informed (and likewise
minus 5% of initial consultation weight) and generally
appropriately consent patients) of the literature, risks,
be in good physical conditioning.
benefits, and alternatives of this technique.
Female patients who are pregnant, breast-feeding, or
those of childbearing potential who are not observing
adequate contraceptive precautions should not receive
Clinical Examination and Patient History treatment. Laboratory studies are generally not necessary
unless during the initial screening the patient reports
Ideal candidates for the procedure have relatively a co-morbid medical condition on history. Patients
small, localized fat deposits on the submental region, should therefore have normal blood counts, serum lipids,
mandible, and jowls. Numerous reports and expert liver and renal function. Darkly pigmented patients

24 A.M. Rotunda
(skin types Fitzpatrick IV–VI) are at increased risk fat in the target areas, therefore fat may return with
for postinflammatory hyperpigmentation. added bodyweight.
At the initial consultation, the patient must com- Pre- and post-treatment photography, examination,
prehend that swelling, local tenderness and nodular- and subjective feedback are used to assess results, as
ity are anticipated and necessary for efficacy. photography cannot convey the “firmer, tighter” sensa-
Further, the patient is explained that multiple treat- tion most patients experience after treatment.
ments (three to four) are necessary to appreciate Comparing standardized photographs of pre- and post-
changes in fat volume. Patients often inquire whether treatment profiles with patients is a useful and gratify-
the effects are “permanent.” Just as liposuction aspi- ing exercise (Figs. 4.1 and 4.2). Selecting the correct
rated fat will not recur, “chemically ablated” fat patient, those who have the most suitable fat collec-
cells will not reappear. Yet, both of these techniques tions and correct expectations, will lead to a satisfied
do not eliminate completely all the subcutaneous patient, physician, and staff.
Fig. 4.1 (a) Profile of patient at baseline. (b) Same patient 2 months after 5 monthly, 1 mL subcutaneous injections of 1% DC into
the submental fat
Fig. 4.2 (a) Profile of patient at baseline. (b) Same patient 2 months after 5 monthly, 1 mL subcutaneous injections of 1% DC into
the submental fat
4 Treatment of Neck Fat with Injectable Adipolytic Therapy 25
Method of Treatment Application (e) Sodium deoxycholate (DC) at 1% (10 mg/mL) in

sterile water (i.e., water for injection with 0.9%
Treatment can be limited to the submental fat or benzyl alcohol) obtained from a compounding
rather, extended to the mandible and jowls (Fig. 4.3). pharmacy
Treatment along the mandible can yield a pleasing (f) Lidocaine (1%) without epinephrine
contour and enhance jawline definition. Combination
The DC and lidocaine are mixed prior to injecting.
treatment using adipolytic therapy to the face and neck
A 3:1 ratio of DC and lidocaine are drawn into the same
along with botulinum toxin to the masseter muscle can
syringe (i.e., 3.75 mL of DC is mixed with 1.25 mL of
provide dramatic facial contouring. Treatment on the
lidocaine for a total volume 5.0 mL). A white precipitate
lower face should be restricted to lateral to the depressor
may become evident transiently as DC is mixed with
anguli oris (DAO) muscle. “When treating submental
lidocaine, but it should resolubilize instantly or with a
(under the chin) area, inject only the subcutaneous fat
gentle mix of the syringe. It is unadvisable to order
by pinching and elevating the skin prior to injection.
premixed lidocaine and DC; the stability and these
Confine the submental treatment to the area bordered
solutions are not known.
laterally by sternocleidomastoid muscles and inferi-
Patients are made comfortable either sitting upright
orly by the hyoid cartilage.”
or lying down and the treatment site is exposed, cleansed,
Generally, pretreatment is not necessary, yet some
and marked in a grid-like fashion, placing the points in
patients may benefit from Arnica several days prior to the
a staggered manner 1.5 cm apart. Refer to Fig. 4.4 for
procedure. Some clinicians prescribe a Medrol dose pack
additional detail of sequence of treatment events, which
started 2 days prior to the procedure to reduce swelling.
are represented grossly and microsopically in Fig. 4.5.
Materials required:
Topical anesthetic is usually not used, but this can be
(a) 30-gauge, 0.5-inch needles for injection and 18-gauge, offered. Injections of 0.25–0.33 mL are made into the
1-inch needles for withdrawing medication. mid-subcutaneous fat to circumvent migration of the
(b) Depending on the total volume, several 1, 3, or solution into the dermis above and the fascia below.
5 mL syringe(s) will suffice. Apply no pressure on the syringe plunger as the needle
(c) Surgical marking or eyeliner pen for mapping of is withdrawn, as this may lead to leakage of the deter-
injection sites gent into the dermis, causing necrosis. The skin is gen-
(d) Isopropyl alcohol with cotton/gauze erally pinched for more accurate and safer placement.
Fig. 4.3 (a) Injection grid before treatment demonstrating injection sites placed 1.5 cm apart on the submental anterior neck.
(b) Patient 1 month after three injection sessions using 5 mL per session of 1% DC
Fig. 4.4 Summary of adipolytic therapy treatment. (a) Cross-section of skin and subcutaneous tissue. (b) 30 g ½ inch needle is
inserted directly into subcutaneous fat. (c) 0.25–0.33 mL solution is injected. (d) An adjacent injection is made at the same depth
1.5 cm apart provides an even plane of treatment. (e) Detergent effects of the solution induce a rapid localized response, including
overlying erythema and subcutaneous edema. (f) Throughout days to weeks, the localized reaction significantly resolves, but the
ablated fat tissue remains surrounded by inflammation histologically and may be apparent as subcutaneous nodules. These mildly
tender to nontender nodules, if recognized, resolve over several weeks (commonly) to months (rarely). (g) The injected site eventually
heals with fibrosis (not apparent cutaneously) with associated reduction of subcutaneous fat thickness
Fig. 4.5 (a) Excised lipoma 48 h after 1% DC injection, revealing gross evidence of hemorrhage and inflammation. (b) Microscopic
findings (H&E,10×) revealing relatively normal appearing fat (right) immediately adjacent to necrosis and significant inflammation
The total volume injected per session is site dependent; Days 2–3
it varies according to the area injected, typically between
2 mL for relatively small submental fat collections to Edema will be moderate to significant, as will focal
upwards of 20 mL should submental, mandible, and jowl tenderness, although erythema will have resolved
regions be treated together. (Fig. 4.6). Swelling is often described as “jelly-like”
Immediately after the procedure, the skin should be by patients. A majority of swelling subsides after
cleansed with water or alcohol (to remove blood, pen 3 days. Cutaneous anesthesia may begin and persist for
marks) and patients can be offered a cold pack for 1–2 weeks. Some patients may experience ecchy-
immediate comfort. Extra-strength acetaminophen (no moses, which will fade over the week. First treatments
NSAIDS) is recommended the day of treatment and are best performed immediately prior to a weekend of
over the next several days as needed. Some clinicians social inactivity. After the initial treatment, patients
recommend gentle pressure garments similar to those will anticipate their reaction and adjust their social
worn after submental liposuction, worn for 3–5 days. schedule accordingly; however, most patients are
Patients are treated typically every 4 weeks, although pleasantly surprised to experience less florid swelling
some authors recommend as short as 2 and as long as and tenderness after subsequent treatmen (even with
8 weeks between sessions. A standard treatment regimen similar volumes).
is four to six consecutive sessions (or less, depending
upon patient’s response) and final evaluation is performed
2–3 months after the last session. In general three treat- Day 3 to 1 Week
ments are required before results are seen or felt by the
patient; the risk of not explaining this to the patient is Tenderness and edema gradually resolve, but may persist
noncompliance, disappointment, and lack of follow-up. to a milder degree, along with superficial paresthesia
(most often mild numbness, not tingling), beyond
this period.
Adverse Effects
Weeks 2–4
Local Effects
Most anticipated adverse events have passed at this
Immediately After Injection – Day 1 point, although firm, minimally tender, subcutaneous
nodules may be felt at the injection site. Patients should
Some patients experience mild tenderness, burning, or be reassured that the nodule is ablated fat, is a good
itching. Erythema and moderate edema will persist. effect (a sign that “it is working”), and will disappear
Fig. 4.6 Patient before (left image), 24 h after (middle image), and 2 months after four injection sessions (right image) using 7.5 mL
of 1% DC combined with lidocaine. Note significant swelling and ecchymoses
28 A.M. Rotunda
slowly as the site recovers. Nodules present at follow- the same location. At the time of this writing (with
up should not be re-injected directly at the follow-up 5 years of follow-up), the author has not witnessed any
treatment, lending additional support for pinching the patient with permanent nodularity (or any untoward
skin prior to injection reaction, for that matter). Patience, reassurance, and
regular follow-up visits until disappearance of the
nodules have been the rule.
Weeks 4+
Persistent paresthesias: Rarely, patients may experi-
ence numbness at the injection site at follow-up (i.e.,
Rarely, localized nodularity persists beyond 4–6 weeks.
4 weeks). A significant number of more patients will
have anesthesia of the skin overlying the treatment site
with shorter treatment cycles (i.e., 2 weeks).
Systemic Effects Paresthesias likely represents persistent subcutaneous
reaction rather than overt nerve necrosis, which has
not been recorded in the literature, nor reported anec-
Gastrointestinal effects (such as nausea and diarrhea) dotally. Reinjection into a site with paresthesia depends
have been described by some authors who use on whether the area is still significantly sore to touch
Lipodissolve® (PC in combination with DC). It is there- and swollen on examination. It is prudent to avoid
fore prudent to limit total volume to 20 mL per session. reinjection at that time and have the patient return in
Published and ongoing studies with DC reveal no several weeks for a reevaluation.
systemic alterations in serum chemistries, lipids, or
blood counts at conservative doses.
The adverse events described above are expected
and should be explained as such to the patient. A call Conclusion
of reassurance the next day to treated patients is good
medicine in general, as these treatments are unlike the Despite the controversy and skepticism, injectable
relatively benign reactions experienced after other adipolytic treatments are here to stay. With additional
injectables (fillers and botulinum toxin), to which rigorous, controlled data in the literature, we will have
patients have become accustomed. It may be that the a deeper understanding of its potential and limitations.
vigorous inflammatory reaction can wholly be attrib- Mandatory and extensive safety testing and numerous
uted to the detergent (necrotic) effects of DC upon the clinical trials will be required for regulatory authority
adipose tissue, release of cellular debris, influx of approval. Until then, physicians interested in the tech-
inflammatory cell and mediators. nique should seek training and become very familiar
More serious, potential adverse effects should with the literature in order to deliver a relatively safe,
be noted: effective, and gratifying procedure to their properly
Skin necrosis: This is a very rare but probable event selected patients.
should the detergent solution be inadvertently injected
superficially. Conservative wound care (occlusion with
emollients) is advised. Suggested Reading
Hyperpigmentation: The brisk inflammatory reaction
may lead to postinflammatory pigmentation in darker Duncan D, Hasengschwandtner F. Lipodissolve for subcutaneous
skin types. fat reduction and skin retraction. Aesthetic Surg J. 2005;
25:530-543.
Significant ecchymoses: More likely to occur in Odo MEY, Cuce LC, Odo LM, Natrielli A. Action of sodium
patients on blood thinners of any type (prescription or deoxycholate on subcutaneous human tissue: local and
systemic effects. Dermatol Surg. 2007;33:178-189.
over the counter). Pretreatment with Arnica is advised Rittes PG. The use of phosphatidylcholine for correction of localized
for those patients at higher risk. fat deposits. Aesthetic Plast Surg. 2003;27:315-318.
Rotunda AM, Ablon G, Kolodney MS. Lipomas treated with
Persistent nodularity (>2 months): More likely to occur subcutaneous deoxycholate injections. J Am Acad Dermatol.
in patients receiving multiple high volume injections at 2005;53:973-978.
Rotunda AM, Kolodney MS. Mesotherapy and phosphatidyl- Salti G, Ghersetich I, Tantussi F, Bovani B, Lotti T.
choline injections: historical clarification and review. Phosphatidylcholine and sodium deoxycholate in the
Dermatol Surg. 2006;32:465-480. treatment of localized fat: a double-blind, randomized study.
Rotunda AM, Suzuki H, Moy RL, Kolodney MS. Detergent Dermatol Surg. 2008;34:60-6.
effects of sodium deoxycholate are a major feature of Schuller-Petrovic S, Wölkart G, Neuhold N, Freisinger F,
an injectable phosphatidylcholine formulation used Brunner F. Tissue toxic effects of Lipostabil after subcutane-
for localized fat dissolution. Dermatol Surg. 2004;30: ous injection for fat dissolution in rats and a human volun-
1001-1008. teer. Dermatol Surg. 2008;34:529-42.
Chapter 5
Treatment of Poikiloderma with Fractional Resurfacing
Zakia Rahman
Introduction and was noted to have improvement of erythema, dys-

chromia, and overall texture for up to 2 months.
Successful treatment of hypopigmentation with
Poikiloderma, by definition, occurs in the setting of
nonablative fractional resurfacing has been reported
hyperpigmentation, hypopigmentation, atrophy, and
in six patients as well.5 Recently, the first report of
telangiectasias. There are numerous entities where
successful treatment of PC with ablative fractional
poikiloderma is present, the most common being a
lasers was published. The authors noted ten patients
result of chronic photodamage and is termed poikilo-
with PC who underwent one to three treatments with
derma of Civatte (PC). PC was initially described by
the Dermal Optical Thermolysis (DOT) laser (Eclipse
Civatte in 1923. Recently, histologic evaluation has
Med, Ltd. Dallas, TX) and had significant improve-
confirmed the aforementioned characteristics, in addi-
ment of erythema, pigmentation, and texture.6
tion to degeneration of collagen bundles and solar
elastosis.1
When PC is present on the neck and chest, it often
displays a geometric V-shaped pattern that appears
unnatural and can draw unwanted attention to the area. Clinical Examination and Patient History
There are numerous modalities that have been used in
the treatment of PC. Given the heterogeneity of signs, Treatment of nonfacial areas should be approached
the condition is difficult to completely eradicate with with greater caution because of the paucity of pilose-
one single treatment modality. The ideal modality baceous units in comparison to the face. Most reports
would repigment skin, eliminate excess pigmentation, of nonfacial treatments have been done with nonabla-
regenerate damaged collagen and elastic fibers as tive fractional lasers. Lines of demarcation, prolonged
well as normalize the dilated dermal blood vessels erythema, and risk of scarring are greater for nonfacial
(Fig. 5.1). ablative treatments. Nonablative fractional treatments
Fractional resurfacing has been used extensively for are characterized by rapid wound healing and a low
resurfacing on and off the face since it was first intro- side effect risk profile. For this reason, nonablative
duced in 2004.2 Various modalities are available on the fractional treatments are recommended for the treat-
market that utilize the concept of fractional treatment, ment of photodamage and PC of the neck and chest.
either in the nonablative or ablative mode. When ablative fractional modalities are utilized, treat-
Wanner et al. reported safe and efficacious treating less than 30% of the skin is recommended to reduce
ment of nonfacial photodamage with the 1,550 nm the likelihood of prolonged healing and subsequent
erbium fiber laser (Fraxel™, Solta Medical Inc., scarring.
Hayward, CA).3 Recently, Behroozan et al. reported Patient history and physical examination should
successful use of a fractional scanned erbium fiber be performed with emphasis on a history of delayed
laser at 1,550 nm (Fraxel™ SR, Solta Medical Inc., or altered wound healing and retinoid use. Blood
Hayward, CA) for the treatment of PC.4 The authors thinners, such as aspirin, NSAIDs, and vitamin E, can
reported one patient who received a single treatment predispose the patient for development of petechiae

32 Z. Rahman
Fig. 5.1 Possible mechanisms of action for fractional laser improvement of PC (Illustration by Alice Y. Chen)
and pinpoint bleeding following fractional laser Method of Device or Treatment

treatment. Contraindications to treatment include Application
active infection, breakdown of skin barrier function,
history of oral retinoid use in the previous 6 months,
and a poor physician–patient relationship. Standardized Stumpp et al. reported the wound healing process fol-
patient photographs are critical to monitoring treatment lowing fractional nonablative treatments through con-
success. focal evaluation.8 Rapid wound healing, as demonstrated
by repair of the dermal–epidermal junction and replace-
The most important preoperative wash-out for frac-
ment of coagulated epidermis, of less than 24 h is
tional treatments is topical retinoids. Upregulation of
achieved when the width of the microthermal zone
heat shock proteins (HSP) following fractional laser
(MTZ) is less than 500 mm. Fractional technology
treatment leads to TGF-b expression and the wound
selection should take into account devices that offer
healing cascade. Tosi et al. reported that retinoids blunt
truly microscopic (less than 500 mm wide) microther-
heat shock response, with the greatest decrease noted
mal zones to prevent negative sequelae. Width of ther-
with all-trans retinoid acid and minimal response with
mal injury, depth of penetration, method of delivery,
13-cis retinoic acid.7 A 2-week washout for topical
and ablative versus nonablative laser tissue interaction
retinoids prevents alteration of cellular response to
are the major differences in the available fractional
laser thermal injury.
technologies (Table 5.1).
Sun protection and sun avoidance should be
stressed as the salient part of every patient’s skin care 1. Dose/setting selection: Treatment energies and cov-
regimen. In addition to preventing melanocyte stimu- erages are patient Fitzpatrick skin type independent
lation following ultraviolet light exposure, sunscreens when treating neck and chest photodamage.
prevent long-term effects of solar elastosis, rhytides, Considerations for nonfacial treatments include
and pigment alteration as manifested in PC. lowering total area of skin treated at one time to less
5 Treatment of Poikiloderma with Fractional Resurfacing 33
Table 5.1 Nonablative fractional devices

Treatment level/ Method of delivery, device
Device Wavelength Energy settings coverages specifications
Affirm 1,440™ 1,440 nm/ 8 J/cm2, 3 ms 3 ms pulse duration Combined Apex Pulse™ (CAP)
Laser (Cynosure) 1,320 nm technology, Stamping, Smart-
Cool air cooling device.10
Affirm™ (Cynosure) 560–950 nm 20 J/cm2 5–35 ms pulse duration Combined Apex Pulse™ (CAP)
Intense technology, Stamping, Smart-
Pulsed Light Cool air cooling device
Fraxel Re:fine™ 1,410 nm 1–10 mJ/cm2 5–20% coverage Intelligent Optical Tracking
(Solta Medical System™ (IOTS), Scanning
Inc.)
Fraxel Re:store™ 1,550 nm 4–70 mJ/cm2 4–48% coverage Intelligent Optical Tracking
(Solta Medical System™ (IOTS), Scanning
Inc.)
Lux 1,540™ 1,540 nm Up to 70 mJ per 100 mbs/pulse for 10 mm Stamping. Contact cooling on tip
(Palomar) microbeam, handpiece (14–100 mJ)
10 mm and
15 mm
handpieces
320 mbs/pulse for 15 mm
handpiece (3–15 mJ),
Approximately 4%
coverage with each
pulse
Mosaic (Lutronic) 1,550 nm 5–40 mJ Dynamic Mode: Normal Multiple treatment tips, Dual operating
speed, Half speed, modes: stamping and CCT
One third speed (Controlled Chaos Technology)
Static Mode: 50–500
spots/cm2
than 40% of the skin to prevent bulk heating. 15th Street Pacific Grove, CA 93950, www.caprx.
If ablative modalities are utilized, total area should com, 831-373-1225) or available as Pliaglis™
be less than 30% of the skin’s surface. Treatment (Galderma Laboratories 14501 North Freeway Ft.
energies used for PC of the neck and chest are usu- Worth, TX 76177, www.pliaglis.com). While the
ally 8–10 mJ/cm2. Higher energies of 40–50 mJ/ majority of patients require some topical anesthetic,
cm2, can be employed for patients with severe PC. approximately 10–20% of patients can be treated
A typical treatment covers 20–40% of the skin at with forced air cooling or contact cooling alone.
each session. Treatment coverage can be reduced in Topical anesthetic can be applied to the area to be
darker skin patients if there is a concern for postin- treated for 45–60 min. Toxicity of anesthetics
flammatory pigmentary alteration. Treatment inter- should be well understood by the treating physi-
vals should also be spaced out every 6 weeks for cian. Limiting the surface area to less than 10% of
such patients. Sessions are spaced 2–4 weeks apart total body surface area per session can limit trans-
and a series of four to six treatments are required to cutaneous absorption of anesthetic. Anesthetic
resurface the entire skin. should always be applied in a supervised medical
2. Treatment techniques: The majority of patients setting and the patient should be monitored fre-
treated with nonablative fractional lasers require quently for signs of toxicity or allergy.
topical anesthetic. The type of anesthetic used varies Cooling of the skin reduces the risk of bulk heating
from topical 5% Lidocaine, 2.5% Lidocaine/2.5% and also increases patient comfort. The most com-
Prilocaine in a Eutectic Mixture (EMLA) to 7% monly used device for cooling employs a forced air
Lidocaine/7% Tetracaine that is either compounded chiller (Zimmer Medizine Systeme, Neu-Ulm,
(Compounded by Central Avenue Pharmacy 133 Germany) that can be used as a stand-alone device
34 Z. Rahman
(Fraxel™ or Mosaic) or incorporated in the hand- with a bidirectional technique work best on the
piece (Affirm™). Although contact cooling is chest. The laser tip should always remain normal to
employed in the Lux 1540™ system, additional use the skin surface during treatment. Certain bony
of forced air cooling can increase patient comfort prominences can present challenges in maintaining
during treatment. a perpendicular position of the laser tip. These are
Treatment techniques vary based on the fractional highlighted in Fig. 5.3.
technology used. Currently, the Affirm™ and 3. Alternative treatment methods: Treatment of PC
Mosaic lasers and the Lux 1540™ handpiece usually employs several different modalities.
employ a stamping technique. Circular or rectangu- Fractional lasers have variable success in treating
lar patterns of MTZs are laid down at a certain rep- the telangiectatic component of PC. Modalities that
etition rate. These technologies are more operator are selective for hemoglobin can be considered if a
dependent in the pattern of microthermal injury that patient fails to respond completely to fractional
is laid down. The Fraxel™ laser employs a rectan- resurfacing. Vascular Lasers and IPLs are modali-
gular pattern with Intelligent Optical Tracking ties with a successful track record in the treatment
System™ (IOTS), which lays down an even density of PC.9 When they are used in conjunction with
of MTZs independent of operator velocity. fractional photothermolysis, a 1-month interval is
Figure 5.2 depicts the unidirectional and bidirec- recommended before initiating these adjunctive
tional treatment techniques that can be employed on modalities.
the neck and chest. The unidirectional technique 4. Postoperative care: A significant advantage of
works best on the neck and perpendicular passes nonablative fractional technology is the limited
Fig. 5.2 Multiple
nonoverlapping passes as
performed to achieve a uniform
treatment. Four to eight passes
usually required. Unidirectional
and bidirectional techniques can
be employed to suit operator
and patient preference.
(Illustration by Alice Y. Chen)
Fig. 5.3 Areas of specific

consideration on the neck
and chest. (Illustration by Alice
Y. Chen)
postoperative care required. The most common 5. Management of Adverse Events: The safety profile
side effect noted is erythema. This can range from of nonablative fractional treatments is high.
mild to moderate and is directly correlated with the Common, transient side effects include erythema,
treatment level. Erythema is directly correlated to edema, and petechiae. When performed properly,
the percentage of skin treated at each session (treat- the risk of bulk heating at densities of less than 40%
ment level). Erythema duration ranges from 1 to 3 total coverage is extremely low. If bulk heating is
days on average, but can persist up to 2 weeks. encountered, there is a risk of blistering of the skin
Erythema can persist longer on the chest as com- and scarring. Improper treatment technique that
pared to the face and neck. Edema is the second involves treatment of a small area of the skin in a
most common side effect, which seems to be more short time interval or repeat firing in the same area
patient-dependent than erythema. Higher energy with a stamping laser can also lead to bulk heating.
treatments usually elicit greater edema. Patients
who are on blood thinners may not some petechiae
after treatment. This usually resolves within 2 to 5
days. Direction for the Future and Conclusions
Immediately after treatment, the neck and chest
should be cleansed gently to remove any remaining Nonablative fractional technology offers a relatively
topical anesthetic. A moisturizing sunscreen can be safe and efficacious treatment for PC and photodamage
applied followed by ice packs for 10-min intervals of the neck and chest. The significant safety profile,
for the first 24 h post-op. Complex aftercare is not lack of lines of demarcation, low risk of hypopig
required with nonablative fractional treatments. mentation, and scarring make this modality preferable
36 Z. Rahman
Fig. 5.4 Forty-eight-years-old (a) female patient treated on the neck and chest. Baseline and 1 month after three treatments on
the chest and four treatments on the neck (b). Chest treated at 6–9 mJ, treatment levels 4–6, every 2 weeks. Neck treated at 15–20
mJ, treatment level 6–7 every two weeks. Note significant improvement of PC
Fig. 5.5 Sixty-three-year-old male treated for PC on the neck treated with the Fraxel SR 750 laser at 8 mJ, 2,000 MTZ/cm2 every 2
weeks for a total of four treatments. Baseline (a) and one month after four treatments (b). Note significant improvement of hypo-
pigmentation
for nonfacial treatments. Fractional lasers offer the results on telangiectasias are variable and can sometimes
greatest improvement of hypopigmentation, hyperpig- require adjunctive treatment with a vascular specific
mentation, and skin atrophy associated with PC. The light device for optimal treatment (Fig. 5.4 and 5.5).
References 5. Glaich AS, Rahman Z, Goldberg LH, et al. Fractional

resurfacing for the treatment of hypopigmented scars.
Dermatol Surg. 2007;33(3):289-294.
1. Katoulis AC, Stavrianeas NG, Panayiotides JG, et al. 6. Tierney EP, Hanke CW. Treatment of poikiloderma of civatte
Poikiloderma of civatte: a histopathological and ultrastruc- with ablative fractional laser resurfacing: a prospective study
tural study. Dermatology. 2007;214:177-182. and review of literature. J Drugs Dermatol. 2009;8(6):527-533.
2. Manstein D, Herron GS, Skin RK, et al. Fractional photo- 7. Tosi P, Visani G, Ottaviani E, et al. Reduction of heat shock
thermolysis: a new concept for cutaneous remodeling using protein-70 after prolonged treatment with retinoids: biological
microscopic patterns of thermal injury. Laser Surg Med. and clinical implications. Am J Hematol. 1997;56(3):143-150.
2004;34:426-438. 8. Stumpp OF, Rahman Z, Jiang K. In-vivo confocal imaging of
3. Wanner M, Tanzi EL, Alster TS. Fractional photothermoly- epidermal cell migration and dermal changes post non-ablative
sis: treatment of facial and nonfacial cutaneous photodam- fractional resurfacing. Lasers Surg Med. 2007;23(Suppl):8.
age with a 1,500 nm erbium-doped fiber laser. Dermatol 9. Rusciani A, Motta A, Fino P, et al. Treatment of poikilo-
Surg. 2007;33:23-28. derma of civatte using intense pulsed light source: seven
4. Behroozan DS, Goldberg LH, Glaich AS, et al. Fractional years of experience. Dermatol Surg. 2008;34(3):314-319.
photothermolysis for treatment of poikiloderma of civatte. 10. Gold MH. Fractional technology: a review and clinical
Dermatol Surg. 2006;32:298-301. approaches. J Drugs Dermatol. 2007;6(8):849-852.
Chapter 6
Treatment of Poikiloderma with Chemical Peeling
Luciana Molina de Medeiros, Arlene Ruiz de Luzuriaga, and Rebecca Tung
Introduction settings of 5.0–6.5 J/cm2, and the DCD (spray of 30 ms

and a delay of 20–30 ms). Meijs et al. treated POC
Poikiloderma of Civatte (POC) is a common skin with a 585 nm pulsed dye laser. They found that by
disorder characterized by reticular hyperpigmentation using lower fluences (5.0 J/cm2 or less) at a fixed pulse
with telangiectasia and slight atrophy involving sun- duration of 450 ms and a larger spot sizes (10 mm), the
exposed areas especially of the neck and upper chest. risk of unwanted pigmentation effects (hypopigmenta-
There is usually a sparing of the submental area. It tion) could be reduced.
occurs most commonly in middle aged fair-skinned Generally, a series of laser or IPL sessions are
women, but is also seen in men. needed. However, these treatments can be costly and
Treatment of POC is challenging and involves the may not consistently treat the hyperpigmentation and
elimination of both vascular and pigmented compo- textural aspect of POC.
nents simultaneously. Although various modalities Recently, the use of fractional photothermolysis
have been used, complete clearing is often difficult to (laser technology which generates microthermal treat-
achieve. Monotherapy can be disappointing while ment zones (MTZ) and spares surrounding skin) has
combination therapy has proven to be more effective in had promising results in the treatment of POC.
clinical practice. Behroozan et al. reported successful clearing with a
Laser and light systems can be primarily employed single treatment using, 1550 nm wavelength Fraxel SR
to address the vascular features.1-3 Intense pulsed light laser (Solta Medical Inc., Hayward, CA) at pulse energy
(IPL) sessions have been shown to be beneficial in the of 8 mJ and a final density of 2,000 MTZ/cm2.4
treatment of POC. Goldman and Weiss demonstrated In our practices, chemical peels play a vital role in
improvement in the extent of both telangiectasias and the therapy of POC. Peels can specifically improve
hyperpigmentation.1 The parameters used to treat most underlying photodamage, including textural irregular-
patients included initial use of 515–570 nm filters and ity and dyschromia. Superficial or medium depth peels
pulse durations of 2–4 ms, separated by a 10 ms delay. may be selected depending on the degree of sun damage.
On average, patients in this study required 2.8 treat- Studies from the literature, report improvement in mild
ments. IPL was found to be a versatile device that ame- to moderate photodamage on the neck and chest with
liorates both pigmentation and telangiectasia-associated chemical peeling. Cook et al. popularized the “Cook
erythema, with minimal side effects.1 Vascular lasers Body Peel,” a procedure for rejuvenating non-facial
such as the V Beam Perfecta (Candela Corp., Wayland, skin, using glycolic acid gel combined with 40%
MA, 595 nm) offer an improved safety profile com- trichloroacetic acid (TCA).5 Gladstone et al. demon-
pared to earlier pulsed dye laser technology due to the strated that the combination of topical glycolic acid
addition of a dynamic cooling device (DCD) and with a series of salicylic acid peels was safe and an
adjustable pulse duration that minimize the risk of effective way to rejuvenate photodamaged skin on the
postprocedural purpura and depigmentation. Typical neck and upper chest.6 Cuce et al. reported improve-
settings of the 595 nm pulsed dye laser when treating ment in the appearance of photodamaged skin, melasma,
poikiloderma of the neck and chest are of a 10 ms pulse and acne following series of 1–5% tretinoin peels.7
duration, an adjustable spot size 7–10 mm, energy Hexsel et al. also demonstrated that retinoic acid 5%

40 L.M. de Medeiros et al.
peels with and without microdermabrasion were effec- Patient Evaluation

tive in the treatment of signs of photoaging.8
It is critical to identify any factors that may result in
suboptimal results and complications (Table 6.2).
A time interval of 12 months after isotretinoin
Clinical Examination and Patient History therapy is recommended prior to medium depth
peeling because this medication produces atrophy of
the pilosebaceous units which can result in delayed
Preoperative Evaluation wound healing and abnormal scarring. Since light
chemical peels target the epidermis to papillary dermis,
Preoperative evaluation is essential to identify cosmetic patients need to wait only 3 months after treatment
concerns, set realistic goals, review downtime issues, with isotretinoin.
and discuss costs with patients. A written overview of Oral contraceptives, hormone supplementation or
the proposed peeling procedure, listing indications and minocycline can lead to increased sun sensitivity and
frequently asked questions, allows a patient to plan and predispose to the development of postinflammatory
prepare with greater understanding. A signed informed hyperpigmentation.
consent form should outline the risks, benefits, alterna- Similarly, significant undermining of the underly-
tives, and limitations associated with chemical peels. ing soft tissues that is commonly performed during
(Table 6.1). flap reconstruction and invasive cosmetic facial and
Additionally, patients need to be informed that neck surgery can temporarily compromise the blood
chemical peels alone may not completely be able to supply and lead to impaired wound healing. Any his-
treat POC. At this point, explanation of how other pro- tory of abnormal scar formation, keloids also warrant
cedures may be used in combination with peels for fur- extra caution. Past exposure to radiation of the head or
ther improvement may be appropriate. neck is also relevant. Therapeutic radiation diminishes
Careful analysis of the patient’s skin can be stan- the number of pilosebaceous units in treated areas and
dardized and may be done using the Fitzpatrick clas- places these patients at an increased risk for the devel-
sification and Glogau system that stratify individuals opment of postoperative scarring.
by skin type (amount of baseline pigmentation and Patients should also be questioned about active or
ability to tan) and extent of photodamage (Glogau previous bacterial, fungal, and viral infections, includ-
stage). While superficial peels are considered safe in ing herpes simplex viral infections. Current infection
all skin types, pigmentary complications can be sig- is an absolute contraindication to all types of chemical
nificant in darker skin types. In most patients with peeling. If a medium depth peel needs to be performed
POC, we begin with a series of superficial peels. on the face, a patient should be given prophylaxis
However, if patients have had recalcitrant POC or pres- (regardless of herpetic history) with an antiviral medi-
ent with advanced sun damage, medium depth peels cation provided there are no contraindications to such
may be indicated at the onset of treatment. In these treatment.
predisposed patients, using topical bleaching agents A history of human immunodeficiency (HIV), hep-
both in the preoperative and postoperative period may atitis or immunosuppression due to systemic disease or
prevent postinflammatory hyperpigmentation. medications should also be identified as there is a
Table 6.1 Preoperative evaluation Table 6.2 Patient evaluation

Evaluation of patient’s cosmetic concerns and goals Complete medical, surgical, and psychosocial history:
Discussion of downtime and budget medications (isotretinoin, minocycline), active infection,
Informed consent (risks, benefits, alternatives, and limitations history of infections (herpes simplex virus), history of
associated with peeling) outlining the details of the radiation to head and neck, history of keloid formation,
procedure, common side effects, recovery time, and history of immunosuppression (disease or medication), and
wound care recent neck or upper chest surgery
Assessment of skin type (Fitzpatrick classification) and degree Skin examination
of photodamage (Glogau classification) Photography, including consent for pre and post photos
6 Treatment of Poikiloderma with Chemical Peeling 41
greater risk of infection and its untoward effects in Table 6.4 Commonly used
these patients. concentrations on the neck
Before and after sequential photographs underscore Glycolic acid (50–70%)
Trichloroacetic acid (10–25%)
any temporary lifestyle modifications that they may
Jessner’s solution
need to make. Detailed written postoperative instruc-
Tretinoin (1–5%)
tions can maximize cosmetic outcome and avoid any Salicylic acid (20–30%)
potential side effects. This regimen includes proper
wound care, sun avoidance, and compliance with post-
operative medications.
Since hyperpigmentation is a hallmark of POC,
pre and posttreatment with topical bleaching agents is
Treatment Application recommended. Topical hydroquinone is most commonly
used. Other non-hydroquinone containing bleaching
agents include azelaic acid, aloesin, vitamin C, arbutin,
Preoperative Patient Preparation glabridin (licorice extract), mequinol (4-Hydroxyanisol),
melatonin, niacinamide, paper mulberry, soy, vitamin E,
Preoperative patient preparation can maximize cos- kojic acid, alpha and beta hydroxy acids, and their
metic results and minimize complications of chemical retinoids. A combination of hydroquinone products such
peels (Table 6.3). as Tri-Luma® cream (Galderma Laboratories, Fort
The American Academy of Dermatology (AAD) Worth, TX) and Glyquin-XM™ can also be used.
has developed Guidelines of Care for chemical peeling. Regular application of sunscreen is an integral part
They recommend pretreatment of the skin with topical of preparing the skin for peels. The main purpose is to
tretinoin as well as postoperative topical tretinoin to reduce baseline hyperpigmentation. All skin types
promote wound healing faster and maintain cosmetic require broad-spectrum sunscreens pre and postpeel-
benefits of chemical peels.9 Patients should start using ing to reduce the risk of pigmentation complications.
topical tretinoin or another tolerated topical retinoid Extra protection in the ultraviolet A (UVA) range is
nightly at least 6 weeks prior to the chemical peel and important to reduce baseline hyperpigmentation and
should discontinue the use of topical treatment at least prevent postinflammatory dyschromias. Ingredients
48 h prior to a peel to ensure an intact epidermal sur- such as ecamsule (Mexoryl®SX), stabilized avoben-
face. In darker-skinned patients, tretinoin increases the zone (Helioplex®), and physical agents (titanium diox-
depth of peeling agents and the possibility of postin- ide and zinc oxide) provide more complete protection
flammatory hyperpigmentation. For this reason, topical against UVA.
retinoids may be discontinued as soon as 2–4 weeks Antiviral prophylaxis is not usually necessary for
before a series of chemical peels in at-risk patients. superficial peels or medium depth peels for the body,
Topical retinoids can be restarted in the postoperative however, it is strongly recommended for all patients
period when erythema has subsided, and a complete prior to perioral or full face medium depth peels.
re-epithelialization has occurred. A commonly used regimen is valacyclovir, 500 mg
twice daily or famciclovir 250 mg twice daily starting
one day before the procedure and continuing for
Table 6.3 Preoperative patient preparation 12–14 days afterwards.
Prepeel regimen can maximize cosmetic results and minimize
complications:
– Topical retinoids: tretinoin, tazarotene, adapalene, or
retinol Chemical Peels
– Alpha Hydroxy Acids (AHAs)
– Hydroquinones may reduce the incidence of post-
inflammatory hyperpigmentation Superficial chemical peels (Table 6.4), when used in
Sun avoidance and broadspectrum sunscreens with sun the treatment of POC, disrupt and exfoliate all or part
protection factor (SPF) 30 plus of the epidermis. They have also been shown to have
Antiviral prophylaxis for all patients before a medium depth peel dermal effects, including stimulation of collagen and
glycosaminoglycan production. Given the limited critical role in re-epithelialization. As a result, if a peel
nature of the injury induced by these peels, patients is performed on non-facial skin such as upper chest
often need multiple treatments on a weekly or monthly and lower neck, one should proceed cautiously and
basis to reach the desired result. concentrations of greater than 25% TCA ought to be
avoided. We also suggest starting with lower concen-
1. Glycolic acid is an alpha-hydroxy acid (AHA), usually
trations for patients with skin types III or higher.
in concentrations up to 70%, that has been used to
treat photoaging via stimulation of new collagen Treatment technique. The skin is prepared similarly
synthesis, as well as hyperpigmentation by remov- as with other peels. Using a lower concentration TCA,
ing melanin from the epidermis.10 It is available erythema and a white speckled frost are noted within
prepackaged as a preprepared pad, in a gel or liquid 1 min. A stinging sensation during peel solution appli-
formulation, or can be compounded (Table 6.5). cation will be felt by the patient, but it should be tran-
sient. Multiple coats of the peeling agent can be used
Treatment technique. The area to be peeled is first
to achieve a uniform frosting and deeper peel. TCA
mildly cleansed and then degreased with alcohol with
does not require neutralization after application.
or without acetone. Rapid application of glycolic acid
Anesthesia is not required because the chemical solu-
to clean the entire affected area, for a period of 2–3 min
tion acts as an anesthetic; but in some patients, topical
on the neck and 3–5 min on the chest. After this dura-
anesthetic creams may be applied before the peel.
tion, the solution is neutralized with sodium bicarbon-
ate or plain water. Physical signs such as intense The level of frost is divided into four groups.
erythema or pinpoint frosting can be used as end
−− Level 0: No frost. There is minimal to no erythema.
points. No anesthesia is required for AHA peels since
It is a fairly superficial peel, that in most cases
they cause only a slight stinging sensation during
affects only the stratum corneum.
application.
−− Level I: Irregular light frost. The skin shows some
Since the skin of the neck is thinner and sensitive,
erythema and areas of the white frost are dissemi-
we suggest starting concentrations at 50% and advanc-
nated. It is a superficial epidermal peel.
ing as tolerated to 70%.
−− Level II: White frost with pink showing through.
2. Trichloroacetic acid (TCA) in concentrations of Skin has uniform white color, but with a pink
10–25% is used extensively as a light peel. The background. It is considered a full thickness epider-
depth of cutaneous penetration varies with concen- mal peel.
tration. In these lower concentrations, it will pro- −− Level III: Solid white frost. Skin has solid and an
duce necrosis of superficial layers by precipitation intense white frost with no pink background.
of epidermal proteins, clinically causing a mild
On the neck and chest, a level I to II frost is appropriate.
epidermal slough (Table 6.6).
Cold wet compresses should be applied immediately
As a rule, non-facial skin takes much longer to heal after the peel. The white frosting resolves within 2 h.
and is at much greater risk of scarring than when using It may take 7–10 days for the skin to heal.
a similar concentration on the face. This is due to the
3. Jessner’s solution also has been introduced as a
higher concentration of pilosebaceous units on the
treatment option for POC (Figs. 6.1 and 6.2), usu-
face compared with non-facial sites. These units play a
ally associated with other methods. It combines
resorcinol, salicylic acid, and lactic acid in ethanol
Table 6.5 Glycolic acid peel formulation (Table 6.7). This superficial peel has keratolytic
Glycolic acid 70% activity.
Gel Sufficient quantity to make 100 g
Treatment technique. Jessner’s solution is applied to
prepped skin and rubbed or painted on, depending on
the degree of penetration desired. It is self neutralizing
Table 6.6 TCA peel formulation (25%) and multiple applications can be performed to obtain a
Trichloroacetic acid 25 g deeper penetration. There is usually no frosting, only
Distilled water 100 mL erythema and white speckling.
Fig. 6.1 Poikiloderma of Civatte prior to Jessner’s solution

treatment
Fig. 6.3 Appearance of tretinoin peel for treatment of
poikiloderma
Treatment technique. Tretinoin peels impart a yellowish

coloration upon application (Fig. 6.3) making it easy
to identify any untreated areas after cleansing the area
with a gentle cleanser followed by alcohol. The peel
(which most often comes as a cream or gel) is applied
and left in contact with the skin for 4–6 h. To improve
efficacy and penetration, a plastic film may be used for
occlusion. After the prescribed exposure period, the
patient is instructed to wash the treated area with plain
water at home.
As the yellowish hue of the tretinoin peel may not
be cosmetically appealing, a foundation color is
often added at the time of compounding. Tretinoin
peels can be safely used in all skin types but care
Fig. 6.2 Poikiloderma of Civatte after Jessner’s Solution
treatment should be taken to avoid excess irritation. To treat areas
of excess erythema, 1% topical hydrocortisone cream
can be applied after the peel. In patients who have
Table 6.7 Jessner’s solution
more advanced photodamage, the effects of retinoic
Resorcinol 14 g
acid peels can be increased by preapplication of one
Salicylic acid 14 g
85% Lactic acid 14 g coat of either Jessner’s solution or a glycolic acid (50–
95% Ethanol Sufficient quantity to make 100 mL 70%) solution. If glycolic acid is chosen, the area must
be neutralized with water or sodium bicarbonate after
3 min prior to the application of the tretinoin peel
4. Tretinoin peeling can be an excellent choice for
(Table 6.8).
improvement of photodamaged skin. Different con-
centrations from 1% to 5% can be applied depend- 5. Salicylic acid, a beta hydroxy acid, has been proven
ing on the particular skin condition. Four to six to be safe and effective for acne, melasma, and pho-
sessions are usually needed and are spaced about toaging in all skin types, including Fitzpatrick types
1–2 weeks apart. IV and higher.11
Treatment technique. Salicylic acid peels offer the Table 6.9 Salicylic acid formulation 20 or 30% available
opportunity to visualize immediately any skipped areas prepackaged or compounded
because white precipitation of salicylic acid crystals Salicylic acid 20–30 g
95% Ethyl alcohol Sufficient quantity to make 100 mL
occurs at the site of application. A neutralizing agent is
not required since the vehicle volatilizes in 2–3 min
and very little of the active agent continues to pene- coat of petrolatum ointment or bland moisturizer is
trate. Salicylic acid has been attributed with anesthetic applied. Topical hydrocortisone may be substituted if
properties and is lipophilic, making it well-suited to there is an increased degree of erythema or, in indi-
treat patients who may have oily or acne-prone skin. viduals with darker skin types, to reduce the recovery
6. Combination peels in non-facial skin time and minimize the chance of postinflammatory
hyperpigmentation.
The Cook Body Peel5 is a technique for non-facial skin Topical retinoids or AHA products should be
using 70% glycolic acid gel (which acts as a partial avoided until the skin returns to normal, typically within
barrier to TCA penetration) followed by application 2–3 days when patient may return to the regular main-
with 40% TCA. The treated skin is monitored to the tenance regimen. Sun block and sun avoidance should
endpoint desired is characterized by erythema with also be emphasized. Routine prophylactic or postpeel
scattered white speckles which usually occurs within antiviral or antibiotic treatments are usually not required
3 min. At this point, neutralization with 10% sodium with superficial peels. For the regimen with the combi-
bicarbonate solution is performed. nation of TCA, patients – wound care is slightly more
Pretreatment with topical tretinoin followed by a involved. Patients apply dilute 0.025% acetic acid (1
methyl salicylate buffered croton oil containing 50% pint warm water with 1 tsp. white vinegar) 3–4 times
salicylic acid ointment peel, and localized 20% TCA per day followed by petrolatum ointment applications.
for actinic keratoses or seborrheic keratoses has been
shown to be effective to improve photodamaged skin
on the body (Table 6.9).12
Monheit introduced Jessner’s + TCA combination Conclusion
peel of 35% as an effective medium depth peeling proce-
dure that produces a medium-depth peel for photoaging A conservative approach should be followed when
skin, actinic keratoses, and rhytides on the face.13 For our treating POC given the risk of uneven removal of pig-
patients with recalcitrant POC, we have seen good results mentation and erythema resulting in a “footprint” like
with a lower concentration combination TCA peel. After appearance (which can represent incipient scarring and
standard preparation, the skin of the neck and chest is potential for scarring on the neck and chest). Any
initially painted with one coat of Jessner’s solution fol- patchy erythema should be aggressively treated with
lowed by the application of 25% TCA. Treated areas hydrocortisone cream 1% 2–3 times daily for 1 week
develop a light level I to II frosting. Light sedation may with or without the addition of low energy pulsed dye
be used before and during the procedure to reduce anxi- laser treatments.
ety and keep the patient more comfortable. Chemical peels are an effective technique to improve
photodamaged skin associated with POC. When peeling
is combined with laser or light treatments, overall results
Postoperative Care can be improved. Patients should understand that mul-
tiple sessions are usually needed to reach a satisfactory
endpoint.
Postoperative care for superficial peels is minimal Developing a consistent technique and acquiring a
and simple. Immediately following the peel, a thin complete understanding of the limitations and compli-
cations associated with all chemical peels used in the
treatment of POC will permit you to be able to select
Table 6.8 Retinoic acid peel formulation (5%) and safely perform the most appropriate peeling
Retinoic acid 5% procedure(s) to accommodate the individual needs of
Gel or cream Sufficient quantity to make 30 g your patients.
References the neck and upper chest. Dermatol Surg. 2000;26(4):

333-337.
7. Cuce L, Bertino M, Scattone L, et al. Tretinoin peeling.
1. Goldman MP, Weiss RA. Treatment of poikiloderma of Dermatol Surg. 2001;27:12-14.
Civatte on the neck with an intense pulsed-light source. Plast 8. Hexsel D, Mazzuco R, Dalforno T, Zechmeisler D.
Reconstr Surg. 2001;107:1376-1381. Microdermabrasion followed by a 5% retinoic acid chemical
2. Wheeland AR, Applebaum J. Flashlamp-pumped pulsed dye peel vs. a 5% retinoic acid chemical peel for the treatment
laser therapy for poikiloderma of Civatte. J Dermatol Surg of photoaging-a pilot study. J Cosmet Dermatol. 2005;4:
Oncol. 1990;16:12-16. 111-116.
3. Meijs MM, Blok FA, de Rie MA. Treatment of poikiloderma 9. Drake LA, Dinehart SM, Goltz RW, et al. Guidelines/out-
of Civatte with the pulsed dye laser: a series of patients with comes committee: American Academy of Dermatology.
severe depigmentation. J Eur Acad Dermatol Venereol. J AM Acad Dermatol. 1995;33:497-503.
2006;20(10):1248-1251. 10. Usuki A, Ohashi A, Sato H, Ochiai Y, Ichihashi M, Funasaka
4. Behroozan DS, Goldberg LH, Glaich AS, Dai T, Friedman Y. The inhibitory effect of glycolic acid and lactic acid on
PM. Fractional photothermolysis for treatment of poikilo- melanin synthesis in melanoma cells. Exp Dermatol.
derma of civatte. Dermatol Surg. 2006;32(2):298-301. 2003;12:43-50.
5. Cook KK, Cook WR Jr. Chemical peel of nonfacial skin 11. Grimes PE. The safety and efficacy of salicylic acid chemi-
using glycolic acid gel augmented with TCA and neutralized cal peels in darker racial-ethnic types. Dermatol Surg.
based on visual staging. Dermatol Surg. 2000;26(11):994- 1999;25:18-22.
999. 12. Swineheart J. Salycilic acid ointment peeling of the hands
6. Gladstone HB, Nguyen SL, Williams R, et al. Efficacy of and forearms. J Dermatol Surg Oncol. 1992;18:495-498.
hydroquinone cream (USP 4%) used alone or in combina- 13. Monheit GD. The Jessner’s + TCA peel: a medium-depth
tion with salicylic acid peels in improving photodamage on chemical peel. J Dermatol Surg Oncol. 1989;15(9):945-950.
Chapter 7
Treatment of Poikiloderma by Pigment
and Vascular Lasers
Mohamed Lotfy Elsaie, Voraphol Vejjabhinanta, Angela C. Martins, and Keyvan Nouri
Introduction In addition, solar elastosis is another histopathological

feature associated with PC, confirming the implication
of sun exposure on the pathogenesis of PC.
Poikiloderma of Civatte (PC) is a condition of the
A Summary of inducing and perpetuating factors is
middle aged fair-skinned women and men. It is charac-
identified in Table 7.1.15,16
terized by a triad of superficial skin atrophy, telangi-
ectasia, and reticulate pattern of pigmentary alterations
(both hyperpigmentation and hypopigmentation).
Discoloration is usually profound at the lateral aspects
Method of Device on Treatment
of the cheeks, the lower anterior and lateral aspects of
the neck, and V shape of the upper chest. The submental Application
area, shaded by the shin, is spared (Fig. 7.1).1–14 Lesions
are usually asymptomatic, although patients occasion- Of all methods used, laser remains to be the most sig-
ally report itching, mild burning, and flushing. nificant effective treatment and will be discussed in
The incidence of the condition is unknown; however, more detail as follows.
one study in Greece estimated the incidence of PC Based on the theory of selective photothermolysis,
among dermatologic conditions to be 1.4%.3 The true a number of laser modalities have been used for target-
incidence appears to be higher, especially among fair ing the vascular and pigmented components of PC.
skinned females in perimenopausal ages with a past Although complete clearance cannot be completely
history of chronic sun exposure. Apparently, PC has achieved and a number of adverse effects were reported,
more predilection to females. Despite the fact that PC laser therapy remains the most efficient convenient
runs a chronic, irreversible but benign course, yet the modality for PC. Some laser can target both hemoglo-
physical disfigurement and self-consciousness about bin and melanin, and selecting appropriate wavelengths
the lesions lead to social withdrawal and has much cos- results in favorable outcomes.
metic implications on the population affected.4 The first laser system used for PC was the blue–
PC is a rather common condition of obscure causes. green argon laser and it had significant scarring side
Several theories and hypothesis have been interpreted effects, the most prominent of them was scarring. The
as either possible pathologies or exacerbating factors. 532 nm KTP laser was introduced shortly afterwards,
The exact etiology and pathogenesis of PC is not fully representing an improvement for PC treatment although
understood. It is believed that it is the sum of genetic marked hypopigmentary adverse effect has been
predisposition in middle aged fair-skinned women reported. The introduction of PDL significantly
added to an exaggerated exposure to sunlight and improved the treatment of PC, however, the first gen-
tendency to use fragrances that results on the develop- eration of PDL has not been frequently used and a few
ment of Poikiloderma. The distribution of the lesions results were recorded regarding its effectiveness.
on sun exposed areas and the characteristic sparing of Newer PDL devices served as a better modality with
shaded parts of the skin suggests and dictates a role even greater results reported so far. Intense pulsed light
of solar radiation in the development of this dermatitis. (IPL) sources with a broad wavelength spectrum have

48 M.L. Elsaie et al.
certain extent, it often led to pitted, atrophic, and

hypopigmented scars. Although oxyhemoglobin is the
chromophore of target for this laser, the surrounding
epidermis, dermis, and melanocytes are also subject to
thermal photodamage by the continuous beam of the
argon laser.19,20
Potassium-titanyl-phosphate Laser
The potassium-titanyl-phosphate (KTP) laser uses a

neodymium/YAG laser source emitting at 1,064 nm in
the infrared portion of the electromagnetic radiation
Fig. 7.1 Poikiloderma of Civatte: Ill-defined patches of bilateral spectrum. The beam of infrared light is then passed
symmetrical reddish-brownish reticulate dyspigmentation with
atrophy and telangiectasia. This figure illustrates a lesion on the
through a crystal made of potassium titanyl phosphate.
side of the neck with sparing submental area The frequency is doubled and the wavelength is
halved so that the KTP laser emits light at a 532 nm
length. At this wavelength, oxyhemoglobin is at a close
Table 7.1 Factors contributing to the onset and development of peak of absorption. In addition, melanin in lesions of
Poikiloderma of Civatte Poikiloderma absorbs light at this wavelength as well.
• Sun exposure The advantage of this laser is targeting both hemoglo-
• Genetic predisposition
bin and melanin at the same time. To our knowledge,
• Lighter skinned population of females in perimenopausal
age group only one study exists in the literature reporting the use
• Hypersensitivity type of reaction involved with exposure to of KTP in PC. Batta and coworkers reported using
phototoxic allergens (Kathon CG, which is a mixture of KTP at 532 nm, 1 msec pulse duration, and a repetition
methylchloroisothiazonilone and methylisothiazonilone, rate of 10 pulses per second at energy fluencies of
was determined to initiate or accentuate the lesions of PC.)
10–15 J/cm2. The study reported very good cosmetic
improvement in reducing both the telangiectasia and
pigmentation.6
lately been used with reports of initial success and
better results.8,17,18 Fractional photothermolysis repre-
sents a more recent modality. The most commonly
used laser therapy modalities for the treatment of PC Pulsed Dye Laser
will be discussed in this chapter.
The pulsed dye laser (PDL) has been significantly
designed for vascular lesions of the skin. According to
selective photothermolysis guidelines, this laser tar-
Argon Laser gets hemoglobin as its main chromophore. Injury can
be induced to a depth of 1.2 mm with minimal destruc-
The argon laser is a nonpulsed, continuous wave laser tion to the surrounding structures. First generation of
emitting blue–green visible light. The peak wavelength PDL at 585 nm was not much assessed in the treatment
emissions of this laser are 488 and 514 nm. These of PC due to the paucity of published studies. Still, it
bands coincide with the first absorption peak of oxyhe- had shown good results at fluencies of 6–7 J/cm2 with
moglobin. The blue–green argon laser was the first a 5 mm spot size (Fig. 7.2). Adverse effects in the form
laser system to be used in treating PC. It offered of purpura, hyperpigmentation, or hypopigmentation
improvement despite many of its adverse events, were reported. With newer PDL devices (595 nm),
mainly scarring. The laser targeted the erythematous many reported studies had been encountered in litera-
component of PC and despite its effectiveness to a ture, however, no guidelines were exactly specified for
7 Treatment of Poikiloderma by Pigment and Vascular Lasers 49
Fig. 7.2 Poikiloderma of Civatte: Before treatment (a), and two months after one treatment with the pulsed dye laser (wavelength
585 nm, pulse duration 450 ms, spot size 10 mm, and fluence 3.5 J/cm2 (b)
Table 7.2 A summary of documented studies on PDL treatment of PC

Study Number of patients Parameters used Efficacy and adverse effects
Haywood and Monk (1999) 8
7 5 J/cm2 with 10 mm spot and Five cases of excellent response, one good
7 J/cm2 with 7 mm spot and one poor and complicated with
hypopigmentation in the setting
of 7 J/cm2 and 7 mm spot size
Clark (1994) 9 1 80% clinical improvement with no side
effects
Meijs et al. (2006) 10 8 3.5–7 J/cm2, using a 7 or Poor results with high fluencies resulting
10 mm spot size in hypopigmentation of six out of the
eight patients
the ideal usage of the PDL for an optimal effect or different skin types for risk of complications. It is
results.8 A small number of published studies targeted advisable to use low fluencies and not exceed an upper
PDL treatment of PC and results were variable. The limit of 5 J/cm2. Furthermore, the use of sun protec-
vascular element of PC responded the best, while the tion, following the procedure, is of outmost importance
hyperpigmentation was not affected or responded for maximum and optimal skin protection.
poorly. A number of adverse events were also noted
within the context of these studies. Haywood and
Monk reported scarring and hypopigmentation in one
patient treated with 7 J/cm2 using a 7 mm spot.8 Intense Pulsed Light
In another study, Meijs and coworkers reported
hypopigmentation in 6 out of 8 patients treated with Poikiloderma of Civatte treatment should always address
variable fluencies ranging between 3.5 and 7 J/cm2 both components, namely the pigmented and vascular
using 7 and 10 mm spot sizes. They concluded that lesions at the same time. As mentioned above, many
lower fluencies produce less adverse events. Table 7.2 treatments had been used without reaching an optimal
shows a summary of some of the documented studies treatment effect and with variable degrees of lesion
on PDL treatment of PC. Despite the side effects, PDL clearance. One of the modalities applied is IPL.17
remains a very safe, effective, and efficient modality IPL is a broad spectrum, noncoherent, laser-like
for the treatment of PC.10 device that uses a flash lamp to produce a light source
Despite the excellent response derived from using in a broad wavelength spectrum of 515–1200 nm. The
PDL in PC, care should be taken when using it on pulse duration, number of pulses, delay between pulses
50 M.L. Elsaie et al.
and fluencies can all be adjusted and varied according neck whom were treated with various IPL settings until
to the requirements. This flexible property allows IPL the desired improvement occurred. They reported an
to be used for different skin types with different skin efficacy of 50–75% after an average of 2.8 treatments
conditions and for many indications such as vascular and only with an incidence of 5% complications.13 A
lesions, pigmented lesion removal, and photoepilation. summary of major studies utilizing IPL as a source of
Owing to its nature and its ability with a wide broad PC treatment is summarized in Table 7.3. Given the
band wavelength spectrum to target both pigmented wide range of potential wave lengths and pulse dura-
and vascular lesions, IPL as a source had been used to tions, it is very reliable to use the IPL devices for treat-
target lesions of PC. IPL utilizes the theory of selective ment of PC minimizing the side effects and the risk of
photothermolysis and targets both chromophores, oxy- scarring and downtime. Caution should be taken into
hemoglobin and melanin. The peaks of oxyhemoglo- consideration when treating darker skin for the risk of
bin absorption are at 418, 542, and 577 nm, whereas atrophy or depigmentation. Test spots using lower flu-
melanin absorbs light in the entire UV radiation to near encies are advisable before engaging in treatment
infrared spectral range. For PC, the choice of cut-off protocol.
filter to be used depends on the pigmentary and the
vascular components of the lesion.17
More than one major study had targeted the lesions Alternative Treatment of Poikiloderma
of PC with IPL devices, and their results showed an of Civatte
overall good response with varying degree of improve-
ments. Both the vascular and pigmentary changes of Offering a therapeutic venue for the treatment of PC
Poikiloderma were targeted. Weiss and coworkers12 is a difficult task. Poikiloderma represents a dermato-
reported earlier a 5-year experience with IPL in the logical condition that represents a cosmetic inconve-
treatment of PC of the neck and chest in 135 patients. nience to patients whom often seeks medical attention
They reported a significant improvement of 82%, mak- for the removal of the erythematous and pigmented
ing the IPL source an effective therapeutic option for components of the lesions. Self-consciousness about
PC and allowing a marked improvement of vascular the lesions can produce a state of social withdrawal
and pigmented lesions with minimal side effects. They and loss of confidence. Moreover, a number of
used parameters starting with a 515 nm cut-off filter patients experience other symptoms such as burning
and a fluence of 20–24 J/cm2 delivered in a single or or itching that must be considered within the scope of
double pulse duration of 2–4 msec, and using 550 or treatment.
570 nm cut-off filters for treatment of larger and deeper Many remedies were utilized to treat mostly the
telangiectasias. The side effects included pain, ery- cosmetic part associated with PC, but they were
thema, purpura, crusting, and hypopigmentation. The proved to be ineffective and inefficient in improving
incidence of purpura and hypopigmentation is 5%. the condition. No specific treatment exists for
Another major study by Goldman and coworkers achieving an optimal result in PC, but there are
included 66 patients with typical changes of PC on the various treatment modalities with variables outcomes.
Table 7.3 A summary of major studies utilizing IPL as a source of PC treatment

Study (number of patients) Parameters used Efficacy Side effects
Weiss et al. 2000 (135) 12
515, 550, 570 nm filters, pulse 82% 5% in terms of purpura, and
duration of 2–4 msec hypopigmentation
Goldman et al. 2001 (66)13 515 nm filter, 2–4 msec pulse 50–75% after an average 5% incidence of purpura,
duration separated by 10 msec of 2.8 treatments erythema, and
delay hypopigmentation
Rusciani et al. 2007 (175)17 550 nm cut-off filter, 2.5–3.5 msec 84% efficacy with Minimal transient effects in 5%
pulse duration with a delay of 75–100% of lesions of patients with no
10–20 msec, fluence ranging completely cleared hypopigmentation
between 32–36 J/cm2
7 Treatment of Poikiloderma by Pigment and Vascular Lasers 51
Bleaching treatments using hydroquinone, electro References

coagulation, cryotherapy, retinoids, and chemical peels
were all used despite of having poor results. 1. Graham R. What is Poikiloderma of Civatte? Practitioner.
1989;233:1210.
2. Katoulis AC, Stavrianeas NG, Georgala S, et al. Poikiloderma
Conclusion of Civatte: a clinical and epidemiological study. J Eur Acad
Dermatol Venereol. 2005;19:444.
3. Katoulis AC, Stavrianeas NG, Georgala S, et al. Familial
In summary, PC remains a condition that has no spe- cases of Poikiloderma of Civatte: genetic implications in its
cific cause, despite its vast association with a number pathogenesis? Clin Exp Dermatol. 1999;24:385-387.
4. Katoulis AC, Stavrianeas NG, Katsarou A, et al. Evaluation
of factors. Discoveries in the field of genetics raised
of the role of contact sensitization and photosensitivity in the
the possibility of the linkage between PC and a geneti- pathogenesis of Poikiloderma of Civatte. Br J Dermatol.
cally transmitted autosomal dominant trait. No single 2002;147:493-497.
effective treatment has yet been devised for the condi- 5. Goldman MP, Fitzpatrick RE. Laser treatment of vascular
lesions. In: Goldman MP, Fitzpatrick RE, eds. Cutaneous
tion despite the fact that a number of different treat-
laser surgery. St Louis: Mosby; 1999:19-178.
ments have been used. Electrocautery, cryotherapy, 6. Batta K, Hindson C, Cotterill JA, et al. Treatment of
bleaching agents, and chemical peels were all offered Poikiloderma of Civatte with the potassium titanyl phos-
as a therapeutic modality, but many resulted in adverse phate (KTP) laser. Br J Dermatol. 1999;140:1191-1192.
7. Wheeland RG, Applebaum J. Flashlamp-pumped pulsed dye
events, making them not the best choice to target PC.
laser therapy for Poikiloderma of Civatte. J Dermatol Surg
Lasers targeting the vascular and pigmentary compo- Oncol. 1990;16:12-16.
nents of the condition by using selective photothermo- 8. Haywood RM, Monk BE. Treatment of Poikiloderma of
lysis properties are the best choice for treatment despite Civatte with the pulsed dye laser: a series of seven cases.
J Cutan Laser Ther. 1999;1:45-48.
the variability of the results with the different treat-
9. Clark RE, Jimenez-Acosta F. Poikiloderma of Civatte.
ment guidelines. The blue–green argon laser was the Resolution after treatment with the pulsed dye laser. NC
first system used for treating PC, and although offered Med J. 1994;55:234-235.
some improvement, it had a significant scarring effect. 10. Meijs M, Blok F, de Rie M. Treatment of Poikiloderma of
Civatte with the pulsed dye laser: a series of patients with
Afterwards, KTP lasers served as a better choice but
severe depigmentation. J Eur Acad Dermatol Venereol.
hypopigmentation, especially with darker skin types, 2006;20:1248-1251.
remained a problem. Pulsed dye lasers emitting 585– 11. Raulin C, Greve B, Grema H. IPL technology: a review.
595 nm produced even a more pronounced effect and Lasers Surg Med. 2003;32:78-87.
12. Weiss RA, Goldmann MP, Weiss MA. Treatment of
significant clearance of the lesions, targeting mainly
Poikiloderma of Civatte with an intense pulsed light source.
oxyhemoglobin as a main chromophore, but still tar- Dermatol Surg. 2000;26:283-828.
geting melanin as a part of its absorption spectrum. 13. Goldman MP, Weiss RA. Treatment of Poikiloderma of
PDL produces posttreatment purpura which might Civatte on the neck with an intense pulsed light source. Plast
Reconstr Surg. 2001;107:1376-1381.
withstand for several days.
14. Anderson RR, Parrish JA. Selective photothermolysis: pre-
Although no single guideline is available, a test spot cise microsurgery by selective absorption of pulsed radia-
using lower fluence is advised before treatment for a tion. Science. 1983;220:524.
more optimal and safer response. IPL with a broad wave 15. Sahoo B, Kumar B. Role of mehylchloroisothiazolinone/
methylisothiazolinone (Kathon® CG) in Poikiloderma of
length spectrum of 515–1200 nm has most recently
Civatte. Contact Dermatitis. 2001;44:249.
been successfully utilized for the treatment of PC despite 16. Lee TY, Lam TH. Allergic contact dermatitis due to Kathon
some of the side effects, which were noted in the form CG in Hong Kong. Contact Dermatitis. 1999;41:41-42.
of purpura, erythema, and crustation. Fractional photo- 17. Rusciani A, Motta A, Fino P, et al. Treatment of poikilo-
derma of Civatte using intense pulsed light source: 7 years
thermolysis is the latest of all laser advances described
of experience. Dermatol Surg. 2008;34(3):314-319.
in the management of PC. Paucity of data regarding 18. Behroozan DS, Goldberg LH, Glaich AS, et al. Fractional
Fraxel necessitates further studying and researching in photothermolysis for treatment of Poikiloderma of Civatte.
order to analyze optimization of the technique for safer Dermatol Surg. 2006;32(2):298-301.
19. Goldberg DJ. Laser treatment for vascular lesions. Clinics in
and more effective results. Above all appropriate dis-
plast surg. 2000;27:173-180.
cussion of risks, benefits, and patients’ expectations are 20. Goldman L, Bauman WE. Laser test treatment for postsolar
essential in treating the targeted population. poikiolderma. Arch Dermatol. 1984;120:578-579.
Part II
Back and Chest
Chapter 8
Treatment of Truncal Acne Scarring
Emmy M. Graber and Kenneth A. Arndt
Introduction treatments are best utilized for scattered individual scars,

while other treatments may be needed for widespread
scars. It is also important to identify the acne scar mor-
Acne vulgaris is a common condition with a lifetime
phology, as different treatment modalities are preferable
incidence of over 80%. Acne scarring is an unfortu-
for particular types of scars. Previous use of isotretinoin
nate, yet, frequent sequela of acne. Any type of acnei-
should be known, since recent use of isotretinoin (within
form lesion, including comedones, papules, pustules,
the last year) may preclude some procedures due to the
or nodulocystic lesions, may result in scarring.
potential increased risk of scarring.
Although it is impossible to pinpoint exactly which
Facial acne scars have been classified into three primary
patients with acne will develop scarring, there are
morphologic types: icepick, boxcar, and rolling scars.
some factors that put a patient at higher risk. Acneiform
While these scar morphologies can also be seen on the
lesions that have been manipulated are more likely to
trunk, acne scars on the chest and back are usually either:
result in scarring. Truncal acne scarring is more com-
(1) hypertrophic/keloidal (Figs. 8.3–8.5), or (2) atrophic
mon in males than females, and Asian and Black
(Figs. 8.6 and 8.7). Some therapies may be directed to
patients are especially prone to keloidal scarring. More
both types of scarring, while other therapies are specific
severe acne and especially acne conglobata, (Fig. 8.1)
to either hypertrophic/keloidal scars or atrophic scars.
has a higher risk of leading to scarring.
Several factors may predispose a patient to acne
scarring. Prolonged angiogenesis is seen in lesions that
proceed to scarring compared to lesions that resolve
Therapeutic Considerations
without scarring. An excess of metalloproteinases, such and Applications
as collagenases, may also play a role in scar formation.1
One study showed that nonscarring patients developed The best treatment for scars on the trunk is prevention.
peak inflammation 48 h after an acneiform lesion had Patients who delay starting antiacne medications for at
arisen. Patients with acne scars developed an inflamma- least 3 years from acne onset, have a greater degree of
tory response later in the acne lesion’s evolution and the scarring than those who start acne treatment earlier.3
inflammation was slower to resolve2 (Fig. 8.2). Isotretinoin therapy is the only proven cure of acne and
should be instituted early in the course of severe acne
in order to prevent scarring.
Patient History and Clinical Examination
Evaluation of a patient with truncal acne scarring Excision

requires consideration of several issues. The age of the
scars should be determined since scars continue to If scarring does occur, either type of acne scars on the
evolve over 12 months and some treatment modalities trunk may be treated by surgical excision. Given the
(such as the pulsed dye laser) work best for newer scars. high tension of the truncal skin, patients should be
The distribution of the scars should be noted as certain warned of the high likelihood that the surgical scar

56 E.M. Graber and K.A. Arndt
Fig. 8.1 Acne conglobata on the

chest of a male patient
Fig. 8.2 Non-scarrers tend to have an earlier inflammatory

response than acne patients that scar. (From: Holland DB et al
Inflammation in acne scarring: a comparison of the responses in
lesions from patients prone and not prone to scar. Br J Dermatol.
2004;150:72-81)
Fig. 8.3 Hypertrophic and keloidal acne scars
might expand or become hypertrophic, resulting in a to the original scar. If a hypertrophic scar is excised,
sub-optimal cosmetic outcome. Surgical excision should ionizing radiotherapy administered within 24–48 h may
be contemplated on the trunk only when the surgeon inhibit fibroblast proliferation and prevent recurrence of
thinks that the replacement scar will be preferable the hypertrophic scar.4
8 Treatment of Truncal Acne Scarring 57
Fig. 8.6 Atrophic scars

Fig. 8.4 Hypertrophic scar. Note the well-circumscribed nodular
morphology and marked collagen deposition
pulsed dye laser to lessen scar erythema was first
recognized in 1993. Alster and colleagues demon-
strated a reduction in scar erythema as well as the
return of normal skin markings and flattening of ele-
vated scars.5 Several studies thereafter have confirmed
these results and also demonstrated that increasing
benefit can be seen with multiple treatments. The
pulsed dye laser’s exact mechanism of action for scar
improvement is not known, but is most likely multifac-
torial. Damaging the microvasculature may cause
ischemia and collagen degradation, thereby, clinically
lessening erythema and flattening scars. Thermal
damage may also cause dissolution of collagen by
Fig. 8.5 Keloid. This type of scar differs from a hypertrophic breaking down collagen disulfide bonds. Other studies
scar in that the scarring extends beyond the site of initial injury. have demonstrated that use of the pulsed dye laser on
Histologically, it is characterized by broad, haphazard bundles atrophic scars can actually induce collagen formation
of eosinophilic collagen
and elevate these depressed scars.6 It is hypothesized
that inflammation that follows microvascular damage
Pulsed Dye Laser may trigger fibroblast activity and lead to new collagen
formation.7 When using the pulsed dye laser (595 nm,
Both atrophic and hypertrophic/keloidal scars may Vbeam, Candela, Wayland, MA) for scars, purpuric
have a red color, especially early in their evolution, due settings should be utilized by delivering energy
to microvasculature in the scar. The use of the 585 nm (6–7.5 mJ/cm2) over a short pulse duration (1.5–6 ms)
58 E.M. Graber and K.A. Arndt
with good short-term results (personal communica-

tion). Although there are no studies currently available
to demonstrate this, fractionated ablative CO2 and
erbium technologies may have a future role in treating
truncal acne scarring.
Semi-ablative Lasers
Nonablative systems, such as the fractionated 1,550 nm

erbium-doped fiber laser (Fraxel, Solta Medical, Inc.
Hayward, CA), can be safely used off the face. The
Fraxel laser induces collagenesis underneath atrophic
scars. Multiple treatments (at least four) are needed to
treat atrophic scars, and patients are counseled that
about 50% improvement in scars can be seen after sev-
eral treatments. We usually start treating at 40 mJ with
a treatment density level of 6 (20% coverage) and over
several treatments increase to 70 mJ at a density of
8 (26% coverage). Fractional resurfacing has been
used to improve the clinical appearance of hypertro-
phic scars. However, an adverse event of this treatment
is hypertrophic scarring, particularly when used off the
Fig. 8.7 Histopathology of atrophic scars demonstrating dimin- face.8
ished collagen and elastic fibers
to have the greatest efficacy. Multiple (4–8) treatments

at 4–6 week intervals are needed to maximize the Nonablative Lasers
benefits of the pulsed dye laser.
Other nonablative lasers in the infrared range, such as
1,320 nm (CoolTouch, Cool Touch Corp., Roseville,
CA), 1,450 nm (Smoothbeam, Candela, Wayland, MA),
Ablative Lasers and 1,540 nm (Aramis, Quantel Medical, France), also
can help to improve atrophic scars. These lasers work
The use of ablative lasers for improving acne scarring by causing thermal injury in the dermis while sparring
on the trunk is limited. Ablative systems (such as the the epidermis with cooling. The infrared lasers are
CO2 and erbium:YAG) that are helpful in improving absorbed by dermal water, and the scattering of thermal
acne scars on the face are not suitable for use on the energy damages dermal collagen, incites an inflamma-
chest and back. The lack of adnexal skin appendages tory response that activates fibroblasts and stimulates
on the trunk makes ablative treatments unlikely to re- collagen remodeling.9 Multiple treatments are needed
epithelialize. However, new fractional ablative tech- to elevate facial atrophic scars with these laser treat-
nologies, such as ActiveFX (10,600 nm CO2 laser, ments. In our opinion, these devices have minimal effi-
Lumenis, Santa Clara, CA), Fraxel re:pair (10,600 nm cacy for acne scars on the trunk. With the exception of
CO2 laser, Solta Medical, Inc. Hayward, CA), and the the 1,540 nm laser (Aramis), the utility of these devices
ProFractional (2,940 nm Erbium laser, Sciton, Palo is limited due to patient discomfort during the proce-
Alto, CA), are being used by some to treat truncal acne dure. The Aramis delivers a series of stacked micro-
scarring without prolonged healing. The Fraxel re:pair pulses (one to four micropulses) with each micropulse
has been used at 35–50% coverage at 50–70 mJ/cm2 delivering 10–12 J/cm2.
8 Treatment of Truncal Acne Scarring 59
Intralesional Corticosteroids permanently due to the formation of collagen around

silicone microdroplets. Silicone should be placed into
Individual hypertrophic and keloidal scars may be each scar using multiple injection points and adminis-
treated with intralesional corticosteroids to soften and tering very small amounts of silicone with each injec-
shrink scars as well as to decrease associated pruritus. tion (0.01–0.02 cc per puncture). Other injectable
Multiple treatments of intralesional triamcinolone ace- materials, such as calcium hydroxyappetite, poly-L
tonide in concentrations ranging from 2.5 to 20 mg/mL lactic acid, and polymethylmethacrylate, may yield
are needed depending on the thickness of the scar. more permanent results, but with the risk of an uneven
To reduce patient discomfort, we use the smallest texture due to granuloma formation.
gauge needle (27G–30G) possible without getting cor-
ticosteroid blockage. A Luer lock syringe is safest to
prevent a clogged needle from dislodging from the Conclusion
syringe. One-inch needles are preferable to ½ in. nee-
dles to minimize needle sticks. Concomitant adminis-
tration of intralesional corticosteroids and pulsed dye Due to the location and widespread distribution of
laser treatment has been shown to have greater resolu- truncal acne scarring, treatment options are more lim-
tion of scars than pulsed dye laser treatment alone.10 ited than for facial acne scarring. Similar to many dis-
Intralesional steroid injection tends to be easier and ease states, the best treatment is prevention. Early
less painful when administered after pulsed dye laser control of acne, especially severe nodulocystic acne,
therapy than prior to laser therapy (personal observa- can prevent permanent sequela. There is currently no
tion). This may be due to laser-induced edema that treatment for truncal acne scarring that will give per-
lessens the resistance of the injection. fect results. Therapies that are helpful require multiple
treatment sessions. Often, using more than one therapy
in combination can optimize results.
Fillers
References
Individual atrophic scars can be improved by elevating
the depression with a filler substance. This may not be 1. Goodman GJ, Baron JA. The management of postacne
a realistic approach in a patient who has copious con- scarring. Dermatol Surg. 2007;33(10):1175-1188.
fluent atrophic scars, but better suited for a patient with 2. Holland DB, Jeremy AH. The role of inflammation in the
pathogenesis of acne and acne scarring. Semin Cutan Med
fewer individual well-demarcated atrophic scars. Scars Surg. 2005;24(2):79-83
may be augmented with substances of varying dura- 3. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation
tion. Some short-lived fillers, such as the collagens of acne scarring and its incidence. Med Exp Dermatol. 1994;
(Zyderm, Zyplast, Cosmoderm, and Cosmoplast, 19:303-308.
4. Decker RH, Wilson LD. Effect of radiation on wound healing
Inamed Aesthetics, Santa Barbara, CA), will only last and the treatment of scarring. In: Arndt KA, ed. Scar Revision.
for 3–4 months. Although the longevity of collagen Amsterdam: Elsevier Saunders; 2006:89-104.
augmentation is limited, it may be beneficial for 5. Alster TS, et al. Alteration of argon laser-induced scars by
patients who want to undergo a non-permanent trial the pulsed dye laser. Lasers Surg Med. 1993;13(3):368-373.
6. Patel N, Clement M. Selective nonablative treatment of acne
before embarking on a more permanent substance. The scarring with 585 nm flashlamp pulsed dye laser. Dermatol
most commonly used fillers for atrophic scars are those Surg. 2002;28(10):942-945; discussion 945.
with a somewhat longer lifespan. Hyaluronic acid fill- 7. Bjerring P, Clement M, Heickendorff L. Selective non-ablative
ers (Restylane, Medicis, Scottsdale, AZ; and Juvederm, wrinkle reduction by laser. J Cutan Laser Ther. 2000;2:9-15.
8. Avram MM, Tope WD, Yu T, Szachowicz E, Nelson JS.
Inamed Aesthetics) last about 6 months when injected Hypertrophic scarring of the neck following ablative fractional
into rhytides. When injected into atrophic scars, carbon dioxide laser resurfacing. Lasers Surg Med. 2009;41:
hyaluronic acid has been observed to last significantly 185-188.
longer than in non-scarred skin (personal observation). 9. Lupton JR, Williams CM, Alster TS. Nonablative laser skin
resurfacing using a 1,540 nm erbium glass laser: a clinical and
Other substances can be used to augment scars and last histologic analysis. Dermatol Surg. 2002;28(9):833-835.
years or even indefinitely. Liquid silicone (Silikon, 10. Goldman MP, Fitzpatrick RE. Laser treatment of scars.
Alcon Labs, Fort Worth, TX, USA) fills atrophic scars [see comment]. Dermatol Surg. 1995;21(8):685-687.
Chapter 9
Truncal Hair Removal
David J. Goldberg
Introduction Excess hair can be classified as either hypertrichosis

or hirsutism. Hypertrichosis occurs in all genders and
may be present at any body site. It can be further sub-
Excess or unwanted hair is a common problem
divided into acquired and congenital as well as local-
affecting both genders. Over time, this problem has
ized and generalized forms.
been dealt with in various ways, including plucking,
Hirsutism is the presence of excess terminal hairs in
threading, shaving, waxing, and electrolysis. Although
women in androgen-dependent locations, most com-
effective for short-term control of hair growth, most of
monly on the face. Excess endogenous androgen may
these methods are associated with significant pain and
be released either by the ovaries or the adrenal glands,
prolonged treatment times, making them fairly imprac-
most commonly in the setting of polycystic ovarian
tical for larger areas such as the human trunk.
syndrome, congenital adrenal hyperplasia, or adrenal
tumors. Exogenous androgens may also cause this con-
dition, whereas most other medications cause hyper-
Clinical Examination trichosis rather than hirsutism. Genetic predisposition
may also play a role, as some ethnic groups have rela-
The majority of laser procedures aimed at truncal hair tively more facial hair than others. Excess truncal hair
removal in both genders are not performed for medi- may be seen with both hypertrichosis and hirsuitism.
cally excessive hair growth but rather for unwanted Generally, three types of hair are recognized: lanugo,
hair. Patient preferences may be influenced by social vellus, and terminal. Lanugo is fetal-type soft, fine hair.
or personal perceptions of normal hair distribution and Vellus hairs are nonpigmented, superficially located, and
density. Thus, a clear understanding of the patient’s are typically under 30 mm in cross-sectional diameter.
specific expectations and of the actual capabilities of Terminal hairs are usually thicker than 40 mm, but may
laser hair removal is a must for anyone undertaking vary widely in their thickness, depending on the size of
such procedures. the hair bulb.2
Anatomically, a terminal hair follicle can be subdi-
vided into the inferior segment, the isthmus, and the
infundibulum. The inferior segment extends from the
Treatment Application deepest portion of the hair follicle to the bulge and
contains the hair bulb with germinative matrix cells
First introduced in the mid-1990s, laser hair removal and melanocytes. It also envelops dermal papilla, a
has become an accepted treatment modality for patients highly vascularized connective tissue. The isthmus
seeking to reduce unwanted hair and has been found to includes the portion of the hair follicle from the bulge,
improve quality of life for many patients.1 Lasers cur- where the arrector pili muscle attaches, to the opening
rently in use for hair removal include the normal-mode of the sebaceous duct. The infundibulum then extends
ruby, normal-mode alexandrite, diode, and neodym- from the sebaceous duct opening to the surface of the
ium: yttrium-aluminum-garnet (Nd:YAG) lasers as epidermis. Of note, hair follicles are angled so that the
well as intense pulsed light devices. bulge lies on the deeper aspect of the follicle.

62 D.J. Goldberg
From the outside in, a hair follicle is composed of process in hair removal, appears to be regulated by
the outer root sheath, the inner root sheath, and the hair changes in the expression of multiple growth factors,
shaft, with further subdivisions within each structure. such as transforming growth factor-beta 2 and fibro-
The inner root sheath provides a rigid support for the blast growth factor 5.
growing hair shaft and disintegrates above the level of During catagen, controlled involution results from
the bulge in the isthmus. The slippage plane between massive apoptosis of follicular epithelial cells in the
thus encased hair shaft and the remainder of the hair inferior segment. By the end of this phase, the dermal
follicle is at the companion layer of the outer root papilla condenses and moves up to the level of the
sheath.i In its turn, the outer root sheath becomes con- bulge, while the involuting epithelial column is reduced
tinuous with the epidermis at the level of the infundibu- to a secondary germ. This is accompanied by cessation
lum. In addition to epithelial cells, the outer root sheath of melanin production and apoptosis of some follicular
contains melanocytes, Langerhans’ cells, mast cells, melanocytes, eventually resulting in depigmented club
Merkel cells, and neuronal stem cells, all of which hairs during telogen. Telogen is characterized by rela-
function within the hair follicle itself and may serve as tive proliferative rest. The mechanism of transition
a reservoir for repopulation of epidermis following back to the active anagen phase is not completely
injury. worked out, but likely involves interactions between
Hair undergoes asynchronous cycling between peri- the secondary germ, the bulge, dermal papilla, and
ods of active synthesis (anagen), regression (catagen), various signal molecules.
rest (telogen), and shedding (exogen). Hair shaft The duration of anagen determines the length of the
growth and pigmentation takes place only during ana- hair shaft. Catagen phase is relatively constant through-
gen, which starts with the secondary hair germ at the out different locations and usually lasts around 3 weeks.
level of the bulge, about 1.5 mm below the surface of On the other hand, telogen and, especially, anagen
the skin. As the anagen phase continues, the hair bulb phases vary significantly between different body sites
moves deeper into the dermis and reaches its deepest (Tables 9.1 and 9.2).3 As will be discussed below, this
position within the subcutaneous fat, about 2–7 mm may have potential implications not only for optimal
below the surface of the skin, depending on the location. frequency of laser treatments, but also for determination
Transition from anagen to catagen, an important of permanency of laser hair removal at a given site.
Table 9.1 Hair cycle based on anatomic location Duration of Duration of % of hair

Body site anagen (months) telogen (months) in telogen
Scalp 48–72 3–4 10–15
Eyebrows 1–2 3–4 85–94
Moustache 2–5 1.5 34
Beard 12 2–3 15–20
Axillae 3–6 3–6 31–79
Arms 1–3 2–4 72–86
Pubic area 3–6 0.5 65–81
Thighs 1–2 2–3 64–83
Lower legs 4–6 3–6 62–88
Table 9.2 Example of treatment parameters

Skin type Device Setting parameters
I–III LightSheer Diode 800 nm (Lumenis, Inc., Santa Clara, 30 J/cm2 12 mm spot size, 15 ms pulses with contact
CA) cooling
GentleLase Alexandrite 755 nm (Candela, Corp., 20 J/cm2 18 mm spot size, 3 ms pulses with cryogen
Wayland, MA) cooling
IV–VI GentleYAG 1,064 nm (Candela, Corp., Wayland, MA) 20 J/cm2 18 mm spot size, 10 ms pulses with cryogen
cooling
CoolGlide Nd:YAG 1,064 nm (Cutera Inc., 30 J/cm2 10 mm spot, 20 ms pulses with contact
Brisbane, CA) cooling
9 Truncal Hair Removal 63
The duration of anagen and telogen truncal hair need to understand that the purpose of treatment is to
cycles are not known. However, since the clinical thin the hair while decreasing the amount of hair in
response to treatment is much like that of the arms and the treated sites. Younger treated males must also
thighs, it can be assumed that the cycles are similar to understand that they will continue to grow “new” hairs
those seen in these two areas. for decades. Thus periodic re-treatments will be
Precise timing of treatments is also not certain. It is required. Most males seeking truncal hair removal
assumed that early anagen may be more amenable to simply have excess hair without any underlying
damage by laser beam.4 As discussed above, the hair medical cause.
bulb is located superficially during this stage, allowing Women seeking truncal hair removal may have
for adequate light penetration. Telogen hair is also hypertrichosis. However, more commonly they seek
superficial; however, the proximal hair shaft is depig- truncal hair removal based on hirsutism, with underly-
mented and hence does not absorb laser energy well. ing polycystic ovarian syndrome being a possible
On the other hand, fat is a better thermal insulator than cause. As is the case, in general, thicker terminal hairs
collagen, so that damage to a hair bulb located in the most readily respond. However, deep seated areolar
subcutaneous tissue would be better confined to the hairs in women can be resistant to treatment. Treatment
hair follicle. Additionally, human hair cycles are not of underlying hormonal issues will only help the laser
synchronized, which further complicates studies on hair removal results.
the influence of hair cycle on laser hair removal. Truncal hair removal is not an uncommon desire of
Consequently, results have been contradictory. both men and women. Today’s technology can lead to
Attempts to correlate effective hair removal with tar- dramatic results in realistic patients (Figs. 9.1–9.4).
geting anagen hairs have, in general, failed. Further
research in this area is needed; in the meantime, most
laser sessions for hair removal are currently carried out
in 4- to 8-week intervals, with small, if any, regard as
to the body site. There is, however, an apparent differ-
ence in response to laser treatment based on location.
The upper lip, chin, scalp, and back are generally asso-
ciated with weakest response, whereas the remainder
of the face, chest, back legs, and axillae typically dem-
onstrate higher clearance rates.
Most published studies with any laser hair removal
systems do not distinguish response rates between dif-
ferent anatomic areas. One study of nonfacial skin,
such as the trunk, did show a somewhat better clear-
ance rate compared to facial sites when treated with a
long-pulsed Nd:YAG laser.5 Conversely, paradoxical
hypertrichosis, a rare complication of laser hair
removal, has also been reported on the trunk after alex-
andrite laser hair removal.
Conclusion
In general, the goals of truncal laser hair removal must

be realistic. It is rare to see 100% total clearance of all Fig. 9.1 Female with excess truncal hair. An excellent candidate
treated hairs in this area. In general, male patients for laser hair removal
64 D.J. Goldberg
Fig. 9.2 Male with excess truncal hair. An excellent

candidate for laser hair removal
Fig. 9.3 Male with unwanted back hair before treatment
Fig. 9.4 Male with unwanted back hair after five laser hair
removal treatments
References 3. Olsen EA. Methods of hair removal. J Am Acad Dermatol.

1999;40:143-155.
4. Dierickx C, Alora MB, Dover JS. A clinical overview of hair
1. Loo WJ, Lanigan SW. Laser treatment improves quality of life removal using lasers and light sources. Dermatol Clin.
of hirsute females. Clin Exp Dermatol. 2002;27:439-441. 1999;17:357-366.
2. Headington JT. Transverse microscopic anatomy of the human 5. Alster TS, Bryan H, Williams CM. Long-pulsed Nd:YAG
scalp: a basis for a morphometric approach to disorders of the laser-assisted hair removal in pigmented skin: a clinical and
hair follicle. Arch Dermatol. 1984;120:449-456. histological evaluation. Arch Dermatol. 2001;137:885-889.
Chapter 10
Revision of Disfiguring Surgical Scars of the Back
Matthew J. Mahlberg, Julie K. Karen, and Vicki J. Levine
Introduction result in functional impairment (i.e., due to restricted

range of motion). Both keloids and hypertrophic scars
Surgical procedures are performed on the back for a occur with greater frequency on the trunk and com-
variety of reasons and universally result in some degree monly result in significant cosmetic disfigurement
of scar formation. Optimally, these scars would result (Fig. 10.4).
in a barely-perceptible, fine line that blends naturally with Because a wide variety of surgical procedures are
the color and texture of adjacent skin. Unfortunately, performed on the back, disfiguring scars in this loca-
an optimal scar is rarely the end result, and a patient tion are not uncommon. Biopsies or excisions of
can be left with a scar that is deemed disfiguring. dysplastic nevi, cysts, and malignant lesions represent
A disfiguring scar is one which has an appearance a large proportion of these procedures, especially in
outside the accepted norm and which is deemed younger persons for whom the back may be a cosmeti-
unsatisfactory by the patient and/or physician. cally sensitive area (Fig. 10.5). Thus, an appreciation
A variety of factors may contribute to the develop- of both prevention and correction of disfiguring scars
ment of an unfavorable surgical scar on the back. Final on the back by the dermatologist is critical. Furthermore,
scar cosmesis depends on many factors, including patients should be counseled about the likelihood of
lesional dimensions and location, surgical technique, scarring prior to any procedure being performed in this
suturing materials, wound tension, and patient ethnic- location.
ity. Suboptimal repair of the original surgical site is
sometimes the culprit, although imperfect scars on
the back plague even the most seasoned surgeons.
Inadequate wound edge eversion may result in a Clinical Examination and Patient History
depressed scar while insufficient undermining or
improper design may lead to closure under excessive The approach to the correction of the disfiguring scar
tension and consequent scar spread (Fig. 10.1). involves several components. First, assessment of the
Infection, hematoma, dehiscence, and other postopera- patient’s concerns should be considered: are there
tive complications can also contribute to suboptimal functional limitations due to the scar or is the concern
results. Of particular importance, the inherent ana- primarily cosmetic and does the patient hope to change
tomic features of the back contribute to an increased the color, contour, size, or orientation with a corrective
propensity to develop a widened (or spread) scar. For procedure? As with all cosmetic procedures, clarifying
example, physical stress due to constant movement of the patient’s objectives is imperative in deeming the
the arms, torso, and even secondary to respiration is procedure a success. Secondly, the clinician’s clinical
thought to result in shearing and opposing forces across history and examination can help to assess the factors
a wound leading to scar spread.1 Finally, the intrinsic contributing to the disfiguring scar. Exclusion of resid-
aspects of wound healing can occur abnormally, result- ual disease, infection, or neoplasia is necessary.
ing in keloidal or hypertrophic scar formation (Figs. 10.2 Duration since the prior surgical procedure should be
and 10.3). These lesions may be painful or pruritic or determined as surgical scars will continue to remodel

66 M.J. Mahlberg et al.
Fig. 10.1 Spread scar at site of prior excision
Fig. 10.4 Scar exhibiting features of spread and hypertrophy on

upper back after excision of malignant melanoma
Fig. 10.2 Keloid scar at site of prior excision
Fig. 10.5 Atrophic scar after deep shave biopsy of dysplastic

nevus
for several months after surgery and premature correction

may be unnecessary. Also, assessment of size, color,
and orientation of the scar should be performed (Table 1).
Fig. 10.3 Hypertrophic and erythematous scar Measurement of a scar’s length, width, height (or depth),
10 Revision of Disfiguring Surgical Scars of the Back 67
and orientation provides important information that Treatment Methods

will further guide management. For example, scars
<2 cm in length can often be improved through fusi-
The history and physical examination as gathered
form ellipse and reclosure alone. In cases where the
above should provide some direction in choosing
scar is oriented away from relaxed skin tension lines
appropriate treatment options (Fig. 10.6).
(RSTL), reorientation may be necessary. Further,
history guiding management includes color of the scar,
patient’s skin phototype, and whether or not the patient
is prone to keloid or hypertrophic scar formation. Topical Treatments
Finally, pre-procedural photographs may be taken, and
the patient should be given realistic expectations and
Topical therapies, including silicone sheeting, mas-
counseled regarding the difficulties of scar revision on
sage, and other topical creams, are most appropriate
this part of the body.
for early intervention when scar formation is less than
optimal. Creams containing such ingredients as
Table 10.1 Scar Characteristics Vitamin E, Vitamin A, and onion extract have long
1. Color been availed with having the ability to limit scar for-
- Red-violaceous
mation, but studies have found minimal benefit and in
- Hypopigmented
some cases the studies have found that the ingredients
2. Contour
- Depressed have caused harm. Topical retinoic acid has been used
- Spread with some success in treating keloids and hypertro-
- Elevated phic scars. Topical silicone gels, ointments, and sheet-
- Hypertrophic ing have demonstrated limited efficacy reducing the
- Keloid size, induration, erythema, and pruritus of pre-existing
3. Orientation hypertrophic scars. Additionally, in high risk patients,
- Along RSTL*
silicone sheeting applied shortly after reepithelia
- Not along RSTL*
4. Size lization has been shown to reduce the formation of
- Length hypertrophic scar formation. Similarly, polyurethane
- Width occlusive dressings may help to improve the appearance
*RSTL: Relaxed Skin Tension Line of mature hypertrophic scars or prevent the formation
Disfiguring Scar
on the Back
Hypertrophic Keloid Atrophic Scar Discolored Scar

Scar
• Silicone sheeting • Silicone sheeting • Fillers Red-violaceo us

• IL-TAC +/- 5-FU* • IL-TAC +/- 5-FU* • Fractional photothermolysis • Time (if immature)
• PDL* • PDL* • Ablative laser • PDL (early initiation)
• Surgical revision • Surgical revision • Surgical revision • Fractional photothermolysis
Hypopigmen ted
• Fr actional pho toth ermo lysis
* Consider comb inat ion th erap y IL-TAC – intralesional triamcinolone

PDL – pulse-dye laser
5-FU – 5-fluorouracil
Fig. 10.6 Revision Technique Algorithm

of new ones. When utilized, both silicone sheeting weekly initially, with the frequency reduced as scars
and polyurethane dressings should be applied under began to respond. Inflamed, indurated, erythematous,
occlusion, as a synergistic effect is likely.2 or otherwise symptomatic scars, as well as younger
Imiquimod 5% cream, an imidazoquinoline, is a scars, were most likely to respond favorably. Side
topical immunomodulator known to induce the syn- effects are generally limited to local pain or discom-
thesis of antifibrotic cytokines, IFN-alpha, and IFN- fort in all patients. Untoward effects commonly
gamma. The success of imiquimod 5% cream in attributed to intralesional corticosteroids (i.e., atro-
reducing earlobe keloid recurrences after excision is phy, telangiectasia, hypopigmentation, and rebound)
well documented and has raised interest in a possible do not occur with 5-FU.6 Treatment with the pulsed
role for this agent in the prevention of hypertrophic dye laser (see below) immediately prior to injection
scars on the trunk. The authors of a recent, prospec- may improve response rates, particularly in more ery-
tive, double-blinded, randomized, vehicle-controlled thematous scars.6 For atrophic scars, fillers such as
trial concluded that there was no benefit to the use of silicone, bovine collagen, hyaluronic acid, calcium
imiquimod 5% cream on healing surgical wounds hydroxylapatite, and fat (lipografting) can be used.7–9
with regard to the improvement of “normal” scar However, due to their high cost, use of these filling
cosmesis.3 However, a limited body of evidence agents has largely been limited to the management of
suggests a possible role for imiquimod 5% cream in atrophic scars in highly cosmetically sensitive regions
the prevention of presternal and breast hypertrophic such as the face.
scarring, although additional, larger studies with
longer follow-up are needed.4,5 There are currently
no studies specifically looking at the use of imiqui-
mod 5% cream in the treatment or prevention of Cryosurgery
disfiguring scars of the back.
Cryosurgery with liquid nitrogen has been success-
fully used to treat keloids and hypertrophic scars in
areas including the back. Lesions that are most likely
Intralesional Injections to respond include younger (<12 months), more vascu-
lar lesions. The therapeutic effects of cryosurgery are
Minimally invasive treatment options such as mediated by direct cellular and microvascular damage.
intralesional injections and fillers can be used for Several, monthly treatments, consisting of two to three
keloids and hypertrophic scars or depressed scars, 30-s freeze-thaw cycles are typically required.
respectively. Intralesional triamcinolone injections in Disadvantages include, but are not limited to, pain,
concentrations of 10–40 mg/mL administered approx- atrophy, and hypopigmentation, rendering this modal-
imately monthly over several months can have a ity of limited utility in dark-skinned patients. Irradiation
profound effect on scar height although they do not has demonstrated disappointing results when used as
affect the width. Higher concentrations can be used monotherapy for the treatment of keloids and hyper-
on the back than in other areas of the body, although trophic scars. However, when used as an adjunct to
as with other areas on the body, careful use is advised surgery, radiation therapy has achieved excellent scar
to minimize side effects of atrophy and hypopigmen- cosmesis with low recurrence rates.10
tation. Fitzpatrick reported the efficacy of intrale-
sional 5-FU in the treatment and prevention of keloids
and hypertrophic scars. In his experience in more
than 1,000 patients, maximal benefit and minimal Laser Treatments
pain were achieved when a combination of 0.9 cc of
5-FU (concentration of 50 mg/cc) and 0.1 cc of triam- Laser therapy has utility in cutaneous scar revision
cinolone (concentration of 10 mg/cc) was injected for hypertrophic scars, keloids, atrophic scars, and dis-
directly into the substance of the scar. In this report, colored scars although results are less impressive on
injections were performed as frequently as thrice the back. Limited long-term stability dampened initial
10 Revision of Disfiguring Surgical Scars of the Back 69
enthusiasm about the use of the argon, Nd:YAG, and tions. Since damage is restricted to noncontiguous
CO2 lasers. More recently, promising results have been microscopic arrays, obvious wounding is avoided,
achieved with the pulsed dye laser (PDL) (585–595 nm) epidermal recovery is rapid, and bulk heating does
and fractional photothermolysis. not occur, minimizing the potential for scar exacerba-
Pulsed dye lasers (PDL), specifically in the 585– tion. With fractional photothermolysis, more subtle
595 nm range, are generally considered the laser therapy improvements should be expected, but there is less
of choice for hypertrophic scars, keloids, and red- associated downtime and less risk of severe pigmen-
colored scars. Beneficial effects reported with PDL tary alteration than with ablative lasers. Significant
treatment include erythema reduction, textural improve- improvements in scar texture and blending can gener-
ment, and overall improved blending with surrounding ally be achieved with a series of 3–5 treatments at
skin. PDL therapy should be initiated with a spot size of approximately 3 week intervals. Newer devices achieve
7 or 10 mm with fluences of 5–6.5 J/cm2 or 4.5–5.5 J/ fractional photothermolysis utilizing ablative modali-
cm2, respectively. In patients with darker skin tones, ties. There are anecdotal reports of these devices effec-
additional fluence reduction may be necessary.11 Variable tively treating hypertrophic scars without the extended
pulse durations, ranging from 450 ms to 1.5 ms may be recovery time and other risks associated with conven-
employed, depending on the degree of post-treatment tional ablative resurfacing.
purpura likely to be tolerated by the patient. Concomitant Several caveats should be considered in laser scar
cryogen cooling should be applied during treatment. revision. Caution is advised when treating patients
Unfortunately, multiple treatments (at 3–8 week inter- with darker skin tones (Fitzpatrick phototypes IV–VI).
vals) are necessary, and complete resolution of scar Melanin present in these patients’ skin acts as a
erythema and/or thickness is not commonly achieved. competing chromophore, thereby decreasing efficacy
More recently, researchers have posited a role for and increasing the risk of untoward effects. These
PDL in the prevention of hypertrophic scar formation. patients should be counseled regarding the potential
Insofar as treatment with PDL may limit angiogenesis, for dyspigmentation and close monitoring of this
upon which scar formation may depend, early inter- adverse effect is prudent. In all patients, if laser therapy
vention may prevent or minimize scarring. Two studies is selected as a treatment option, patients should be
using three treatments with PDL, initiated at the time instructed to refrain from tanning for several weeks
of suture removal, demonstrated efficacy in the pre- prior to treatment. General techniques for laser ther-
vention of unfavorable scars.12,13 However, single treat- apy, such as using preprocedural anesthetics, are
ment of PDL at suture removal is not efficacious, nor equally applicable to laser use on the back for scar
is there increased efficacy with concomitant use of revision.
intralesional corticosteroids.14,15 In any case, in addi-
tion to its role in the treatment of disfiguring scars,
PDL may play a role in preventing disfiguring scars
and may be a useful adjuvant in surgical scar revision. Surgical Treatments
Although there are reports documenting the efficacy of
PDL as monotherapy, this modality is perhaps best uti- Surgical revision of disfiguring surgical scars is an
lized as one component of a multifaceted approach to option as on other parts of the body. However, because
suboptimal scars.6 the back is inherently prone to disfiguring scars,
The 308-nm excimer laser has some efficacies in aggressive surgical revisions should be approached
the treatment of hypopigmented disorders, including with caution and should be avoided if possible. For
vitiligo and mature striae. There may be a limited role very large procedures on the back, when complete and
for this laser in the treatment of hypopigmented scars immediate removal is not mandatory, a staged resec-
on the back. However, since results are short-lived, tion may be considered, as this will permit skin stretch
ongoing treatments must be continued to maintain and thereby lessen wound tension. Fusiform or ellipti-
repigmentation.16 cal excisions of scars can be useful when the scar is
Fractional photothermolysis is increasingly consid- small (preferably less than 2 cm) and when the scar is
ered a popular option for unfavorable scars in all loca- oriented along RSTL. Z-plasty repair may be useful
for correction of scars that are not already oriented References

along RSTLs. However, the thickness of the dermis on
the back may make the technique less favorable in that 1. McGillis ST, Lucas AR. Scar revision. Dermatol Clin.
location as it makes transposition of the triangular 1998;16:165-180.
flaps difficult. Techniques such as W-plasty and 2. Zurada JM, Kriegel D, Davis IC. Topical treatments for hyper-
trophic scars. J Am Acad Dermatol. 2006;55:1024-1031.
Geometric Broken Line Closure (GBLC) are also use-
3. Berman B, Frankel S, Villa AM, Ramirez CC, Poochareon
ful techniques elsewhere on the body for long scars V, Nouri K. Double-blind, randomized, placebo-controlled,
along RSTLs, which help to create a less conspicuous prospective study evaluating the tolerability and effectiveness
scar line. However, the necessary removal of skin in of imiquimod applied to postsurgical excisions on scar
cosmesis. Dermatol Surg. 2005;31:1399-1403.
these techniques increases the risk of scar tension and
4. Prado A, Andrades P, Benitez S, Umana M. Scar management
resultant spread in an area that is already under a great after breast surgery: preliminary results of a prospective,
deal of tension. Thus, these techniques should be randomized, and double-blind clinical study with aldara
avoided on the back. As discussed above, surgical clo- cream 5% (imiquimod). Plast Reconstr Surg. 2005;115:
966-972.
sure of primary wounds or revisions on the back require
5. Malhotra AK, Gupta S, Khaitan BK, Sharma VK. Imiquimod
great care for optimal cosmetic outcome. Adequate 5% cream for the prevention of recurrence after excision of
undermining with placement of buried vertical mat- presternal keloids. Dermatology. 2007;215:63-65.
tress sutures minimizes wound tension and helps to 6. Fitzpatrick RE. Treatment of inflamed hypertrophjic scars
using intralesional 5-FU. Derm Surg. 1999;25:224-232.
create proper wound eversion. Use of a running subcu-
7. Barnett JG, Barnett CR. Treatment of acne scars with
ticular suture is an option to avoid “track marks,” liquid silicone injections: 30-year perspective. Dermatol
which may develop from cuticular sutures, and Surg. 2005;31:1542-1549.
steristrips should be placed routinely after the removal 8. Goldberg DJ, Amin S, Hussain M. Acne scar correction
suing calcium hydroxylapatite in a carrier-based gel.
of sutures to decrease cutaneous wound tension.
J Cosmet Laser Ther. 2006;8:134-136
Other adjuvant measures to be considered include PDL 9. Coleman SR. Structural fat grafting: more than a permanent
treatment at the time of suture removal as discussed filler. Plast Reconstr Surg. 2006;118:108S-120S.
above, and where cosmesis is to be achieved at any 10. English RS, Shenefelt PD. Keloids and hypertrophic scars.
Dermatol Surg. 1999;25:631-638.
cost, temporary extremity immobilization with brace
11. Alster TS. Laser treatment of scars and striae. In: Alster TS,
or sling can be considered. ed. Manual of cutaneous laser techniques. Philadelphia:
Lippincott-Raven; 2000:89-107.
12. Conologue TD, Norwood C. Treatment of surgical scars
with the cryogen-cooled 595 nm pulsed dye laser starting on
Conclusion the day of suture removal. Dermatol Sug. 2006;32:13-20.
13. Nouri K, Jimenez GP, Harrison-Balestra C, Elgart GW.
585-nm pulsed dye laser in the treatment of surgical scars
In summary, a variety of treatment options are avail- starting on the suture removal day. Dermatol Surg. 2003;29:
65-73.
able for the revision of disfiguring surgical scars on the 14. Alam M, Pon K, Van Laborde S, Kaminer MS, Arndt KA,
back though none is ideal. Important regional differ- Dover JS. Clinical effect of a single pulsed dye laser treat-
ences on the back alter choices and technique comment of fresh surgical scars: randomized controlled trial.
pared to other areas of the body. These difficulties, Dermatol Surg. 2006;32:21-25.
15. Alster TS. Laser scar revision: comparison study of 585-nm
along with the risks inherent to surgical revision of pulsed dye laser with and without intralesional corticoster-
scars anywhere on the body, should be discussed thor- oids. Dermatol Surg. 2003;29:25-29.
oughly with patients before embarking on a treatment 16. Goldberg DJ, Sarradet D, Hussain M. 308-nm Excimer laser
course and realistic expectations should be established. treatment of mature hypopigmented striae. Dermatol Surg.
2003;29:596-598.
In the future, development of newer techniques, includ- 17. Iannello S, Milazzo P, Bordonaro F, Belfiore F. Low-dose
ing new types of lasers, the use of oral medications, enalapril in the treatment of surgical cutaneous hypertrophic
and gene therapy techniques that suppress pro-fibrotic scar and keloid – two case reports and literature review. Med
TGF-b, may bring improved novel approaches for scar Gen Med. 2006;8:60.
18. Ono I, Yamashita T, Hida T, et al. Local administration of
revision.17,18 For now, though, disfiguring scars on the hepatocyte growth factor gene enhances the regeneration
back are a reality even in the setting of meticulous of dermis in acute incisional wounds. J Surg Res. 2004;
surgical technique and ideal post-operative care. 120:47-55.
Part III
Breast
Chapter 11
Breast Reduction Through Liposuction
Michael S. Kaminer
Introduction via liposuction is less than that achieved by excision,

therefore patients who expect considerable reduction
may not be good candidates. On average, breast size
Tumescent liposuction has revolutionized the surgeon’s
can be reduced by 1–2 cup sizes with liposuction alone.
ability to remove unwanted fat in a minimally
Although liposuction of the breast can give a certain
invasive, outpatient procedure. Requiring only local
amount of lift to the breast, it is not always predict-
anesthetic, in some cases with the addition of oral or
able and should not be exaggerated when discussing
intramuscular analgesia, tumescent liposuction is a
results with the patient. However, for some women,
superb option for many women who are interested in
the amount of correction of both nipple and breast
breast reduction.1–3
ptosis can be significant. Ptosis of the breast is
Excessive breast tissue can be a physically impairing
measured as the shortest distance between the infra-
issue for women. Large, pendulous breasts can cause
mammary crease and the lowest point of the breast
back pain, shoulder pain, and can lead to poor posture.
profile (Fig. 11.1). There is a relative contraindication
For women with extremely large breast size, significant
for patients who have a family history of breast cancer,
skin laxity, and/or downward oriented nipples (nipple
and all women should have pre and 6–12 month
ptosis), cold steel breast reduction is appropriate. For
postoperative mammograms performed.
women with only 1–2 cup sizes over what they desire,
Women with a history of polycystic ovary disease
in the absence of significant nipple ptosis or excess
and breast cysts as well as significant swelling and pain
skin laxity, liposuction of the breasts may be an appro-
with menstruation should be carefully screened prior to
priate option. Liposuction can also be used for patients
surgery. These women have a tendency to glandular,
who have asymmetrical breasts and/or a modest amount
firm breast tissue that can be a challenge to remove
of breast ptosis. It can also be useful in women who may
with liposuction cannulas. Although in many cases
be predisposed to poor wound healing.4 Liposuction
these women can be effectively treated with liposuction,
provides a quick, virtually scarless alternative to the
expectations as to final result should be carefully
traditional breast reduction procedure.
discussed and conservatively modified. Conversely,
women who relate a history of significant breast size
increase when they have gained weight can be superb
candidates for breast reduction with liposuction.
Clinical Examination and Patient History
The most appropriate female candidates are those with

Method of Device and Treatment
good skin tone, an anteriorly oriented nipple complex
and lack of nipple ptosis, and relatively fatty breast Application
tissue with the absence of a prominent glandular
component. Younger women tend to have more glandular Perioperative antibiotics are begun 24 h prior to surgery
tissues than older women and are therefore less favorable (Cephalexin) and continued for a total of 7 days. Patients
candidates. The amount of fat that can be removed are also instructed to discontinue all medications and

74 M.S. Kaminer
Fig. 11.1 Breast measurements. Breast ptosis is measured as

Fig. 11.3 The preoperative water displacement measurement
the distance from the ruler (line P) to line S
technique for breast volume
in the upright position. It is important to draw the

contours to include the inframammary crease as a
landmark and to include the superolateral triangle of
tissue near the axillae, if this area is to be treated in the
cosmetic unit (Fig. 11.3).
It is imperative that sterile technique be used for all
surgical aspects of the liposuction breast reduction
procedure. The breast is anesthetized with 0.1% tumes-
cent lidocaine anesthesia through small incisions
placed inferolaterally, inferomedially, and in the
anterior axillary line. These same incisions are used
Fig. 11.2 Preoperative markings including the tail of the breast for the aspiration and heal nearly imperceptibly.
as well as lateral breast, axillary fat Twenty gauge needles can be used to deliver the
anesthesia, or the standard short sprinkler tip infusion
vitamin supplements that can promote bleeding at least cannula can be used. It is important to thoroughly
10–14 days prior to the procedure. anesthetize all levels of the breast tissue (superficial,
After photographs have been taken, the patient’s mid, and deep). Typically, the volume of anesthesia
breast size may be measured via the water displacement required will be from 120 to 150% of the volume of
method. A 4-liter beaker is filled to the brim, and with the breast measured by the water displacement test.
the patient standing, the breast is immersed in the bea- On average, this requires 750–1,250 cc per breast.
ker (Fig. 11.2). The water that is displaced is caught in After placement of the anesthesia is completed, it
an underlying bowl or pan, and that water volume is should be given 30–45 min to fully take effect.
measured. This should be repeated twice on each breast Prior to suctioning, it is advantageous to position
to obtain precise measurements. Alternatively, a digital the patient on the operating table so that her back is
handheld scale can be used to measure breast weight. approximately 30° above horizontal, with the side to
Preoperative markings should be made with the patient be treated elevated on one to two rolled surgical towels.
11 Breast Reduction Through Liposuction 75
Fig. 11.4 Periareolar incision used for liposuction

Fig. 11.5 Intraoperative assessment of liposuction after left
breast has been treated
In most cases, the ipsilateral arm is raised above the
head to facilitate access to the cannula insertion sites.
This positions the breast in the optimal neutral position Thereafter, a supportive sports-type bra should be worn
and allows the surgeon to evaluate the progress of 23 h a day for 3 months. Most patients can resume normal
breast reduction more accurately. activities within 5–7 days. Care should be taken when
Aspiration begins in the mid-layer of the breast with resuming upper body exercises, often requiring patients
a mid-level aggressive cannula such as the 12 gauge to use less weight and/or fewer repetitions.
Klein dual port spatula. It is important to use the smart Due to swelling, results are difficult to assess in
(nondominant) hand to steady the breast tissue and the first 4–6 weeks. Patients will often reveal approxi-
allow for even planes of suctioning. After the mid layer mately 50% of their final breast reduction result at
is suctioned in all four quadrants, it is important to 6 weeks, and it can take as long as 4–6 months to see
address both the superficial (cautiously) and deep the full measure of improvement. The average patient
levels. The central and superficial tissue often has a will achieve a 1–2 cup size reduction at 6 months
glandular component, and it may be difficult to remove (Fig. 11.6). If a repeat procedure is to be considered to
sufficient fat from these areas. Using a 12 or 14 gauge obtain additional breast size reduction, it is advisable to
Capistrano cannula can help to remove fat from these wait at least 6 months from the date of the original
glandular areas. A stab incision on the upper outer surgery.
perimeter of the areola can also be used to access the
adipose, which is intertwined with the glandular tissue
under the nipple (Fig. 11.4). Approximately, 25–50%
of the volume of breast weight (based on the preop Management of Adverse Events
volume) should be removed. The better the skin
quality and breast position preoperatively, the more Postoperative complications are uncommon. The most
aggressive the surgeon can be intraoperatively. After frequently seen events include pain, swelling, erythema,
suctioning is complete, it is important to measure the and edema. Occasionally, patients develop superficial
amount of fat removed from one breast to be consistent blisters on the inferior surface of the breast 2–5 days
with volume reduction in the other breast (Fig. 11.5). after the procedure, presumably due to gravitational-
related movement of fluid and swelling. These resolve
without scarring and are treated with local wound
care including the application of petrolatum based
Results and Postoperative Care ointments.
Infection, bleeding, and necrosis as well as deep
Postoperatively, absorbent padding and a chest-binding vein thrombosis of the legs are extremely rare events
garment are worn for 24 h. The garment is then worn that, when present, require immediate and aggressive
for 23 h a day for the first 3 or 4 days after surgery. intervention. Contour irregularities of the breast are also
76 M.S. Kaminer
Fig. 11.6 (a) Before breast reduction with liposuction. (b) After breast reduction with liposuction
rarely encountered when proper technique is used and and shoulder pain is often significant.5 Although nearly
care is taken to avoid suctioning too much superficial all women who desire a reduction in breast size can
breast tissue. Treatment of contour problems often be treated, those with a predominance of fatty tissue
requires a second liposuction procedure, which can (often associated with advanced age) are more suitable
present a challenge to the surgeon. Asymmetry of the candidates.
breast following surgery can occur, and it is therefore Powered reciprocating liposuction cannulas, as
important to have careful preoperative photographs well as some of the recently introduced laser-assisted
and breast weight measurements to refer to in the post- technologies (SmartLipo, Cynosure, Inc. and ProLipo,
operative period. Many women will have preexisting Sciton, Inc.), may enhance results in the future.
asymmetry, and the preoperative data can be incredibly Although several noninvasive fat removal technologies
useful when discussing results with patients. In almost are currently in the development phase, it remains to
all cases, it is advisable to point out to patients any be seen whether these will be suitable and appropriate
preexisting asymmetry prior to the procedure. When for breast reduction.
asymmetry is surgically induced, a repeat procedure
can be of significant benefit.
References
Conclusion 1. Mellul SD, Dryden RM, Remigio DJ, Wulc AE. Breast
reduction performed by liposuction. Dermatol Surg. 2006;
32(9):1124–1133.
Minimally invasive breast reduction utilizing tumescent 2. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B.
liposuction has become an accepted stand-alone treat- Current preferences for breast reduction techniques: a survey
of board-certified plastic surgeons 2002. Plast Reconstr Surg.
ment method. Previously performed only in conjunction 2004;114(7):1724–1733.
with cold steel surgery, liposuction is now able to precisely 3. Sadove R. New observations in liposuction-only breast reduc-
and predictably reduce the size of the female breast by tion. Aesthetic Plast Surg. 2005;29(1):28–31.
one to two bra cup sizes. In addition, natural shape and 4. Moskovitz MJ, Baxt SA, Jain AK, Hausman RE. Liposuction
breast reduction: a prospective trial in African American women.
sensation are retained, and in some women, a modest Plast Reconstr Surg. 2007;119(2):718–726.
amount of lifting and correction of breast ptosis can 5. Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuc-
be achieved. Symptomatic improvement in neck, back, tion breast reduction. Plast Reconstr Surg. 2004;114(1):55–60.
Chapter 12
Botulinum Toxin A for Upper Thoracic Posture
and the Appearance of a “Breast Lift”
Kevin C. Smith
Introduction BTX-A has a long history of being used to improve

posture in a variety of conditions.5,6 The position of the
shoulders is determined largely by the balance of forces
The author (KCS) and others1 have suggested that
between the pectoralis minor and pectoralis major
injection of BTX-A could, in selected patients, produce
muscles (Fig. 12.1), which tend to rotate the shoulders
a pleasing change in upper thoracic posture and conse-
medially and depress them and the action of the oppos-
quently in breast presentation such that the patient
ing muscles of the back, for example, the rhomboids.
would obtain a “BOTOX® Breast Lift” (more properly
The pectoralis minor muscles are accessory muscles
termed a “BTX-A upper thoracic posture lift”). This
that assist during strong exhalation. One author (KCS)
could result if muscles responsible for a “head forward”
has noted that three doses of 10 units of BOTOX®
posture were relaxed with BTX-A, so that opposing
injected on each side into the pectoralis minor muscles
muscle groups responsible for erect upper thoracic pos-
in women who are slightly round shouldered can lead
ture could work with less opposition.
to a more erect posture with shoulders back – resulting
KCS has pointed out, in the New York Times2 and
in what they consider to be a more aesthetically pleasing
elsewhere, that before any attempt is made to offer
presentation of the breasts (Fig. 12.2).
“BOTOX® Breast Lift” to patients, double-blind
clinical trials should be done to determine whether
the observed effect is the result of placebo or has a
physiological basis. If there is a physiological basis for Patient Selection
this observation, it will be necessary to optimize patient
selection criteria and treatment protocols.
KCS noted that the ideal candidate for this treatment is
a slightly round-shouldered, physically fit, nonobese
woman with a slightly “head forward” posture, between
Clinical Examination 35 and 50 years of age, with A or B cup-size breasts.
These individuals could be described as having a mild
Recent contributions by Lang3 and by Finkelstein and degree of cervical hyperlordosis, forward head pos-
Katsis4 have improved our understanding of the poten- ture, and lumbar kyphosis. Older women, and those
tial for the use of BTX-A to enhance upper thoracic with larger breasts, tend to respond more slowly and to
posture, and in particular, they have provided evidence a lesser extent.
of improved results when a program of physiotherapy
was added to the treatment with BOTOX®. When the
patient has strengthened the interscapular muscles as a
result of a program of prescribed exercises, improve- Treatment Application
ment may be greater and may be maintained longer,
with reduced long-term need for BOTOX® and a The benefits of BOTOX® treatment usually develop
reduced rate of reversion to the “head forward” state of over a period of 1–2 weeks, and persist for 3–4 months.
poor upper thoracic posture. The duration of effect is somewhat longer than might

78 K.C. Smith
Fig. 12.1 BOTOX® injection sites reported by Drs. Smith and Atamoros
Fig. 12.2 Forty-eight-year-old woman before treatment of the pectoralis minor muscles with three 10 unit doses of BOTOX®
on each side. There was improved posture with improved presentation of the breasts at 3 weeks follow-up, and the patient was
very pleased
be expected considering the relatively low doses of weeks. The reasons for this are not known. Perhaps
BOTOX® in proportion to the size of the muscles. It projection of the breasts as a result of improved shoul-
may be that improvements in shoulder posture persist der posture leads to increased mechanical stimulation
for a while once posture has been improved by of the nipples under some circumstances.
BOTOX® altering the balance of forces between the
pectoralis minor and/or major muscles and the oppos-
ing muscles in the back.
Some women have noted that not only are the Treatment Technique
breasts and nipples elevated by their more erect pos-
ture with shoulders back but that there is also a pleas- BOTOX® is administered using a 30G 1 in. needle.
ing erection of the nipples, which develops about a One author (KCS) usually uses a reconstitution of
week after BOTOX® treatment and persists for 3–4 100 units of BOTOX® in 2.5 ml of normal saline with
12 Botulinum Toxin A for Upper Thoracic Posture and the Appearance of a “Breast Lift” 79
benzyl alcohol preservative. The pectoralis minor 1.6 cm. Sixty-five of ninety-two patients rated the
arises on the third, fourth, and fifth ribs and runs under results good to very good, and 73 of 92 would repeat
the clavicle to insert on the coracoid process of the the procedure. Like Dr. Smith, Dr. Pérez Atamoros has
scapula. The pectoralis minor muscles are located by noted that the best candidates are physically fit women
having the patient hold her arms up slightly above in the age range 30–55 years, with small to moderate
shoulder height, pressing the palms together when sized breasts. Five patients had pain lasting longer
requested to do so, allowing the examiner palpate the than a week. Dr. Pérez Atamoros has suggested that
pectoralis minor starting about 2.5 cm inferior to the relaxation of the inferior portion of the pectoralis
lateral third of the clavicle. Injections points are gener- major muscle allows the superior portion to lift the
ally about 2.5, 5, and 7.5 cm inferior to the lateral third ptotic breast. (Personal communications, Botox®,
of the clavicle. Injections are done at a depth of less Fillers & More, Vancouver BC, August 2003; American
than 2 cm. Apart from occasional muscle or fascia ten- Academy of Dermatology, Washington DC, February
derness for several days, there have been no complica- 2004, and April 2004). For a comparison of the injection
tions from this treatment. In particular, pneumothorax sites used by Drs. Kevin Smith and Pérez Atamoros,
or bleeding have not been seen, but the possibility of see Fig. 12.1.
such problems must be considered, even when work- Issues that remain to be resolved include optimiza-
ing with a 30G 1 in. needle. The risk of entering the tion of patient selection, Botox® dosing and the place-
pleural space can be reduced by limiting needle inser- ment of Botox® doses, the issue of placebo effect vs.
tion depth to less than 2 cm. biomechanical effect, and elucidation of the mecha-
This proposed mechanism of action has been criti- nism of action if indeed there is a biomechanical effect
cized by Dr. Otto Wegelin (personal communication, from Botox® treatment of the pectoralis minor and/or
April 2004), who argues that: pectoralis major muscles with Botox®.
1. The muscles (pectoralis minor and rhomboid minor)
invoked to carry out the postural changes are far too
small to do what is expected of them. Clinical Trial
2. The muscles do not in fact rotate the shoulder but
rather act primarily stabilize the scapula – an
A clinical trial could contain some of the following
entirely different function.
elements, depending on the resources available. The
3. The muscles are not antagonistic in action as are the
clinical trial would ideally be double-blind, placebo-
frontalis and the orbicularis occuli but rather
controlled with respect to BOTOX®, and there might
synergistic.
be an element of dose ranging, so that the patients
4. There is no way to determine how much, if any, of
would get either saline or 10 or 20 units of BOTOX® at
the Botox is actually acting on the pectoralis minor
each injection site. There would be three injection sites
as the Botox can diffuse widely in a three dimen-
in each of the pectoralis minor muscles, and three in
sional plane unlike the forehead where there is the
each of the horizontal components of the superior por-
boney skull limiting diffusion.
tions of the pectoralis major muscles (Fig. 12.3).
Dr. Doris Hexsel (personal communication, July The patients could further be classified into two
2004) in a study of six women was not able to obtain arms of the study: one receiving physiotherapy, which
satisfactory results, and in two cases noted that the is intended to improve upper thoracic posture and a
nipples hung lower. second group receiving no physiotherapy or sham
Dr. Francisco Pérez-Atamoros of Mexico City has physiotherapy. This could help to determine the role
obtained elevation of the breast on the side where the and relative contribution of physiotherapy to the over-
nipple is lower by injecting three doses of 15 units of all improvement, if any. The physiotherapy program
BOTOX® into the parts of the pectoralis major muscle, could be based on elements of O.N.E.U.P. (Optimizing
which lies medial and inferior to the pectoralis minor Neurotoxin Efficacy Utilizing Physiotherapy) pro-
muscles. In a series of almost 100 patients, Dr. Pérez gram, which includes a patient instruction booklet and
Atamoros has obtained an elevation of the ptotic breast an accompanying DVD with video clips illustrating
averaging 0.8 cm with the maximum elevation being the elements of the stretching and exercise program.7
80 K.C. Smith
Elements of that program intend to stretch the muscles Standardized photography at baseline and at each
involved in depression and internal rotation of the follow-up visit could help to determine whether patient
shoulders, to stretch the pectoralis major and minor posture and breast presentation (in the case of female
muscles, and to strengthen the rhomboids. Exercises subjects) was improved by the interventions being
are also intended to strengthen the muscles responsible studied. Patients could wear a thin “see through” white
for erect upper thoracic posture and external rotation tank top for modesty during photography (Fig. 12.4).
of the shoulders. Standardized measurements on pre and posttreatment
photos (using a vertical line from the tragus of the
ear and comparing that with a marker on the anterior
border of the acromion) could be used to determine
whether or not there had been correction of “head
forward posture”, and to measure the degree of
correction.
Special Considerations
• There is likely to be a strong placebo effect during

the study; and so, patients can be put through a
range of motions (perhaps on video) so that they
will be caught “off guard”. Then, standard frames at
Fig. 12.3 Proposed sites for injections of BOTOX® 10 or 15 certain points could be extracted from the video and
units in the pectoralis major and minor muscles used for analysis.
Fig. 12.4 Example of head forward posture, with some improvement after treatment of the pectoralis minor muscles with 30 units
of BOTOX® on each side (Photo courtesy of Dr. S. Sapra)
12 Botulinum Toxin A for Upper Thoracic Posture and the Appearance of a “Breast Lift” 81
• Because breast size and position may change at In this regard, assessments of depression (for exam-
various points in the menstrual cycle, it will be opti- ple, Beck Depression Inventory, Hamilton Depression
mal for treatments and assessments to be done as Rating Scale) might also be useful to determine if there
close as possible to the same point in the menstrual was a relationship between objective improvements in
cycle at each visit. upper thoracic posture and the patient’s emotional state
• Changes in medications (particularly, those affect- and self-image (for example, using the Rosenberg
ing breast size, including estrogens and medications Self-Esteem Scale).
affecting prolactin) will need to be carefully moni- Because disorders of the soft tissues and structure
tored at each visit. of the cervical spine have been associated with cervi-
• Patients should be weighed at each visit. cal pain, thoracic pain, and headaches,9 it will be
important to collect information about those problems
Subject and investigator global assessments, using a
at baseline and at follow-up visits so that effects of
Likert scale, would also be taken at baseline and at
BOTOX® and/or physiotherapy on those parameters
each follow-up visit. Efficacy endpoints could also
will be detected and quantified.
include the following measures (Fig. 12.5):
• Nipple to nipple Distance

• Nipple to Sternal Notch Distance
Conclusion
• Interscapular Distance could also be recorded, with
the patient standing in a standard, relaxed posture
There is increasing evidence that treatment with
Functional magnetic image resonance (MRI) imaging BOTOX®, or more likely a combined treatment with
before and after BTX-A treatment might provide useful BOTOX® and a program of physiotherapy, may pro-
insights. T-2 weighted MRI, with a repetition time of duce improvements in upper thoracic posture. These
1,500 ms, two echoes at 30 and 60 ms immediately improvements in posture may result in a more aestheti-
after exercise can demonstrate areas of flaccid paralysis cally pleasing presentation of the female breast, creat-
resulting from BOTOX® treatment. ing the appearance of a “breast lift”. Additional
It will be interesting to see if improved and more benefits, for both men and women, may include
“positive” posture is reliably associated with improved improved mood and/or reductions in some types of
mood, in a manner similar to improvements in mood headache and other pain, which can be related to
associated with improved and more “positive” facial problems with upper thoracic posture. A properly
expressions, which are reported to result after inter- designed and executed clinical trial is needed to deter-
ventions like treatment of negative facial expressions mine whether or not, or to what extent, BOTOX® and
with BOTOX®.8 physiotherapy are useful for the improvement of upper
Fig. 12.5 Nipple to nipple and sternal notch to nipple measure- These distances are influenced by posture and by breast size,
ments, with the patient standing in a standardized, relaxed posture. which can fluctuate with the menstrual cycle and with weight
82 K.C. Smith
thoracic posture and produce in women the appearance 4. Finkelstein I, Katsis E. Botulinum toxin type A (BotoxR)
of a “BOTOX® Breast Lift.” Such a trial could also improves chronic tension-type headache by altering biome-
chanics in the cervico-thoracic area: a case study. Cephalalgia.
help us to define optimal patient selection criteria and 2005;25:1189-1205.
treatment protocols. 5. Traba Lopez A, Esteban A. Botulinum toxin in motor disor-
ders: practical considerations with emphasis on interventional
Disclosure: Dr. Smith is a consultant and investigator for neurophysiology. Neurophysiol Clin. 2001; 31(4):220-229.
Allergan. 6. Gallien P, Nicolas B, Petrilli S, et al. Role for botulinum toxin
in back pain treatment in adults with cerebral palsy: report of
a case. Joint Bone Spine. 2004;71(1):76-78.
7. Vad VB, Donatelli RA, Joshi M, Lang AM, Sims V. O.N.E.U.P.
References cervicothoracic & lumbar pain syndromes program. Beth
Israel Medical Center, Office of Continuing Medical
Education, 1st Avenue at 16th St., New York NY 10003.
1. Smith KC, Pérez-Atamoros F. Other dermatologic uses of Accessed January 2008.
botulinum toxin. In: Benedetto AV, ed. Botulinum toxin in 8. Alam M, Barrett KC, Hodapp RM, Arndt KA. The facial
clinical dermatology. London: Taylor and Francis; 2006: feed-back hypothesis applied to cosmetic procedures: change
219-236. in emotions resulting from facial muscle activity and contour
2. Cosmetic injections expand to points below the chin, New York change induced by botulinum toxin injection. J Am Acad
Times, January 26, 2006 http://www.nytimes.com/2006/01/26/ Dermatol. 2008;58:1061–1072.
fashion/thursdaystyles/26sside.html?_r=1&oref=slogin 9. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG.
Accessed 07.09.07. Manipulation and mobilization of the cervical spine:
3. Lang AM. Considerations for the use of botulinum toxin in pain a systematic review of the literature. Spine. 1996;21:
management. Lippincotts Case Manag. 2006;11:279-282. 1746-1759.
Part IV
Hands (and Feet)
Chapter 13
Treatment of Keratoses and Lentigines with Peels and PDT
John Strasswimmer
Introduction areas, patient education must be thorough. Expectations

not only of the clinician but also the patient must be
delineated. Explanation to the patient of how the
The dorsum of the hands can portray an aged
face is not the only indicator of age and how other
appearance due to sun damage. Contributing to the
sun exposed areas also incur damage is a must. With
aged appearance are epidermal and dermal atrophy,
your treatment plan, the extent of sun damage must
prominent veins, solar lentigines, and actinic keratoses.
be portrayed to the patient. For example, an area
Treatment of nonfacial solar lentigines and actinic
such as the dorsum of the hands approaches the
keratosis is critical in providing a true age defying
importance of facial lesions. Describing to patients
body rejuvenation. With actinic keratoses considered
the added benefit of removing potentially disfiguring
a precancerous disease state, treatment is not only
skin cancers and the importance in removing them in
cosmetically appealing but also medically pertinent.
general must also be emphasized. Examination should
Treatment is often unrewarding using conventional
already be included with initial consultation for body
approaches for facial lesions such as cryotherapy, topical
rejuvenation. Clinically suspicious lesions for neo-
fluorouracil, topical hydroquinone, and lasers due to
plasms should be treated before endeavoring on
discomfort, scarring, dyspigmentation, lack of efficacy,
PDT or peels, as these are not conventional treatment
healing time, and cost.1 Given how some treatments
options for both melanomatous and nonmelanoma
require a considerable amount of patience and patient
skin cancers. With photodynamic therapy, concur-
compliance, practicality also becomes an issue. The lack
rent photosensitive diseases such as lupus erythema-
of abundant sebaceous material, which confers subop-
tosus, polymorphous light eruption, and xeroderma
timal healing, in the hands does not allow for aggressive
pigmentosa 2 might be a contraindication. Drug
treatment. Ultimately, patients would like to achieve
history is also critical. Known photosensitive drug
success with removing age defining lesions, such as solar
eruptions (lupus such as toxic, etc.) may occur with
lentigines and actinic keratoses with the same success
its use. PDT is also considered pregnancy class C.
and ease which clinicians have been performing on the
Likewise, chemical peel patient selection is also
face. Fortunately, two relatively old treatments for this
important. Proper skin typing using a standardized
situation, photodynamic therapy (PDT) and chemical
scale such as the Fitzpatrick scale is essential for
peels, have been revisited with surprising success,
selecting not only the candidate but also concluding
offering good clearance and relative ease of application
which peel would be most appropriate. Recent sys-
and most importantly excellent patient satisfaction.
temic retinoid therapy is also important. Previous
peels, both facial and extrafacial, are part of obtain-
ing patient history pertaining to scarring potential
Patient History and Clinical Examination and previous successes and failures. As with any
medical procedure, previous treatments the patient
Just as in any procedure, patient identification and might have received must be known to help pinpoint
selection is paramount. When dealing with nonfacial the best options.

86 J. Strasswimmer
Method of Device and Treatment IX (PPIX) within a few minutes. If a patient has not
Application had significant response to this protocol, then the
subsequent procedure may use an emollient applied
For facial treatments, dosing and guidelines of after the ALA to maintain the ALA in solution and to
performing PDT and peels are quite extensively found facilitate penetration. The incubation time may also be
in the literature. However, very little data exist on expanded to overnight. We do not recommend this in
nonfacial applications. The few reported studies are the first treatment, as the reaction with light exposure
outlined in Table 1 for PDT and Table 2 for peels. can be quite robust.
Extrafacial PDT for photodamaged as not been widely The chemical is washed off with a soapy cleanser
reported, however, one report does show promise.3 and water. This step removes the excess ALA from
As with these treatments, like many others in derma- the surface, but there remains ALA within the skin
tology, actual use differs greatly and ultimately rests for 48 h as discussed below. The choice light source
on clinical confidence and personal experience. Finding then becomes another decision. Most decisions are
the proper time for application of the photosensitizer obviously to use whatever equipment the clinician
for PDT also remains elusive. Peels will in general may already possess. The peak absorption curves
confer a better response with less risk of untoward occur at wavelengths in the 410 nm (blue) range
effects in lighter skin types. (Fig. 13.1). However, additional minor absorption
peaks can be found in the green, yellow, and red por-
tions of the color spectra. Thus, light in these wave
lengths can, in theory, activate. Blue light offers
Photodynamic Therapy more extensive absorption (20-fold) and thus the
most “potent” activation of PPIX. It also is not as
PDT is useful in the treatment of photodamage and deeply penetrating as the red light3. If the goal is to
actinic keratoses (AK)4. Scaliness and redness of the target epidermal changes (keratoses, lentigos, epi-
hands may resolve after 1–3 treatments. For PDT, dermal atrophy), this is optimal. However, if the goal
emphasis is placed on the patient receiving as little of is to stimulate dermal remodeling then longer wave-
ultraviolet radiation as possible leading up to their lengths are ideal. To this end, a continuous wave red
procedure. Initial consents should be completed along light source might be ideal. The devices readily avail-
with any medical history. When utilizing this procedure able and used to target other wavelengths are “pulsed”
for actinic keratosis (AK), we remove excess crust and thus are less likely to activate the PPIX.3 Long
from the lesions to facilitate penetration; however, for
rejuvenation, this is not needed. In the treatment of
facial actinic keratoses, the topical 5-aminolevulinic
acid (ALA) is allowed to preferently penetrate the
parakeratotic skin found on AKs. This alone leads to
most of the reported selectivity. In contrast, for a more
broad rejuvenation, it is important to facilitate even
penetration of the medication. The skin is first scrubbed
with acetone to remove the lipid layer barrier. Second,
a gentle (1–2 pass) microdermabrasion procedure
might be done if the facility is available to allow
penetration. Application of the sensitizing agent,
topical 5-aminolevulinic acid (ALA), is completed
first with varying time before treatment. We recommend
20% ALA with initially a 2 h incubation time. This is
in contrast to the face, where even a 30 min incubation
allows enough diffusion of the medication. On a
cellular level, once the ALA has encountered a cell, it Fig. 13.1 Protoporphyrin IX absorption curve with visible light
is metabolized to the photosensitizer protoporphyrin absorption
13 Treatment of Keratoses and Lentigines with Peels and PDT 87
pulsed pulse dye laser (585–595 nm), with the non- We usually opt for the medium depth because the
purpuric setting, can be used.5 In addition, intense goal is to get a permanent improvement. Patients are
pulse light (IPL) may be used and is frequently one pretreated with topical retinoids at least 14 days before
of the choices since it is present in many cosmetic the procedure to help with even penetration and this is
offices, it alone is able to treat lentigenes, and vari- particularly important for the thicker areas of skin such
ous filters can be used to treat. Because of the as the hands6. The retinoid is stopped 5 days prior to
extremely short pulse time, there might not be enough treatment. Acetone scrub is done to degrease the area.
oxygen available to produce a true “photodynamic” This is followed by one even application of Jessner’s
response, but might rather produce a “photothermal” solution. Subsequently, 25–35% TCA is applied in
effect to good benefit. The standard treatment is to an even pattern in perpendicular directions to maxi-
use the laser or IPL as if one were treating with out mize even coverage. The chemical should be layered
the ALA. Immediately following, the patient must cautiously and before starting a new application,
practice total avoidance of visible (not just UV) light, waiting for frost to appear. TCA and Jessner’s solution
because the ALA remains in the skin and can be are “self neutralizing” and the frost is the endpoint.
metabolized to PPIX for up to 48 h. Inadvertent light The procedure should not be painful. An even frost
exposure, such as a 20 min drive home after the pro- demonstrates a successful application. Spot treating
cedure, may be enough to produce a brisk phototoxic difficult lesions such as hyperkeratotic actinic keratosis
reaction manifested by excess erythema, swelling, with increased number of applications may be necessary.
and pain. Instruct patient that a reaction similar to a If a patient has not responded to this protocol, it may
light sunburn, burn and peel can be expected after be repeated in 1–2 months with additional “spot”
72 h. Follow visits should be around 72 h for reassur- touching of 50% TCA after the application of the 35%
ance and again at 2–4 weeks for re-evaluation and TCA. We do not recommend higher concentration
possible reapplication. For the weeks following the because of the risk of scarring. Likewise, we do not
procedure, such as for peels, UV protection helps to recommend “deep” chemical peels (such as phenol
prevent dyspigmentation. containing peels) in nonfacial locations due to the risk
of scarring.
Postoperative care for chemical peels is usually
simple and straightforward. There is a wide array of
Chemical Peeling options for patient comfort post procedure ranging
from simple cool compresses with cold water to
Chemical peeling on the hands and arms is more of a emollients to more sophisticated topical treatments
challenge because of the uneven nature of the skin including hyaluronic acid and other anti-inflammatories.
thickness and the dramatic hyperkeratosis seen on Restarting previous topical therapy is also advised
some portions of the hand. Depending on patient including retinoids and any topical bleaching agents.
medical history, pertinent prophylactic antimicrobial Follow up is again simple. A 24–48 h check would
therapy should be instituted, especially for impetigo reassure patient and would be a good indicator of
and herpetic infections. Prior to peeling, one needs to success of application. Following that, a recheck at
decide whether superficial peeling (Jessner’s solution, 4 weeks would be prudent as this would be an oppor-
glycolic acid, low percentage of trichloroacetic acid tune time for an additional peel if necessary.
(TCA) that targets epidermis is the goal or if deeper When adverse effects do arise, and they will, proper
medium depth (35% TCA pretreated by Jessner’s solu- anticipation and treatment options must be recognized
tion) is to be performed. While a superficial chemical by the clinician. The main side effects of both proce-
peel is optimal for patients with mild photodamage dures include erythema (overabundant and nonexistent),
and color abnormalities, a medium depth chemical edema, and crusting. There are many variables that can
peel is effective for patients with lots of pigment be changed with PDT to decrease these side effects,
alterations, especially brown and tan pigmentations including decreasing incubation time and using less
and seborrheic keratoses. However, the medium depth irritating light sources such as long pulse laser. If they
chemical peel will require longer healing times than do occur, topical mid potency corticosteroids often
the superficial chemical peel and PDT treatment. will suffice. Adjunct topical anti-inflammatories can
88 J. Strasswimmer
also be used. Posttreatment hyperpigmentation that can extremely safe and still yield significant results. Overall,
occur with both treatment modalities can be remedied PDT and chemical peels are viable, safe, and relatively
with use of bleaching agents. Most often times, simple treatments to help eliminate solar lentigines and
reassurance is warranted and review of preoperative actinic keratoses on photodamaged hands. This is an
education will alleviate most concerns. Post treatment important component of total body rejuvenation.
hypopigmentation is rare with peeling and rarer with
PDT, but can be permanent. Acknowledgments Dr Strasswimmer gratefully acknowledges
the assistance of John Mini DO and Danika Przekop DO, resi-
dent physicians from the Palm Beach Centre for Graduate
Medical Education.
Conclusion
The future of these treatment modalities is promising. References

As popularity increases especially in the field of
photodynamic therapy, this will become more and 1. Todd MM, et al. A Comparison of three Lasers and liquid
more popular. Advances in sensitizers, incubation times, nitrogen in the treatment of solar lentigines: a randomized
controlled comparative trial. Arch Derm. 2000;136:841-846.
and tailoring light sources to each patient to ensure a 2. Leonard AL, Hanke CW. Cosmetic Dermatology Procedure
great cosmetic result with minimal side effects will occur Manual. New York: Physicians’ Continuing Education Corp;
as more and more clinicians become familiar with this 2007:168.
technology. As literature prevails pointing out the pos- 3. Strasswimmer J, Grande DJ. Do pulsed laser activate PDT?
Lasers Surg Med. 2006;38:22–25.
sible preventative nature of PDT for nonmelanomatous 4. Gold MH, Nestor MS. Current treatments of actinic keratoses.
skin cancers, medical and cosmetic indications will J Drugs Dermatol. 2006;5(Suppl):17–24.
meld and make this much more of a viable option, even 5. Alexiades-Armenakas MR, Geronemus RG. Laser-mediated
in noncosmetic based offices. Peels have been stal- photodynamic therapy of actinic keratoses. Arch Derm. 2003;
139:1313–1320.
wart and remain effective for numerous applications. 6. Nemeth HO, Taylor JR AJ. Tretinoin accelerates healing after
Using less destructive peels with combinations products trichloroacetic acid chemical peel. Arch Derm. 1991;127(5):
(retinoids and other peels) may make these procedures 678–682.
Chapter 14
Off-Face Laser Treatment of Keratoses and Lentigines
Paul M. Friedman and Brenda Chrastil-LaTowsky
Introduction the patient’s concerns, physical findings, and other

pertinent factors. Baseline and posttreatment photo-
graphs of previous patients treated with different treat-
Laser procedures for the skin continue to become more
ment options are helpful, as are photographs of
and more popular: 590,000 procedures were performed
immediate posttreatment findings, such as erythema
in 2004, up by 300% since 2003, according to the
and edema. A detailed description of the treatment,
American Society for Aesthetic Plastic Surgery. Many
expected downtime, and posttreatment protocol are
dermatologists have been asked by patients, friends,
important parts of the treatment process.
and relatives: “What can I do about these brown and
red spots on my neck and chest?”
Traditionally, treatment modalities of keratoses
and lentigines have been focused on facial lesions. Method of Device and Treatment
With greater treatment success, coupled with modern Application
dress, patients now demand treatment options for
lesions off the face. Laser treatment of these lesions
532 nm Q-Switched Nd:
will be discussed in this chapter, including the
Q-switched (QS) Nd:YAG laser (532 nm), QS ruby YAG and 694 nm QS Ruby Lasers
laser (694 nm), fractional photothermolysis (1,550 nm
erbium laser), and pulsed dye laser-mediated photo- The QS ruby and 532 nm QS Nd:YAG lasers have
dynamic therapy (PDT). Intense pulse light therapy, been found to be effective in the removal of lentigines
which is noncoherent light, will not be discussed in on the dorsal hands, forearms, chest, and back
this chapter, but has also been used to treat lentigines. (Figs. 14.1–14.3). When compared, the QS ruby laser
Of note, traditional ablative resurfacing is not used on produced slightly better treatment results, but caused
nonfacial skin in our practice because of the risk of more discomfort during treatment. However, the 532
scarring, although fractional CO2 treatment will likely nm QS Nd:YAG laser produced more posttreatment
play a role in the future. discomfort.1 The 532 nm QS Nd:YAG has been found
to produce superior results when a head-to-head com-
parison was performed with cryotherapy. Patients also
preferred laser therapy over cryotherapy.2
Clinical Examination and Patient History Please see Table 14.1 for suggested settings in the
treatment of lentigines and seborrheic keratoses with
The most important aspect of the pretreatment history the 532 nm QS Nd:YAG based on skin type.
and physical exam is the establishment of the patient’s Treatment technique is similar to on-face treat-
expectations as well as communicating the importance ment. It should be emphasized that using subthera-
of realistic expectations. The patient must be educated peutic fluences in patients with darker skin types may
that usually more than one treatment will be required. cause posttreatment hyperpigmentation, lasting
More than one modality should be offered, based on weeks to months. Aggressive fluences may cause skin

90 P.M. Friedman and B. Chrastil-LaTowsky
Fig. 14.1 Lentigines and seborrheic keratoses treated with 532 nm QS Nd:YAG and QS ruby. (a) Patient’s back at baseline.
(b) Three months after treatment. The patient had one treatment with the QS Nd:YAG (fluence of 3 J/cm2, spot size of 3 mm). Two
weeks later, the patient was treated with the QS ruby laser (fluence of 3.5 J/cm2 and spot size of 5 mm)
Fig. 14.2 Lentigines and seborrheic keratoses treated with 532 nm QS Nd:YAG. (a) Patient’s chest at baseline. (b) Ten months after
a single treatment with the 532 nm QS Nd:YAG (fluence of 3.2 J/cm2, spot size 3 mm)
sloughing and postinflammatory hypo- or hyper- should be sought during treatment and used to
pigmentation. The clinical endpoint of whitening adjust laser settings (Fig. 14.4). Wound healing is
14 Off-Face Laser Treatment of Keratoses and Lentigines 91
Fig. 14.3 Treatment of lentigines of the dorsal hand with the ruby laser. (a) Patient’s hand at baseline. (b) Patient’s hand 9 months
after a single treatment with the ruby laser
Table 14.1 Suggested treatment settings of lentigines and macular seborrheic keratoses with the QS Nd:YAG
(532 nm). Standard Treatment of Lentigines and Macular Seborrheic Keratoses with the QS Nd:YAG (532 nm)
Fitzpatrick Skin Type Spot Size (mm) Fluence (J/cm2)
I–III 3 3.0
IV–V 3 1.4–1.6
Fig. 14.4 Treatment of a macular seborrheic keratosis in a patient with Fitzpatrick skin type IV. (a) Patient at baseline. (b) Patient
immediately after treatment. Note the clinically-apparent white endpoint of the treated lesion
fastest when the lowest therapeutic fluences are used. clinical response. Post-op care instructions are generally
One to three treatment sessions every 3–4 weeks are consistent with that of the treatment of facial lentigines
generally recommended, but adjusted to patient’s (Table 14.2).
Table 14.2 An example of posttreatment instructions given to patients after Q-switched Ruby &
Nd:YAG laser therapy. Courtesy of Dr. Roy G. Geronemus
1,550 nm Erbium-Doped Fractional

actinic porokeratosis (DSAP).4 In a series of 4 patients,
Photothermolysis (Fraxel™) we found that two patients using the Fraxel SR 750
achieved a 50–75% improvement of DSAP lesions and
Fractional photothermolysis can safely be used off the skin texture after 3–6 treatments (Fig. 14.8). Two
face and is routinely used in our practice for photoreju- patients treated with more aggressive treatment settings
venation of the neck, chest, dorsal hands, and extremi- using the Fraxel SR 1500 device achieved greater than
ties (Figs. 14.5–14.7).3 We have also had outstanding 75% improvement after 5–6 treatments every 4 weeks4
results using this device to treat disseminated superficial (Figs. 14.9–14.11). Additionally, preliminary results
Fig. 14.5 Lentigines and photodamage treated with fractional photothermolysis. (a) The patient’s chest at baseline. Note lentigines,
keratoses and poikiloderma. (b) The patient after only one treatment. Treatment settings: energy of 11 mJ, 15 mm spot, 6–8 passes
1,500–2,000 microscopic treatment zones/cm2 (MTZs/cm2). Zimmer cooling system was set at level 3
Fig. 14.6 Dyschromia treated with fractional photothermolysis. (a) The patient’s neck at baseline. (b) The patient after three treat-
ments with fractional photothermolysis. Note marked improvement of the dyschromia, as well as skin texture. Treatment settings
were: energy setting of 40 mJ, 15 mm spot size, 8 passes. Total kJ ranged from 4.02–4.88. Zimmer cooling system settings ranged
from 3 to 5
Fig. 14.7 Fractional photothermolysis for the treatment of lentigines of the hand. (a) Patient’s dorsal hand at baseline. (b) Dorsal
hands three months after 5 treatments of fractional photothermolysis. Treatments were spaced at 2–3 week intervals. Treatments
settings were: energy of 8–9 mJ and density of 2,500 microscopic treatment zones/cm2. Photographs courtesy of Dr. Ming Jih.
Permission for publication given by Dermatologic Surgery3
Fig. 14.8 DSAP treated with fractional photothermolysis. (a) The patient’s thigh at baseline. (b) Thigh one month after three treat-
ments with fractional photolysis (Fraxel SR 750). Ecchymosis is unrelated to treatment. (c) Thigh one month after 6 treatments.
Energy settings ranged from 8 to 12 mJ and a final treatment density of 2,000–2,500 MTZs/cm2
of an ongoing study at our facility have shown that parameters range from 10 to 40 mJ when treating off-
fractional photothermolysis may effectively treat face for improvement of pigmentation and texture.
actinic keratoses. High energies (50–70 mJ) should be used with caution
Energy parameters should be appropriate for the and in limited areas only when the maximum
indication being treated (Table 14.3). Usually, energy penetration and remodeling are required, such as
Fig. 14.9 DSAP treated with fractional photothermolysis. (a) Leg at baseline. (b) Leg three months after three treatments with fractional
photothermolysis (second model, Fraxel SR 1500). Energy ranged from 35–50 mJ and treatment level was 10
Fig. 14.10 DSAP treated with fractional photothermolysis. The same patient as in Fig. 14.7: (a) legs at baseline. (b) Three months
after three treatments. Patient reported complete resolution of pruritus associated with the DSAP and was completely satisfied with
treatment
hyperkeratotic lesions. Wound healing is prolonged pendicularly to the skin surface. Treatment density
off-face and treatment levels (TL) should be conserva- is maximized when treating keratoses, including
tive (i.e., TL 6-TL 9). actinic keratoses, in our practice. Thicker, hyperk-
Treatment technique is similar to facial fractional eratotic lesions should receive 2–4 extra passes. The
resurfacing. The laser handpiece should be held per- treated skin edges should be feathered, especially on
Fig. 14.11 DSAP treated with fractional photothermolysis. (a) Patient’s forearm at baseline. (b) Two months after four treatments
with fractional photothermolysis (Fraxel SR 1500). Note biopsy site (biopsy showed actinic keratoses). Energy ranged from 35–50
mJ and treatment level was 10. Patient reported >90% improvement. Physician improvement graded as >75% improved
Table 14.3 Examples of recommended treatment parameters using Fraxel™ off the face
Treatment Level Treatment Level
Off Face Indication Energy Fitzpatrick Skin Type I–III Fitzpatrick Skin Type IV–V
Resurfacing and Lentigines 10–40 mJ 7–11 4–7
Acne and Surgical Scars 20–50 mJ 7–11 4–7
Note that for off-face applications, a more conservative treatment level, or density, is used than for face treatments.
darker skin types, to avoid potential (transient) Laser-Mediated Photodynamic Therapy

postinflammatory hyperpigmentation. This is done with Pulsed Dye Laser (PDL) (595 nm)
by performing fewer passes further out from the
central treatment area. Laser-mediated PDT may be used for keratoses, len-
Posttreatment care is similar to that of facial treat- tigines, and photorejuvenation. Previous studies utiliz-
ment (Table 14.4). The patient should wear loose-fitting ing the pulsed-dye laser as a light source have found
clothing for more comfort posttreatment. that extremity lesions cleared in 83.1% at 10-day post-
In our experience, there have been no severe treatment evaluation and 70.9% at 4-month follow-up,
adverse events, such as blistering or scarring. Post- which is less clearance than that of the face.5 These
treatment erythema and edema may be prolonged results are consistent with those experienced in our
compared to facial treatments and ranges from 5–21 practice. Figure 14.12 demonstrates a patient’s scalp
days posttreatment. one month after a single treatment.
Table 14.4 An example of posttreatment instructions given to patients after fractional

photothermolysis treatment. Courtesy of Dr. Roy G. Geronemus
Pre-op treatment of pulsed-dye laser-mediated PDT See Table 14.5 for the laser-mediated PDT protocol
is similar to treatment of the face (Table 14.5). used in our office. Treatment technique is the same as
In our practice, the following parameters are used that of facial treatment.
for the pulse dye laser after 20% ALA application: 10 Posttreatment care is similar to treatment of the face
mm spot size, fluence range of 7.5–9 J/cm2, and 10 and is listed in Table 14.5.
msec pulse width. A dynamic cooling (tetrafluoro- One of the challenges in using PDT off the face is
ethane) spray is used for pre-treatment and posttreat- ensuring sun avoidance post-therapy. Any type of
ment cooling. The spray is fired twice: 30 msec prior to ambient light may augment the treatment; however,
each laser pulse followed by a 30 msec post-laser pulse excess exposure may cause complications such as
delay. increased edema, erythema, and blistering. The
Fig. 14.12 Actinic keratoses of the scalp treated with laser-mediated PDT. (a) Patient’s scalp at baseline. (b) Patient’s scalp one
month after a single treatment of laser-mediated PDT using the PDL. Please see text for suggested treatment settings
Table 14.5 Pre-treatment protocol, treatment technique, posttreatment protocol used for laser-mediated PDT using
the 595-nm pulsed-dye laser
Pretreatment Confirm diagnosis: lentigines versus AKs
Acetone applied to treatment area
Microdermabrasion of treatment area
Treatment technique 20% ALA application with three-hour incubation
20% ALA re-applied 60 min after first application
Topical anesthetic applied 45–60 min before laser treatment
595-nm pulsed dye laser, 1–2 passes to treatment area (see text for laser parameters)
Posttreatment technique Treatment area cleansed with soap and water
Apply physical sunscreen such as titanium dioxide or zinc oxide
Vigilon hydrogel dressing applied to treatment area for 30–60 min
Patient instructed on strict sun avoidance for two days
Patient instructed to expect desquamation and erythema for 2–3 days.
Biafine emollient is applied to treatment area twice a day for 5–7 days
Aquaphor ointment is applied to rough, dry or scaly areas as needed
Follow-up in 4–6 weeks for evaluation
patient should be counseled that driving gloves and References

long sleeves are necessary, even indoors and during
driving time. 1. Tse Y, Levine VJ, McClain SA et al. The removal of cutaneous
pigmented lesions with the Q-switched ruby laser and the
Q-switched neodymium: yttrium-aluminum-garnet laser. A com-
parative study. J Dermatol Surg Oncol 1994; 20(12):795–800
2. Todd MM, Rallis TM, Gerwels JW et al. A comparison of 3
lasers and liquid nitrogen in the treatment of solar lentigines:
Conclusion a randomized, controlled, comparative trial. Arch Dermatol
2000; 136(7):841–846
3. Jih MH, Goldberg LH, Kimyai-Asadi A. Fractional photo-
Clinicians should tailor their treatment approach based
thermolysis for photoaging of hands. Dermatol Surg 2008;
on clinical setting and maximum benefits for the patients. 34(1):73–78
PDT parameters: ALA incubation time and delivery, 4. Chrastil B, Glaich AS, Goldberg LH et al. Fractional photother-
light source settings, number of treatments, and treat- molysis: a novel treatment for disseminated superficial actinic
porokeratosis. Arch Dermatol 2007; 143(11):1450–1452
ment intervals will be continually refined to deliver
5. Alexiades-Armenakas MR, Geronemus RG. Laser-mediated
maximum efficacy. Future treatment of lentigines and photodynamic therapy of Actinic Keratoses. Arch Dermatol
keratoses will also focus on fractional CO2 devices. 2003; 139:1313–1320
Chapter 15
Treatment of Hand Veins with Sclerotherapy
Neil S. Sadick
Introduction fewer adverse effects, fewer required treatments, and

superior overall benefit. The sclerosing solution and
Sclerotherapy is not a new science, but has evolved blood have greater contact with each other as the air
into a more exact and effective way to shrink aestheti- presses the blood cells against the wall of the vein.
cally undesirable veins, including those of the dorsum Other advantages are that the foam, rather than mixing
of the hand. The technique for treating hand veins by with the blood, actually replaces the blood and is in
sclerotherapy is similar to the technique for treating contact with the vein for a longer period.3
leg veins.1 Clinical trials to evaluate the long-term efficacy and
In sclerotherapy, a sterile “sclerosing” solution is safety of foam sclerotherapy are in progress in Europe
injected into the target vessels that induce inflammation and the US. In the meantime, the following consensus
of the intima layers and destroys the endothelial cells, statements for foam sclerotherapy have been published2:
causing the vessels to collapse and dissolve. Sotradecol
• Sclerosing foam is an appropriate treatment for
(sodium tetradecyl sulfate (STS), ESI Lederle Generics,
varicose veins
Philadelphia, PA) (0.25%) is the only FDA-cleared
• Foam sclerotherapy is a powerful procedure when
sclerosing solution available and is administered by
performed by an experienced surgeon
traditional injection technique.
• Sclerosing foam is more powerful than liquid
A newer option is foam sclerotherapy. Since com-
sclerosing solution
mercial preparations of the foam are not available,
• Most recommendations for conventional sclero-
STS (0.2%) foam, fluid or viscous, must be made in
therapy are applicable to foam sclerotherapy
the physician’s office by either the Tessari or double-
syringe technique. A 3-way stopcock, sclerosing solu- Traditional and foam sclerotherapy are the gold
tion, 3-mL disposable plastic syringe, and 30-gauge standards for treating hand veins. Ambulatory phle-
needle are needed. First, a syringe containing liquid bectomy, endovascular laser treatment, and radiofre-
is connected to a similar air-containing syringe via quency closure are less commonly used.3 Sclerotherapy
the 3-way stopcock. Then, for fluid foam, the liquid causes less trauma than surgical procedures. It is
and air are pumped back and forth 20 times and for also safe, effective, economical, and less dependent
viscous foam, five times with additional pressure and on technique than other procedures. On the downside,
seven times without additional pressure.2,3 Local sclerotherapy may cause bruising, require several
anesthesia is given before injection and ultrasound is sessions to achieve maximum clinical benefit, and may
used to visualize the target vein. When the foam scle- result in extravasation of the sclerosing solution into
rosing solution is injected into the vein, the foam the perivascular tissue, leading to localized cutaneous
forces blood from the vein, oxygen bubbles dissolve, ulcers. (Even the most experienced physician may
and the vein deflates. accidentally inject a small amount of sclerosing solution
Foam sclerotherapy is currently safe, effective, rapid, into the perivascular tissue4).The advantages and
sterile, and reproducible. Compared with traditional disadvantages of sclerotherapy vs. endovenous laser
sclerotherapy, foam sclerotherapy is associated with hand vein ablation (EVLH) are shown in Table 15.1.

100 N.S. Sadick
Table 15.1 Comparison of hand vein sclerotherapy and volume of adipose tissue and dermal collagen. A loss
endovenous laser hand vein ablation (EVLH) of elasticity occurs in both the skin and superficial
Advantages Disadvantages blood vessels. Sun exposure, in turn, produces wrinkles,
Sclerotherapy Nonsurgical May require multiple dyschromia, and protuberant, tortuous varicosities
treatments
Cost effective Risk of extravasation
of the superficial hand veins. Patients consider these
Increased bruising veins cosmetically unacceptable and seek treatment
EVLH Usually single High cost to remove them.1
treatment
Requires minor Requires knowledge of
surgical tumescent anesthesia
intervention
Use of laser fiber Risk of laser skin burns Method of Device and Treatment
Application
Clinical Examination and Patient The size and diameter of hand veins do not determine
History the treatment modality. Rather, the choice is determined
by the physician’s experience and preferences and
Potential candidates for sclerotherapy have protuberant by the patients’ desires. For hand veins, sclerotherapy
veins. Patients can be told that the procedure is simply requires multiple sessions while intravenous laser
the injection of a solution that irritates the lining of procedures require only a single session. The appropriate
the vein which causes the vein to become inflamed, concentrations of foam sclerosing solution for vessels of
collapse, and be absorbed by the body. Patients should various diameters are shown in Table 15.2.
withdraw from antiplatelet medicines, NSAIDS, and The technique for treating hand veins is a simple
aspirin before treatment. Stopping the of antiplatelet injection. Injecting one hand at a time permits the
and antithrombotic medication is not recommended patient to have the use of the other hand while the
except in consultation with and in approval of the pretreated hand recovers. It is possible, however, to treat
scribing physician. There is an evidence that periop- multiple vessels in one session. Posttreatment com-
erative discontinuation of such agents is rarely pression for a few days enhances the results and pre-
associated with serious adverse events increasing pul- vents hyperpigmentation.5 Excessive compression of
monary embolus, stroke, and valvular dysfunction. If a the skin covering the treated vein should be avoided, as
patient is taking daily aspirin for routine health main- it may produce tissue anoxia and subsequent localized
tenance without the instruction of a physician, this cutaneous ulceration.4 Hand sclerotherapy is tech-
may be discontinued as early as 2 weeks before the nique dependent and should be performed only by
procedure and resumed 2–3 days after the procedure. physicians with training and experience. Other than
Physicians should review the histories for anticoagu- the face, hands are the most commonly noticed
lant, disulfram, antabuse, and other sclerosant interac- anatomical area of the body and should be protected
tive medications; coagulation disorders; bruising from photodamage with regular use of sunblocks or
easily; and hand rejuvenation procedures. Pregnancy, antioxidant creams. Clinical examples are shown in
hypercoagulable disorder, recurrent thrombophlebitis, Figs. 15.1–15.4.
connective tissue disease, disabling arthritis, severe
asthma and allergies, soft-tissue infection, severe neuro-
logic or circulatory disease, and chronic hand problems Table 15.2 Suggested concentration of foamed
sclerosant for management of dorsal arch hand veins
(pain, weakness, edema, carpal tunnel syndrome) are with sclerotherapy based upon vein diameter
contraindications for sclerotherapy.1 Vein diameter (mm) STS (%)
Hand veins range from 1 to 6 mm in diameter and 1–2 0.1–0.2
are identified by their ropey, protuberant appearance. 2–4 0.2–0.25
Unlike leg veins, which protrude due to valvular 4–6 0.25–0.5
incompetence, hand veins protrude as we age due to 6–8 0.5–1.0
muscle atrophy, bone demineralization, and loss of STS sodium tetradecyl sulfate
15 Treatment of Hand Veins with Sclerotherapy 101
Fig. 15.1 The right hand of a 64-year-old woman as her dorsal veins receive the first of two treatments with the foam sclerosing
solution. Photographs courtesy of Neil S. Sadick, MD
Fig. 15.2 Gauze secured by elastic adhesive bandage

covering the dorsal vein areas after injection of the foam
sclerosing solution. Both hands were injected in a single
treatment session. Photographs courtesy of Neil S. Sadick, MD
Fig. 15.3 The right hand before the first treatment (left) and 3 months after the final of two treatments (right) with the foam sclerosing
102 N.S. Sadick
Fig. 15.4 The left hand before the first treatment (left) and 3 months after the final of two treatments (right) with the foam sclerosing
To prepare the foam sclerotherapy solution, the solution, and postprocedure wound care materials
following are needed: (elastic adhesive bandage and gauze) for cleaning
purposes and if needed, for compression on injection
• Syringe (3 mL) × 2
sites that bleed.
• Bacteriostatic water, 30-mL vial
Posttreatment care focuses on appropriate compres-
• STS (3%), 2-mL vial
sion of the treated veins. The treated hand is cleaned
• Fluid Dispensing Connector or adaptor
with either hydrogen peroxide or alcohol and gauze. If
• Drape (nonsterile)
bleeding persists at the injection sites, gauze is rolled
• Gloves (nonsterile)
or folded and placed on the bleeding site. Gauze is
• Gauze (nonsterile, 4 × 4 cm)
then secured by elastic adhesive bandage wrapped
• Alcohol prep pads
with appropriate compression (according to the patient,
• Elastic adhesive bandage (5-cm wide, 1 roll)
not too tight or too loose) distally from the wrist, then
The sclerosing solution (STS, 0.25%) is prepared by proximally toward the fingers around the dorsal and
diluting 2 mL STS (3%) with 22 mL bacteriostatic palmar areas of the hand. The compression bandage
water. Remove 8 mL from a 30-mL vial of bacteriostatic should be worn for 24 h after treatment.
water and transfer the entire contents of a 2-mL vial of Adverse effects with sclerotherapy are minimal;
STS (3%) to the remaining 22 mL of bacteriostatic water. hyperpigmentation and ulceration are extremely rare.
Fill one syringe with fresh sclerosing solution and For Posttreatment care, our patients receive 1–3 treatments
draw 1 mL of air into the other syringe. Connect with healing ointment (Aquaphor, Beiersdorf AG,
the two syringes to a Fluid Dispensing Connector Hamburg, Germany) at 4 to 6-week intervals. We treat
(B. Braun Medical Inc., Bethlehem, PA) and depress bruising with vitamin K cream and use arnica to
the plungers to push the sclerosing solution and air accelerate wound healing. Hydroquinone cream can
back and forth until the mixture becomes a foam. Then, be used for whitening skin and retinoid creams for
attach a 30 G ½″ hypodermic fine-inject needle to the repairing photodamage.
syringe with the foam sclerosing solution. Other therapies can be used in combination with
The tray (Fig. 15.5) should include the drape, gloves, sclerotherapy. Dermal fillers such as Radiesse (Bioform
gauze, alcohol prep pads, syringe of foam sclerosing Medical, Inc., San Mateo, CA) or Sculptra (Dermik
15 Treatment of Hand Veins with Sclerotherapy 103
Fig. 15.5 Tray setup. Photographs courtesy of Neil S. Sadick, MD
Laboratories, Inc., Berwyn, PA) correct volume loss Training in sclerotherapy for hand veins is available
in the hands, thus improving the appearance of the through the American College of Phlebology at http://
elevated veins. Fractional laser procedures or plasma www.phlebology.org/.
portrait technology can correct skin wrinkling or
discoloration, and radiofrequency can improve laxity.
Sclerotherapy will eventually give way to endovenous
laser therapy for vein removal because fewer treat- References
ments are required and bruising occurs less frequently
with the laser procedure. 1. Duffy DM, Garcia C, Clark RE. The role of sclerotherapy in
abnormal varicose hand veins. Plast Reconstr Surg. 1999;104:
1474-1479.
2. Breu FX, Guggenbichler S. European consensus meeting on
foam sclerotherapy, April, 4–6, 2003, Tegernsee, Germany.
Conclusion Dermatol Surg. 2004;30:709-717.
3. Sadick NS. Advances in the treatment of varicose veins:
ambulatory phlebectomy, foam sclerotherapy, endovascular
Full-body rejuvenation is the future of aesthetic laser, and radiofrequency closure. Dermatol Clin. 2005;23:
443–455.
medicine. Many technologies are available to improve 4. Goldman MP, Sadick NS, Weiss RA. Cutaneous necrosis,
the face and more people are looking for ways to telangiectatic matting, and hyperpigmentation following scle-
improve the look of their aging hands as well. rotherapy. Etiology, prevention, and treatment. Dermatol
Combination approaches that include radiofrequency, Surg. 1995;21:19-29.
5. Weiss RA, Sadick NS, Goldman MP, Weiss MA. Post-
fractional laser treatment, injectable dermal fillers, and sclerotherapy compression: controlled comparative study of
endovenous laser treatment can improve the hands as duration of compression and its effects on clinical outcome.
well as the face. Dermatol Surg. 1999;25:105-108.
Chapter 16
Treatment of Hand Atrophy with Fat Transplantation
Samuel M. Lam
Introduction is seeking hand rejuvenation that is office-based, I

offer them either hyaluronic-acid-based products or
calcium hydroxylapatite injections to improve the lost
The aging process is multifaceted, encompassing the
volume, albeit temporary as compared to the relative
manifestation of wrinkles, gravity, and volume loss.
permanence of fat injections to the hand. Office-based
The last – soft-tissue, bone, and fat loss – is a relatively
alternatives to hand volume replacement lie beyond
new concept of how aging occurs, and it has become
the scope of this chapter.
the cornerstone to my rejuvenation practice. I truly
believe that volume loss, especially around the eyes, is
the principal expression of aging and merits the most
attention. Fat grafting, which is the subject of this Treatment Application
chapter, is the main method by which I restore lost
volume to the face as well as to the hands. When a
person is clothed, the two exposed parts of the body
Anesthesia Considerations
that give away aging are the face and the hands.
Therefore, I believe that hand rejuvenation can be I perform all fat grafting under either intravenous
secondary only to the face in terms of importance in sedation or full general anesthesia in my own private
overall face/body rejuvenation. surgical suite. Therefore, the techniques that I will
elaborate upon have that inherent bias disclosed. After
the patient is properly sedated, a 50/50 mixture of 1%
lidocaine with 1:100,000 epinephrine and sterile saline,
Clinical Examination 10 cc of each, is injected with a spinal needle into the
fat pad intended for harvesting. Generally, I would
When approaching hand rejuvenation, there are place one 20 cc mixture into the lower abdomen,although
obviously two major components to aging: aging of I prefer placing a 20 cc mixture into each thigh planned
the skin as exhibited by rhytids, dyschromias, and poor for harvesting.
texture/tone and the focus of this chapter, volume loss The hand is then anesthetized with a ring block
with concomitant exposure of deeper structures such consisting of straight 1% lidocaine with 1:100,000
as the veins and bones. Fat grafting to the hands is epinephrine across the dorsum of the wrist, with a second
targeted to manage volume loss. However, I have seen ring placed just distal to that first block, again along
some textural improvements to the skin along with the dorsum of the wrist. A total of usually 2–3 cc per hand
reduction in surface dyschromias over a period of a is all that is necessary to achieve adequate anesthesia
year or more. The current thinking as to why this may to the entire dorsum of the hand with this double-
occur focuses on possible stem-cell changes to the ring block technique to the dorsal half of the wrist.
skin overlying the transplanted fat. This dermatologic Finally, additional local anesthesia of 1% lidocaine
improvement does not consistently occur and should with 1:100,000 epinephrine is infiltrated into the sites
not be proffered as a guarantee of any kind. If the patient where skin entry will be undertaken with the 18-gauge

106 S.M. Lam
Fig. 16.1 Triport cannula (Tulip, Inc.)
needle (through which the cannula will be introduced).

More specifically, each quadrant of the dorsum along
with access points for each proximal phalanx is
infiltrated with a small aliquot of local anesthetic.
Direct local anesthesia into the entire dorsal hand is
unnecessary and will cause unwanted ecchymosis and
tissue distortion.
Fat Harvesting
Fat is harvested from the areas where a patient is most

recalcitrant to lose fat, e.g., lower abdomen for men
and either lower abdomen or thighs for women. Fat
Fig. 16.2 Johnny Lock (Tulip, Inc.)
harvesting is undertaken with a harvesting cannula
(I prefer the Triport model (Fig. 16.1) manufactured
by Tulip Inc., San Diego, CA)1 attached to a 10-cc
Luer-Lok syringe. A 16-Gauge Nokor needle is used to
bed will promote overharvesting of one area since the
make the stab incision through the skin as an entry point,
cannula tip in effect has not moved over to the adjacent
inferior aspect of the umbilicus to access the lower
site, which can in turn create contour problems in
abdomen and along the inguinal line for the thighs.
the donor area. When harvesting the inner thigh, the
I have also found that a Johnny Lock device (Tulip Inc.)
surgeon should keep the leg to be harvested straight
(Fig. 16.2) can help maintain 2–3 cc of negative suction
and not bent to minimize the occurrence of a contour
pressure on the syringe without manually having to
problem. Furthermore, the cannula should pierce through
hold that pressure with one’s fingers, which greatly
an initial fascial layer so that the cannula cannot be
alleviates strain injury. With the aforementioned 2–3 cc
seen abrading the skin or causing tenting changes to
of negative pressure on the syringe, the fat is harvested
the overlying skin, which would indicate too superficial
and then prepared for processing, to be described.
a harvest and the potential for contour problems in the
A few technical points should be emphasized for
donor area.
the novice surgeon undertaking fat harvesting. It is
The total amount of fat to be transplanted per hand
important to retract the harvesting cannula almost all
varies between 20 cc for a conservative injection and
the way back to the skin entry point before readjusting
30 cc for a more aggressive transplant and 25 cc on
the cannula tip to the next adjacent site for harvesting.
average. For a normal harvest that is not too bloody,
Simply twisting the cannula tip over to the adjacent fat
expect about 50% of the 10 cc syringe to contain usable
fat. Accordingly, to attain 25 cc per hand or 50 cc total
I have no financial affiliation with any medical device or any
1 of viable fat, one will most likely need 10 syringes.
medical companies. I typically place between 35 and 55 cc of fat into the
16 Treatment of Hand Atrophy with Fat Transplantation 107
face for facial rejuvenation, so you can see that the Fat Injections
hands require quite a bit of fat to achieve a durable and
appreciable change. Whereas I do not overfill the face, Fat injection into the hand is one of the technically
I tend to overfill the hands by about 20% since they are easiest procedures to perform when undertaking fat
highly mobile and are prone to a little bit of absorp- grafting. If one is just starting out with fat transfer,
tion. Also, a hand that is slightly overfilled and main- comfort level can be attained by starting with some
tains the fat will not in most cases be noticeable to an hand fat transfers. Unlike the face where fat grafting
observer. Conversely, a face that is even slightly over- into a prescribed area cannot be readily adjusted after
filled can be deforming. injection, the fat immediately just transplanted into the
hand can be easily spread out and smoothed with
gentle digital manipulation.
Fat transfer to the hand is directed at two principal
Fat Processing areas for correction: the dorsum of the hand and the
sides of the proximal phalanages, with the former area
To attain a purified column of fat, free of lidocaine, being the most important aesthetic area to rejuvenate.
blood and lysed fat cells, centrifuge the syringe outfit- As mentioned, all entry sites are created with an 18-gauge
ted with specialized caps and plugs at 3,000 rpm for stab incision. Starting with the fingers, the injection
3 min duration then pour off the supranatant consisting cannula (I prefer the Tulip 1.2 mm cannula as my
of oily lysed free fatty acids and then drain off the workhorse injection cannula) is used to inject approxi-
infranatant consisting of blood and lidocaine. Place a mately 0.5 cc into each side of the proximal phalanx.
4 × 4 gauze into the open back side of the syringe to The easiest port of entry is at the base of the proximal
wick away any remaining oily supranatant for 5–10 min phalanx in the interphalangeal space, which can be
before loading the fat into 1 cc syringes in preparation used to access the sides of two adjacent fingers. For the
for injection. dorsum of the hand, I like to divide the dorsum into
Fig. 16.3 Hand fat transfer using 20 cc per hand across the dorsum and proximal phalanges and shown before (a,c) and a year after
surgery (b, d)
108 S.M. Lam
four quadrants and place between 4 and 5 cc per quadrant. for compressive dressings of any kind. Although no
Then, feather between 1 and 3 cc of fat into the dorsum strict restrictions in hand movement are required, a
of the hand by coming back through the points that general limitation in excessive manual labor should be
were used to access the proximal phalanges and spread entertained for the first 7–14 days. The hand will in
the fat in a wide arc to make sure that the grafted fat general look a bit puffy for the first 4–6 weeks, but
that was originally performed per quadrant appears as the hands are an area that is not often studied in
smooth and free of any abrupt transitions. Again, detail, the distortion oftentimes escapes detection. Hand
any fat that appears lumpy after transplantation can rejuvenation with fat grafting can provide a wonderful
be easily remedied by gentle digital manipulation and durable aesthetic enhancement with minimal
immediately after injection. morbidity (Fig. 16.3).
Postoperative Management
Reference
There is really no postoperative management except 1. Lam SM, Glasgold MJ, Glasgold RA. Complementary Fat
application of ice to minimize edema and soreness for Grafting. Philadelphia, PA: Lippincott, Williams, & Wilkins;
the first 48–72 h following surgery. There is no need 2007.
Part V
Arms (and Legs)
Chapter 17
Reduction of Arm Fat by Liposuction
Hayes B. Gladstone
Introduction generalized accumulation of subcutaneous fat with

moderate skin laxity, group 3: generalized obesity and
extensive skin laxity, and group 4: minimal subcutaneous
While liposuction of the abdomen, flanks, and hips
fat and extensive skin laxity.1 In all patients, it is essential
remains the most popular areas for contouring, the
to evaluate the skin tone with the pinch test to ensure that
upper arm is a significant esthetic concern for most
the skin will shrink adequately to give a cosmetically
women. A properly contoured arm enhances the fit of
acceptable result. Patients with minimal to moderate
blouses and dresses. Tapered upper arms are viewed
subcutaneous fat with minimal skin laxity have a cir-
as a sign of youth and vigor. Despite vigorous activity
cumferential increase in fat volume but adequate skin
and weight training, fatty deposits and lax skin may
turgor and elasticity. These individuals can benefit
remain in the posterior triceps aspect of the arm extend-
greatly from tumescent liposuction of the posterior arm
ing to the axilla. This upper arm deformity progresses
without the need for brachioplasty. Patients described in
with age into what is known as “butcher” arms.
groups 2 through 4 will require increasingly more aggres-
The surgical rejuvenation of the upper arm remains a
sive surgical interventions, with more noticeable scar-
persistent challenge despite the many techniques that
ring, to address the ptosis of the skin.
have been proposed for its improvement.1 With the
advent of tumescent liposuction of the arm, removal
of excess fat can be accomplished easily with minimal Contraindications
scarring and fewer complications.2,3 The problem of
newly created or preexisting skin ptosis remains in those
patients with poor elasticity of the skin. For excess skin, Absolute contraindications include active infection,
a limited excision brachioplasty can be performed. blood clotting disorders, and pregnancy. Relative con-
traindications include a history of keloids, hypertrophic
scarring, or any condition with healing abnormalities.
Indications Relative contraindications include significant weight
loss resulting in very loose skin. A full brachioplasty
would be indicated.4,5
Tumescent liposuction of the medial and posterior arm
is indicated for the recontouring of the arm in patients
with excess fat and good skin elasticity. Treatment Application
Clinical Examination and Patient History Procedural Protocol
Upper arm changes can be divided into four general Tray Setup
categories with different treatment options for each.
These groups include group 1: minimal to moderate There should be up to three trays. The first is for the
subcutaneous fat with minimal skin laxity, group 2: tumescent anesthesia. A 20-gauge spinal needle is

112 H.B. Gladstone
Fig. 17.1 Infiltrating the tumescent anesthesia
attached to a Klein pump. The second tray contains the

cannulas for this procedure, 16- and 14-gauge micro-
cannulas should be used. These are used with suction.
Though some practitioners use ultrasound liposuction,
this increases the risk of burns, particularly in this ana-
tomic region. A third tray with an excision tray is
needed if a limited excision brachioplasty is being
considered.
Relevant Anatomical Structures
The main venous drainage of the arm is provided by Fig. 17.2 Marking the upper arm
the basilic vein on the medial arm and the cephalic
vein overlying the biceps brachii muscle. The posterior
cutaneous and inferior lateral cutaneous nerves of the Technique
arm, which are derived from the radial nerve, providing
sensation to the posterior and lateral arm. Sensation of Following informed consent and photos from the
the superior posterior arm is provided by the superior anterior, oblique, and posterior perspectives, the skin
lateral cutaneous nerve, which is derived from the is marked. The patient should be sitting with the
axillary nerve. The ulnar nerve, which has no branches arm abducted. The distal extent of the liposuction is
above the elbow, is most superficial at the medial approximately 1 cm proximal to the epicondyle groove.
epicondyle. Unlike the cutaneous nerves of the posterior At the lowest point of the posterior upper arm, the skin
arm derived from the radial nerve, the ulnar nerve is is pinched between the finger and thumb. This maneuver
deep to the fascia enveloping the muscles of the arm. will determine the medial and lateral boundaries of the
liposuction. The proximal border of the liposuction is
in the preaxillary groove just distal to the axilla proper.
Anesthesia A line should connect these boundaries creating a
rectangular area where the liposuction will be performed.
One percent lidocaine with 1:100,000 epinephrine is The sidewall of the chest extending posteriorly to the
used to anesthetize the puncture sites and 0.1% lidocaine back is often included in the liposuction since it further
with 1:1,000,000 epinephrine is infiltrated using a Klein defines this region (Figs. 17.2 and 17.3). As for most
pump. Depending on the size of the arm, 200–400 cc’s patients, there will be at least some ptotic proximal
are infiltrated (Fig. 17.1). Because this procedure is skin which would benefit from the additional tightening
minimally invasive, sedation is not required. provided by a limited excision axillary brachioplasty.6
17 Reduction of Arm Fat by Liposuction 113
This excision is defined by a simple ellipse hidden be made at the edge of axilla so that liposuctioning
within the axilla. Its anterior and posterior apices can also be performed from a proximal to distal manner.
are defined by those respective borders of the axilla. This will result in a smoother result. If a brachio-
The width of the ellipse is determined by the amount plasty is being performed, then the liposuction can enter
of posterior arm skin that can be grasped between through this excision.
finger and thumb. A typical ellipse is between 2 and The excision is performed down to the subcutaneous
4 cm in width. plane avoiding deeper vessels and nerves in this area.
While external ultrasound can be used, it is not usu- Some sweat glands may also be removed, and the
ally necessary since the fat is not very fibrous in the patient should be educated before the procedure that
posterior arm. Following tumescent anesthesia, a nick there may be less perspiration in this area following
incision with an 11 blade is made just proximal to the the surgery – most patients welcome this added benefit.
elbow. Using a microcannula, for instance, an 18-, 16-, or Undermining is performed in order to reduce tension
14-guage Capistrano, or a 16-, or 14-guage Klein, long on the wound (Fig. 17.5). It is then closed with 3–0
sweeping strokes are used in order to prevent an uneven vicryl buried sutures and 4–0 nylon running epidermal
result (Fig. 17.4). Similar to other anatomic areas, a sutures (Fig. 17.6). Occasionally dog ears may form, and
layer of fat should be left to avoid dimpling. While the should be removed which may extend the incision on
patient may want dramatic results, over liposuctioning to the posterior arm. A postoperative dressing is applied
will result in an unnatural appearance and disharmony which should have a Coban wrap (Fig. 17.7a–d).
with the forearm. A liposuction entry point should also
Postoperative Instructions
Patients should keep the arms wrapped for the first

24 h. Unlike tumescent liposuction of other areas
where there may be significant drainage, it is minimal
in this location. At the first dressing change, the wounds
should be cleaned with dilute hydrogen peroxide and
polysporin and nonstick Telfa bandages should be
applied. A coverlet band aid can cover the Telfa.
Bandages are changed on a daily basis. A compression
arm garment should be worn for up to 2 weeks which
will decrease swelling and bruising and may aid in
Fig. 17.3 Marking the chest wall and posterior extension uniform skin contraction. When the limited excision
Fig. 17.4 Using a 14G microcannula and liposuctioning in broad, crisscrossing strokes

114 H.B. Gladstone
Fig. 17.6 Brachioplasty incision closed with 3-0 vicryl and 4-0

Fig. 17.5 Following the limited axillary brachioplasty incision nylon. No drain is needed since this is a superficial excision
Fig. 17.7 (a) Pre-right arm anterior. (b) Post-right arm anterior. (c) Pre-right arm posterior. (d) Post-right arm posterior
17 Reduction of Arm Fat by Liposuction 115
brachioplasty is performed, it is imperative that the 5. The depth of the brachioplasty incision only needs to
patient does not extend her upper arms beyond ninety go to the subcutaneous level. This will prevent any
degrees, or lift objects for 4–6 weeks. type of potential nerve damage or lymphedema.
6. Because the brachioplasty ellipse is within the axilla,
the patient may have the added benefit of decreased
axillary hidrosis.
Complications
Minor complications include ecchymosis and swelling.

Other complications include hematoma, infection, keloid Conclusion
or hypertrophic scarring, nerve damage, and asymmetry.
There can also be dimpling if a thin layer of fat is not The upper arm is often an overlooked cosmetic unit. Yet,
maintained as well as striae if the liposuction is too it plays an important role in fashion and what society
superficial. Dehiscence of the incision is a risk for considers being active and fit. Upper arm rejuvenation
the limited excision brachioplasty if the upper arm is with tumescent liposuction and limited excision
extended. brachioplasty is a minimally invasive method for
producing more esthetically appealing arms. Recovery
time is relatively short and serious complications are
rare. This procedure should be in every dermatologic
Pearls surgeon’s cosmetic procedure armentarium.
1. Tumescent anesthesia is the key to this procedure

and allows it to be performed under local anesthesia
in an office setting. References
2. When performing liposuction, use 12 inch cannulas
so that there are long smooth strokes. As with any 1. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm.
other anatomic region, multiple entry points will Plast Reconstr Surg. 1998;102(2):545-551.
2. Lillis PJ. Liposuction of the arms. Dermatol Clin. 1999;17(4):
result in a smoother outcome. 783-797.
3. At the distal aspect of the upper arm near the elbow, 3. Lillis PJ. Liposuction of the arms, calves and ankles. Dermatol
avoid suctioning medially since this may increase Surg. 1997;23(12):1161-1168.
the risk of ulnar nerve injury. 4. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to
upper arm contouring. Plast Reconstr Surg. 2006;118(1):
4. If liposuction is indicated, then in most of these 237-246.
patients, there will also be sufficient skin laxity at 5. Hurwitz DJ, Holland SW. The L brachioplasty: an innovative
the proximal upper arm to perform a limited excision approach to correct excess tissue of the upper arm, axilla, and
brachioplasty. This excision will produce much tauter lateral chest. Plast Reconstr Surg. 2006;117:403-411.
6. Trussler AP, Rohrich RJ. Limited incision medial brachio-
skin and contour when compared with liposuction plasty: technical refinements in upper arm contouring. Plast
alone or a skin tightening device. Reconstr Surg. 2008;121:305-307.
Chapter 18
Reduction of Excess Arm Skin via Surgical Excision
John Y.S. Kim, Robert D. Galiano, and Donald W. Buck
Introduction Clinical Examination and Patient History
With natural aging or with significant weight loss, the Patients seeking brachioplasty should be approached
skin and soft tissue of the upper arm undergo changes in a similar fashion as those seeking any cosmetic surgi-
in their fat-skin composition and elastic properties. cal intervention. A thorough history should be obtained,
The relative laxity of supportive tissue and the relative with a focus on existing comorbidities, such as cardio-
excess of skin vis-à-vis underlying subcutaneous fat pulmonary disease, diabetes, or other chronic illnesses,
will lead to varying degrees of upper extremity ptosis. which could place them at risk for adverse events.
Not only is the appearance of this excess skin cosmeti- Sound clinical judgment should be used when deter-
cally problematic, but can also be functionally impair- mining a patient’s candidacy for exposure to surgical
ing with redundant soft tissue hampering adduction of and general anesthetic risk. It is also important to
the arm and occasionally leading to dermatitis within obtain a detailed past surgical history, documenting
the folds. any prior upper extremity procedures that might alter
In cases of milder upper arm excess and milder the anatomic position of integral upper arm and axil-
ptosis, where the skin has retained elasticity, liposuc- lary structures. Prior surgery of the arms or axilla could
tion alone may be an option. However, when the skin affect the viability of brachioplasty flaps and also – in
excess and laxity are more pronounced, direct surgical the case of axillary node dissection – enhance the risk
excision – brachioplasty – is necessary. Since brachio- of lymphedema. It is imperative over the course of the
plasty was first described in 1954 by Correa–Iturraspe consultation to establish the patient’s motivation for
and Fernandez, the essential promise and pitfall of bra- seeking out surgical assistance and to counsel them
chioplasty have remained the same: to restore normal regarding their overall expectations and the expected
contour by excision of excess skin while concomi- surgical outcome.
tantly minimizing visible scars. Finally, after a thorough history has been obtained,
There has certainly been a recent surge of interest it is important to conduct a detailed physical examina-
in brachioplasty with the heightened interest in both tion, including documentation of cardiopulmonary
aesthetic and bariatric surgery. According to recent exam findings. In addition to the overall appearance of
statistics from the American Society of Plastic the skin and soft tissue of the upper extremity, it is
Surgeons (ASPS), there were 14,886 brachioplasty imperative to conduct a full neurovascular examina-
procedures performed in 2006 alone – an increase of tion. Preoperative assessment of upper extremity motor
over 4,300% since 2000.1 Moreover, as bariatric sur- and sensory function is crucial and becomes important
gery continues to improve technologically and com- in the postoperative period if motor or sensory deficits
mand a greater presence in the modern healthcare are encountered. The proper physical exam should be
milieu, subsequent postbariatric surgery for the body conducted with the patient standing or seated in an
contouring, including the upper arms, is projected to upright position, with both arms abducted at 90°
increase significantly. from the trunk. In this position, excess skin is easily

118 J.Y.S. Kim et al.
visualized and can be better characterized via palpation At the proximal aspect of the upper arm, within the
and the “pinch test.” axillary fold, it is best to tailor the incision by first gen-
Several surgeons have attempted to establish grading erating an axillary reference line. The axillary refer-
systems of upper extremity skin ptosis as a way to deter- ence line is highlighted by drawing a short line within
mine the appropriate surgical technique for upper extrem- the axillary fold, at the proximal aspect of the upper
ity rejuvenation.2,3 In general, it is best to approach the arm, which is perpendicular to the upper arm reference
upper arm with regard to two major factors: the degree of line. Along the axillary reference line, you can again
subcutaneous fat deposition and overall amount of skin use the pinch test to set your incisional borders and
excess. Patients who suffer from excess fat deposition, determine an acceptable amount of skin excess to
but lack skin excess, probably benefit most from upper excise. Some surgeons have advocated the use of a
extremity suction lipectomy. Patients who have excess z-plasty within the axillary fold, instead of a wedge
skin, regardless of fat deposition, will require brachio- pattern, to reduce the overall tension within the fold
plasty for best results. If patients have both excess fat after excess skin has been excised (See Fig. 18.1).
deposition and excess skin, suction lipectomy and After generating skin markings, finish the preopera-
brachioplasty can be judiciously performed in tandem. tive assessment by reexamining both arm markings
Some cosmetic surgeons prefer to use suction lipec- together to assess for symmetry and accuracy. If dis-
tomy on all patients undergoing brachioplasty, regard- crepancies are apparent, repeat the marking process to
less of fat deposition characteristics. It is their belief insure accuracy, remembering the tenet: look twice,
that suction lipectomy reduces upper arm volume cut once. The above marking technique, without
without damaging important lymphatics, nerves, or z-plasty, will generate a closure pattern and scar in the
vessels, and allows better tissue mobilization. shape of a T.
The patient should be placed under general anesthe-
sia for the procedure. They should be placed in the
supine position on the operating room table, with both
Treatment Application arms abducted to 90°. The upper extremities should be
prepped circumferentially with sterile prep solution,
On the day of surgery, it is imperative to mark the patient remembering to apply also a wide prep to the axilla.
preoperatively. Again, have the patient standing, or Routine sterile draping should also be used.
seated in the upright position, with both arms abducted Of note, if suction lipectomy of the upper arms is
90° from the trunk. With your hands, palpate the inter- also being performed, it is generally performed first,
muscular groove on the inferomedial aspect of the upper prior to skin excision. Depending on the degree of
arm, between the biceps and triceps muscles. With a skin elasticity of the skin and overall surgical plan, the lipo-
marker, trace along the intermuscular septum from the suction can be performed just prior to the excision or
axilla to the medial epicondyle of the humerus. This line staged as a separate earlier procedure.
will act as a reference, and represents the positioning of Once the patient is prepped and draped, incise the
the future scar. Next, using the pinch test centered about skin along your preestablished incision borders. It is
your reference line, you can easily trace out the borders imperative to remain superficial with your incisions, as
of your upper and lower incision lines, creating an ellipse only the excess skin should be removed. Incision into
of “excess” skin that can be excised. A conservative and dissection of deeper tissue planes places important
approach is generally preferred, as it is easy to remove neurovascular structures at risk, especially those struc-
extra skin margins in the operating room if warranted. tures with a superficial course, including the medial
With regard to the axillary skin excess, several tech- antebrachial cutaneous nerve and the medial brachial
niques have been described and are available to the cutaneous nerves which perforate the intermuscular
surgeon, including the use of a wedge, L, or T pattern septum to supply the skin and soft tissue of the medial
incision.5,6 Axillary and trunk skin excess is discussed upper arm. In addition, deep dissection could lead to
in a separate chapter, thus only upper arm skin excess lymphatic disruption and the development of a lym-
is presented here. It is important to keep in mind that phocele or seroma (Fig. 18.2).4 Particular attention
massive weight loss patients may require reduction of should be paid to the axillary incisions, so as to avoid
both upper arm and axillary skin for optimal results. injury to both major vascular and lymphatic networks.
18 Reduction of Excess Arm Skin via Surgical Excision 119
Fig. 18.1 Preoperative skin markings. This image shows the proper preoperative markings for the brachioplasty procedure. The
reference line is indicated by the dotted line. The upper and lower incision lines were created by using the pinch test about the refer-
ence line. The elliptical incision marking within the axilla were also created using the pinch test. Orienting the axillary incisions
perpendicular to the upper arm incision will help to pull the skin taught into the axilla, enhancing the upper arm “lift”
Fig. 18.2 Intraoperative skin excision. This image details the dissection plane for proper excess skin excision. Carrying your
dissection plane too deep within the subcutaneous tissue can injure the lymphatics and lead to an increased risk of seroma formation
Once the skin is incised and the superficial layer is two major functions: minimizing deadspace and reducing
dissected free from the field, it is time to turn your tension on the epidermal layer. If a large deadspace
attention to wound closure and skin approximation. exists, a small Jackson-Pratt (JP) drain can be placed
Adequate hemostasis is crucial to limit the risk of to reduce the risk of postoperative hematoma/seroma.
hematoma formation. The remaining wound should be After adequate deep dermal closure, a 4–0 absorbable
closed in layers. The deepest layer is closed using a suture can be used to approximate the epidermis via a
3–0 absorbable suture (Fig. 18.3). This deep layer serves subcuticular stitch. Alternatively, a 4–0 nonabsorbable
120 J.Y.S. Kim et al.
despite numerous technique modifications, unsightly

and/or hypertrophic scars have not been eliminated
altogether. Patients should be instructed on appropriate
postoperative care, including the reduction of suture
line stress and tension, as well as how to recognize
infection/dehiscence. They should be seen in clinic for
follow-up examination on regular intervals to insure
proper wound healing. If hypertrophic scarring devel-
ops, steroid injections and pressure dressings have
been used with variable results. In severe cases, where
possible, scar revision may be necessary.
Fig. 18.3 Intraoperative skin closure. This image depicts the

brachioplasty defect just prior to skin closure. Penetrating towel
Conclusion
clips can be used to help align the skin edges and reduce the tension
while sutures are being placed
The number of patients seeking surgical assistance
with upper extremity rejuvenation is rising exponen-
tially (over 4,300% increase since 2000). This number
suture can be used to close the epidermis in a running
will only continue to climb as the baby boomers age
fashion. Steri-strips can be applied to add an extra ele-
and the number of bariatric procedures increases.
ment of support. The incision should be dressed with
Brachioplasty remains the gold-standard treatment of
sterile gauze and the entire upper extremity wrapped
upper extremity skin excess, and can be performed in
with ACE bandages. The compressive dressing should
conjunction with liposuction when indicated. There
be kept in place for 5–7 days. JP drainage should be
are a number of standard incisions, technical modifica-
carefully monitored. To reduce seroma formation, the
tions, and evolving strategies regarding differential
drain should not be removed until there is less than
liposuction which will continue to enhance outcomes
30 mL of drainage over 24 h.
and scar cosmesis after the brachioplasty procedure.
With proper patient selection and counseling and a
thorough understanding of upper extremity anatomy,
brachioplasty can be performed safely with excellent
Outcomes and Complications cosmetic results and overall patient satisfaction.
The most common complications resulting from bra-

chioplasty are similar to other procedures involving
excess skin excision. In a recent review within the lit- References
erature, the reported incidence of complications after
brachioplasty was approximately 25%.4 The majority 1. 2000/2005/2006 National plastic surgery statistics. American
Society of Plastic Surgeons. http://www.plasticsurgery.org.
of these complications were minor, requiring reopera- Accessed 1.30.2008.
tion in only 5% of cases. The most common complica- 2. Cannistra C, Valero R, Benelli C, Marmuse JP. Brachioplasty
tions encountered were seroma formation and after massive weight loss: a simple algorithm for surgical
hypertrophic scarring (10%), followed by cellulitis and plan. Aesth Plast Surg. 2007;31:6-9.
3. Khatib HA. Classification of brachial ptosis: strategy for treat-
wound dehiscence (7.5%). Although complications ment. Plast Reconstr Surg. 2007;119:1337-1342.
can occur commonly, when encountered they can gen- 4. Knoetgen J, Moran SL. Long-term outcomes and complications
erally be treated conservatively with good results. associated with brachioplasty: a retrospective review and cadav-
The most difficult aspect to address following bra- eric study. Plast Reconstr Surg. 2006;117(7):2219-2223.
5. Pascal JF, Le Louarn C. Brachioplasty. Aesth Plast Surg.
chioplasty is overall scar cosmesis. It is important that 2005;29:423-429.
patients undergoing brachioplasty understand that they 6. Strauch B, Greenspun D, Levine J, Baum T. A technique of
will have a visible scar postoperatively. Unfortunately, brachioplasty. Plast Reconstr Surg. 2004;113(3):1044-1048.
Chapter 19
Skin Tightening of the Arms and Legs
with Radiofrequency and Broadband Light
Matthew J. Mahlberg, Julie K. Karen, and Elizabeth K. Hale
Introduction In contrast to most dermatologic lasers that are

coherent light sources and target-specific chro-
With increasing age, skin that was once full and firm mophores, RF energy is produced by an electrical cur-
begins to sag, developing laxity and redundancy. rent. RF energy produces a thermal effect when its
Traditionally, a surgical procedure was required for high-frequency electrical current flows through target
treatment of this laxity as in rhytidectomy, browlift, or skin and encounters tissue of high impedance in the
brachioplasty. More recently, technological advances deep dermis and subcutaneous fat.1 These properties
have shifted the treatments toward nonsurgical alterna- allow RF to circumvent energy scatter and absorption
tives in place of plastic surgery. Further refinement by epidermal pigment and therefore, generate signifi-
toward nonablative tissue remodeling has proven pop- cant thermal energy within deeper tissue layers. This
ular because of its efficacy and markedly reduced three-dimensional volumetric heating of the deep der-
downtime and complication rate. The major emphasis mis leads to collagen denaturation, remodeling, and
in the field of nonablative tissue remodeling has been tissue contraction.2 Ultimately, these effects lead to
on facial rejuvenation; however, these techniques can improvement in skin laxity without alteration of the
be applied to other areas of the body as well. Of par- superficial portions of skin.
ticular interest has been the development of the non- RF devices have one of two different electrode con-
surgical techniques for areas of loose skin on the figurations–monopolar or bipolar. Monopolar devices
posterior upper arms and around the knees, sites of have two electrodes, one that emits the RF energy and
concern particularly for many women. These areas of a second dispersive electrode that serves as a ground-
tissue redundancy are troublesome as they can be dif- ing pad. Monopolar devices are characterized by high
ficult to otherwise treat and are not necessarily a reflec- power density and relatively deep penetration
tion of body weight or thinness. Certain devices, (Fig. 19.1). In contrast, bipolar devices have two iden-
particularly radiofrequency (RF) and broadband light tical electrodes set at a short, fixed distance. Electrical
sources, have demonstrated utility for tightening and current flow is restricted to this small distance, result-
nonsurgical contouring of mild to moderate skin laxity ing in a more controlled current distribution, but sig-
in these regions. nificantly less depth of power penetration.3 Examples
RF and broadband light sources are well-established, of currently available RF devices are found in
nonablative modalities for the treatment of unwanted Table 19.1.
structural changes and can be particularly useful for Intense pulsed light (IPL), a form of broadband
body contouring and the treatment of mild to moderate light, is frequently used for photorejuvenation. Tradi-
laxity on the arms and legs. These noninvasive devices tionally, IPL uses a flashlamp combined with optical
produce directed delivery of energy to deep dermal filters selective for wavelengths between 500–900 nm
tissue, inducing collagen contraction and dermal remod- to target melanin and hemoglobin. This form of IPL is
eling eventuating in neocollagenesis. However, these well established as a nonablative method to reduce
techniques differ substantially with respect to their telangiectasias and pigmentary alteration and improve
specific mechanisms. superficial skin texture.4 Histologic examination of

Fig. 19.1 Heating profile of the STC tip and DC tip (Thermage, Inc.)
Table 19.1 Devices utilizing radiofrequency for tissue tightening Table 19.2 Devices utilizing broadband infrared light for
Device name Manufacturer Type tissue tightening
ThermaCool NXT™ Thermage Monopolar RF Wavelengths
and TC™ Device name Manufacturer targeted
Polaris™ Syneron Bipolar RF Starlux IR® and Palomar 850–1,350 nm
with diode (900 nm) DeppIR®
ReFirme™ Syneron Bipolar RF Titan™ Cutera 1,100–1,800 nm
with diode (900 nm) SkinTyte™ Sciton 800–1,400 nm
Aluma™ Lumenis Bipolar RF
with vacuum
Accent/Accent XL™ Alma Lasers Unipolar Combination treatment options utilizing radiofre-
and bipolar RF
quency with a variety of light sources have been
designed with the hope of augmenting the actions of
skin after treatment with these devices exhibits new both treatments while minimizing adverse effects.
upper papillary dermal collagen formation.5 More Examples of such devices are outlined in Table 19.3.
recently, though, IPL devices utilizing broadband Termed electro-optical synergy, the optical energy pro-
infrared light (wavelengths: 800–1,800 nm) have been vided by the light source preheats dermal structures,
introduced. These longer wavelength devices target creating a temperature differential between targeted
water as a chromophore and achieve penetration to the structures and adjacent tissue. The temperature changes
deep dermis, thereby eliciting collagen denaturation allow for more targeted RF energy application, reduced
with subsequent remodeling.6 The epidermis is pro- impedance, and ultimately lowered optical energy lev-
tected through contact cooling allowing for deep heat- els.1 In addition to improving skin texture and laxity,
ing without epidermal damage. Examples of broadband other aspects of skin rejuvenation are improved such
infrared light devices are found in Table 19.2. as rhytides, pigmentation, and vascularity.
19 Skin Tightening of the Arms and Legs with Radiofrequency and Broadband Light 123
Table 19.3 Combination radiofrequency and light devices for To minimize the risk of burn injury while using these
tissue tightening tissue tightening devices, all residue on the skin sur-
Device Manufacturer Components face should be removed with a gentle cleanser. This
Aurora SR™ Syneron RF + IR (400–980 nm; includes wiping the skin clean of any topical anes-
580–980 nm;
680–980 nm) thetic. Infiltration of local anesthesia should be avoided
Polaris WR™ Syneron RF + Diode (900 nm) as this may unpredictably alter tissue resistance and
ReFirme™ Syneron RF + IR (700–2,000 nm) potentially increase the risk of thermal injury.
VelaSmooth™ Syneron RF + IR The skin must always have a generous layer of cou-
(700–2,000 nm) + Vacuum pling fluid (before radiofrequency) or cooling gel
(before broadband light sources) to further minimize
the risk of burn injury. Grid markings may be applied
Clinical Examination before the procedure is initiated to facilitate tracking
which areas have already been treated. These grid pat-
These nonsurgical skin tightening modalities can
terns are often included with the device. Alternatively,
provide skin tightening and improvement of skin
a white gel pen can be used to mark the skin before the
redundancy with minimal complications, no down-
procedure. Care must be taken to avoid any type of
time, and no surgical incision. Still, appropriate patient
marking which may contain metal, as there is a theo-
selection and counseling is essential to ensure proce-
retical risk of inadvertent burn if the device comes into
dural success and patient satisfaction. The best candi-
contact with metal residues. It is helpful to mark the
dates for the procedure are those with mild to moderate
areas to be treated while the patient is standing, so that
skin laxity and minimal excess fat in the treatment
the dependent areas are more prominent. This is espe-
area. Common areas for treatment include the poste-
cially useful for the loose skin which is common
rior upper arms and the anterior thighs, just proximal
around the knees. When the patient assumes a recum-
to the knees. Patients with more severe laxity, excess
bent position, a return pad needs to be affixed to the
fat, or those who want more dramatic improvement
patient if a monopolar radiofrequency device is being
should be counseled to consider an alternative surgical
utilized.
procedure. Prior to performing the procedure, all
When treating nonfacial skin, treatment parameters
patients should be counseled to ensure realistic expec-
should be adjusted to reflect anatomic differences such
tations. Pre- and postprocedural photographs and mea-
as increased skin thickness and the absence of underly-
surements may be taken with standardized lighting and
ing vital structures. Particular attention should be paid
positioning to illustrate treatment outcome which may
to sensitive areas including the inner arm and inner
be subtle to the patient’s eye. Finally, as with any med-
thighs. In general, higher energy levels are used to treat
ical procedure, a thorough medical history should be
the arms and legs relative to the face. For certain
performed to ascertain the patient’s general health and
devices (i.e., Thermage™), a designated tip with a
exclude patients with specific contraindications.
larger surface area is used to treat the arms and legs.
Special consideration should be given to patients with
Patient feedback is very important with these tissue
tattoos over the areas to be treated given the potential
tightening devices, as the patient should be able to feel
for bulk heating.
warmth. Initial treatment parameters were associated
with significant, sometimes intolerable pain. Newer
parameters, however, rely on multiple passes at lower
fluences and are generally well-tolerated. There is sig-
Treatment Application nificantly less pain associated with treatment with cer-
tain vacuum-assisted bipolar RF devices (i.e., Aluma™,
Patients are usually offered some combination of an VelaSmooth™). Prior to treatment with more painful
oral or intramuscular analgesic and/or a mild anxi- devices, the patient is provided with a 4-point feed-
olytic before the procedure. A topical anesthetic may back scale (0-nothing, 1-warm, 2-hot, 3-very hot,
be used to ease patient anxiety, but because these 4-intolerable). The patient is instructed to anticipate
devices generally produce deep dermal heat, anesthetic accumulating warmth, which should be uncomfortable
applied to the surface does little to reduce discomfort. but still tolerable (a 2 or 3 on the feedback scale).
After the initial treatment, a patient may appreciate Adverse events are uncommon in RF and IPL when
some initial improvement of the treated areas due to used for tissue tightening. Both modalities may produce
immediate collagen contraction. Generally, the treated prolonged erythema or edema which may be treated
collagen remodels over a course of several months. The with a tapering course of corticosteroids. Superficial
patient is seen back 3–4 months after the procedure, burns are very uncommon and usually only occur from
and the patient and treating physician can decide electrical arcing due to uneven contact between elec-
together whether or not a second procedure is indicated. trode and skin. They should be treated with local wound
Postprocedural care after both RF and IPL is minimal. care. In one report, infrared-based IPL caused scarring
Patients may experience a warm sensation in the skin due to bulk heating and consequent third-degree burns.9
for several hours after the procedure. In addition, there Overall, though, both therapies are well tolerated, and
may be mild edema and/or erythema that can last for the incidence of complications is extremely rare.
1–2 days. Water or cooling gels can be applied to the
skin for patient comfort. Follow up in cases without
complications should be in 4–6 weeks and then spaced
several months apart to monitor for continued tighten- Conclusion
ing from a single treatment which may continue up to 6
months after the procedure in studies on facial and neck Although radiofrequency and broadband light sources
skin.7,8 (Figs. 19.2 and 19.3). Durability of effect on the are effective in skin tightening, they are only able to
arms and legs has not yet been reported. make an impact in cases of mild to moderate skin laxity
Fig. 19.2 (a) Before and (b) 2 months after Thermage procedure to treat the arm
Fig. 19.3 (a) Before and (b) 12 months after Thermage procedure to treat thighs
19 Skin Tightening of the Arms and Legs with Radiofrequency and Broadband Light 125
and the results may be suboptimal when compared to based nonablative dermal remodeling device: a pilot study.
more invasive options. Ideally, a device could even Arch Dermatol. 2004;140:204-209.
3. Gold MH, Goldman MP, Rao J, Carcamo AS, Ehrlich M.
more precisely and dramatically contour and tighten Treatment of wrinkles and elastosis using vacuum-assisted
with results approximating a surgical approach. Newer bipolar radiofrequency heating of the dermis. Dermatol Surg.
technologies and techniques are being investigated to 2007;33:300-309.
assist in this goal. These include more precise methods 4. Narurkar VA. Lasers, light sources, and radiofrequency
devices for skin rejuvenation. Semm Cutan Med Surg.
of delivering energy such as an RF device with fine 2006;25:145-150.
needle electrodes10 and an infrared light device that 5. Goldberg DJ. New collagen formation after dermal remodel-
allows for variable depth heating.11 An alternative ing with intense pulsed light sources. J Cutan Laser Ther.
treatment option, transcutaneous ultrasound, has 2000;2:59-61.
6. Gold MH. Tissue tightening: a hot topic utilizing deep der-
shown promise in tissue tightening of the forehead, mal heating. J Drugs Dermatol. 2007;12:1238-1242.
cheek, and neck in a preliminary study.12 While these 7. Alster TS, Tanzi E. Improvement of neck and cheek laxity
newer technologies are developed, more detailed and with a nonablative radiofrequency device: a lifting experi-
longer-term studies of current devices should help to ence. Dermatol Surg. 2004;30:503-507.
8. Fitzpatrck R, Geronemus R, Goldberg D, Kaminer M, Kilmer
better define the role of radiofrequency and broadband S, Ruiz-Esparza J. Multicenter study of noninvasive radiof-
light sources in the nonsurgical treatment of skin laxity requency for periorbital tissue tightening. Lasers Surg Med.
of the arms and legs. 2003;33:232-242.
9. Narukar V. Full thickness permanent scars from bulk heating
using an infrared light source. Lasers Surg Med.
2006;S18:S96.
10. Laubach HJ, Manstein D. Histologic evaluation of minimally
References invasive radiofrequency exposure. Lasers Surg Med.
2006;S18:S28.
11. Ross EV, Thomas BC, Clinton TS, Paithankar DY. Variable
1. Alster TS, Lupton JR. Nonablative cutaneous remodeling depth laser skin heating and tightening. Lasers Surg Med.
using radiofrequency devices. Clin Dermatol. 2007;25: 2006;S18:S96.
487-491. 12. Alam M, White L, Majzoub R, Martin N, Yoo S. Safety and
2. Zelickson BD, Kist D, Bernstein E, et al. Histologic and efficacy of transcutaneous ultrasound for forehead, cheek,
ultrastructural evaluation of the effects of radiofrequency and neck tissue tightening. Laser Surg Med. 2007;S19:S56.
Chapter 20
Sclerotherapy of Leg Veins
Mary Martini and Katherine K. Brown
Introduction device to detect points of reflux. Incompetent varicose

veins will be distinguished on Doppler by retrograde
flow. Large vessel disease of reticular veins, perfora-
Sclerotherapy is the injection of a chemical irritant
tors, or deep incompetent veins exist must be
into small and large venous varicosities to create com-
addressed before treating superficial telangiectasias
plete destruction of the vessel wall via irreversible
with sclerotherapy. For small vessels, check for rapid
endothelial damage and localized thrombosis. The aim
capillary filling, which suggests high flow rate and
is improved hemodynamics, elimination of symptoms,
possible resistance to sclerotherapy. One primary
and achievement of an improved aesthetic result.4
goal of the exam is to create a topography of all
Sclerotherapy is a first-line treatment for small intracu-
known areas of superficial reflux. After marking the
taneous varicosities, and is ideally suited for vessels
venous map, photographs should be included in the
measuring 0.3mm-0.5 mm.
medical record to assist with accurate operative plan-
ning and to serve as a comparison tool illustrating
posttreatment results.
Clinical Exam and Patient Selection In selecting appropriate candidates, it is helpful to
understand patient goals and expectations for the pro-
Achieving good outcomes with sclerotherapy begins cedure. Are they considering treatment for cosmetic
with appropriate patient selection and a thorough medi- reasons or do they expect relief of symptoms? Do they
cal history. The presence and extent of symptoms of understand the expected, as well as rare, sequelae and
venous insufficiency, should be addressed during ini- risks? Are they willing to utilize short- and long-term
tial patient assessment. Absolute and relative contrain- compression to maximize outcome? During the preop-
dications to fluid and foam sclerotherapy are reviewed erative evaluation, one should discuss postoperative
here. The most commonly encountered side effects care and downtime. Downtime depends on the scope
include pain and edema at injection site, hyperpigmen- of treatment, but one can expect 2 or 3 weeks of restric-
tation, and matting. Despite these, in experienced tions on lifting and intense exercise. Expected side
hands, sclerotherapy remains the most effective tech- effect is pain with injection and edema. Minor risks
nique to treat small venous varicose vessels of the include hyperpigmentation, local thrombosis, and mat-
lower extremities. ting. Rare and serious adverse events are anaphylaxis,
Physical evaluation should include both standing nerve damage, thrombophlebitis, skin necrosis, and
and supine inspection and palpation. Keys for an complications of thromboembolism, including deep
effective clinical evaluation include adequate even venous thrombosis, pulmonary emboli, and visual
lighting and use of a handheld Doppler auscultation disturbances.

128 M. Martini and K.K. Brown
Table 20.1 Preoperative interview- pertinent findings very painful and has inconsistent results, especially on
HPI elements Medical history elements larger vessels. Chromated glycerin is in the irritant
Age Hypertension class of sclerosants. This practitioner finds it useful on
Weight, height, BMI Diabetes mellitus only the very smallest (<0.2 mm) veins. Individual
Duration/progression of Cardiovascular disease
practitioners vary in their preference of sclerosant, but
varicosities
Associated symptoms Vasculitis in general, the detergents are the most widely used
Exacerbating factors Thromboembolic disease because of their efficacy and versatility.
Prior treatment Coagulopathy
Venous trauma or disease Malignancy
Obstetric history Allergies/anaphylaxis
Family history of vascular/ Tobacco, alcohol, illicit drug use Treatment Algorithm for Large
venous disease and Small Vessels
Lifestyle factors (active vs. Use of medications (hormones,
sedentary, occupational anticoagulants, NSAIDS)
sitting/standing) Regional variation in response and efficacy is com-
mon; therefore, it is helpful to divide the lower extrem-
ity into treatment regions that correspond to venous
Table 20.2 Contraindications to sclerotherapy beds. In the authors’ experience, we find the posterior
Absolute Allergy to sclerosant thigh responds well, the medial and lateral thighs are
Acute DVT prone to matting, and the ankles are often treatment
Local infection
resistant and prone to ulceration. As a general rule,
Severe systemic infection
Immobility large vessel sclerotherapy, which would address
Peripheral arterial disease (stage 3 or 4) saphenofemoral and saphenopopliteal junctions, per-
Hyperthyroidism forators and large (>3 mm) reticular veins, should be
Pregnancy 1st trimester or late 3rd trimester completed before proceeding to small vessel sclero-
Relative Leg edema/ulcer therapy to treat small (<3 mm) reticular veins and sur-
Peripheral arterial disease (stage 2) face spider veins (Fig. 20.1).
Hypercoagulability
A treatment algorithm based predominantly on
Thrombophilia with history of DVT
Bronchial asthma
vessel size is summarized in Table 20.4. When mea-
Extensive comorbidity suring veins, one should avoid stretching the skin,
Diabetic polyneuropathy which may falsely widen visible vessels. Helpful sup-
plies include a clear plastic ruler, a magnifying eye-
piece, and both a 25 gauge and a 30 gauge needle for
Treatment Application comparison, which measure 0.3 and 0.5 mm diameter,
respectively (Table 20.5).
The dose of detergent sclerosants should be adjusted
Sclerosants to fit the clinical scenario. Lower concentrations should
be considered in a patient who bruises easily, who is
The four most commonly used liquid sclerosants are older than 60, and for thin-walled vessels. For a vessel
compared in Table 20.3 to highlight the advantages less than 0.3 mm, increasing concentration threefold
and disadvantages of each. The detergent class of scle- rarely improves result but may increase pigmentation.
rosants act by disrupting the vein cell membrane and For a vessel 0.5–0.9 mm, the practitioner may be able
include polidocanol and sodium tetradecyl sulfate to increase sclerosant twofold with beneficial results.
(STS). STS has FDA approval for the treatment of For a vessel greater than 2 mm, the sclerosant concen-
varicosities of the lower extremity, while polidocanol tration often must be increased to overcome high vol-
is widely used outside the US, but is not currently an ume blood flow within the vessel.
FDA approved sclerosant. Hypertonic saline is a hyper- To inject large varicose veins, it is important to
osmolar agent used off-label for sclerotherapy. It has a place the leg in a horizontal position, occasionally ele-
good safety profile and may be the ideal choice for a vating it 5–30°, to obtain adequate emptying.2 This
patient at risk for allergy to other agents; however, it is technique helps maximize sclerosant contact with the
20 Sclerotherapy of Leg Veins
Table 20.3 Comparison of common sclerosants

Solution Concentration Max dose Advantages Disadvantages Complications
Sodium tetradecyl 0.1–3% 10 cc per session FDA approved for sclerotherapy. Mild discomfort on injection. No PE, anaphylaxis, DVT; deaths
sulfate Most potent agent, useful for more effective than saline for reported at therapeutic
large veins at high strengths and small veins. May cause volumes and concentrations;
small veins at low strengths significant hyperpigmentation CTN at 1% and greater
Polidocanol 0.5–5% 20 cc of 3% (max May be used to treat wide range of Not FDA approved. Transient PE, anaphylaxis; death from
2 mg/kg) vessel sizes. Nearly painless to urticaria and pruritus pulmonary failure after
inject; no CTN at 3% overdose (600 mg)
intradermally, no deaths
reported at therapeutic doses or
concentrations
Hypertonic saline 23.40% 20 cc per session No reported allergies. Pigmentation
Injections moderately painful; PE; no reports of deaths; CTN at
is mild muscle cramps; ineffective for >10%
large veins. Use for sclero-
therapy is off-label
Chromated glycerin 1.11% 10 cc of pure solution No CTN at full-strength. Most Not FDA approved. Painful to Necrosis and allergic reactions
per session effective on the very smallest inject. Not effective for large very rare. Hematuria
vessels (e.g., 0.2 mm or less) veins
CTN contact tissue necrosis, DVT deep vein thrombosis, PE pulmonary embolism. Adapted from Duffy DM. Sclerotherapy. In: Alam M, Nguyen T, eds. Treatment of Leg
Veins1, 87–88
129
Fig. 20.1 Cross-sectional anatomy of superficial venous system depicting relationship between large and small vessels, including
small reticular veins and surface telangiectasias. Adapted from Bogle MA, Sadick NS, Laser Surgery. In: Alam M, Nguyen T, eds.
Treatment of Leg Veins.1 (Illustration by Alice Y. Chen)
Table 20.4 Treatment algorithm based on vessel size

Vessel size Color Sclerosant concentration Number of treatments Treatment interval (weeks)
0.1–0.2 mm Red P = 0.5% 2–4 4–6
HS = 23.4%
S = 0.2–0.3%
CG = 1.11%
0.3 mm Red P = 0.5% 2–6 4–6
HS = 23.4%
S = 0.2–0.3%
0.5 mm Red/magenta P = 0.5–0.75% 1–4 1–2
HS = 23.4%
S = 0.2–0.3%
0.6–0.9 mm Magenta/ P = 0.5–0.75% 1–2 1–2
blue–green HS = 23.4%
S = 0.2%–0.3%
1–1.6 mm Blue–green P = 0.75%–1.5% 1–2 1–2
S = 0.3–0.5%
1.6–2.5 mm Blue–green P = 1–3% 1–2 1–2
S = 0.5–1.5%
2.5+ mm Blue–green P = 1.5–3% 1–2 1–2
S = 0.5–1.5%
S Sodium tetradecyl sulfate, CG Chromated glycerin, P polidocanol, HS hypertonic saline. Adapted from Duffy DM. Sclerotherapy.
In: Alam M, Nguyen T, eds. Treatment of Leg Veins.
vein wall and minimizes dilution of the sclerosant. short bevel is appropriate. The vein is punctured with
With the non-dominant hand, countertraction is applied the needle placed at 30°. The practitioner then checks
to the injection site. For spider veins, a small needle ½″ for intravascular placement before slowly and steadily
30 gauge needle is ideal; for larger veins, a 25-gauge injecting the sclerosant. If placement is correct, there
20 Sclerotherapy of Leg Veins 131
should be very little resistance during injection and Foam Sclerotherapy

immediate blanching of the target vessel is seen
(Fig. 20.2). Immediately after removal of the needle, To target larger varicosities and recurrent varicose veins
compression is applied along sclerosed vein. The resistant to fluid sclerotherapy, foam sclerotherapy is
patient should briefly walk afterwards to dilute sclero- another option. It involves the injection of detergent
sant, while monitoring for signs of an allergic reaction sclerosants (polidocanol, STS) that have been converted
or vasovagal response.5 into finer foam preparations. Foam sclerosants, due to
Duplex ultrasound-guided sclerotherapy is a visuali the increased amount of displaced blood, allow for
zation technique to gain more control, improve efficacy, more intimal contact over a greater distance and for a
and minimize complications. If used successfully, the longer duration. Due to increased potency, smaller vol-
physician is able to confirm the intraluminal locali umes and lower concentrations can be used and punc-
zation of the needle tip and visualize the infusion of ture sites are minimized. However, foam sclerosants
sclerosant. There are different views regarding can be difficult to use, there are no standardized prepa-
whether this technique adds significant information; rations available, and the FDA has not examined or
however, it may be most helpful when the target ves- approved the use of foam for sclerotherapy.
sel is not visible from the skin surface or when scle- To prepare the foam sclerosant, the Tessari tech-
rosing near the saphenofemoral junction to confirm nique is commonly used and involves filling one
placement of the needle at a safe distance from the syringe with air and another with sclerosant in a 4:1 air
junction. to sclerosant ratio. To mix, one passes the materials
back and forth vigorously through a 3-way stopcock
until viscous foam is produced (Fig. 20.3). A maxi-
Table 20.5 Sclerotherapy supplies mum of 6–8 ml per session should be injected using
Rubbing alcohol this technique, and far less if treating the lesser saphen-
Needle (25¢ and 30¢) ous vein.5 Delaying compression by a few minutes
Syringes 1 cc and 3 cc prevents premature displacement of the foam and
Disposable basin maximizes contact with the vessel lumen. Elevation of
Sclerosant the extremity during the injection of large veins will
Cotton balls help to slow absorption into the deep venous system.
Compression bandages/hose The addition of Duplex ultrasound guidance for
Gauze
saphenous veins, recurrent varicose veins, and perfo-
Paper tape
Three-way stopcock rating veins has been recommended by some authors.
Plastic ruler Concerns about the safety profile of foam prepara-
Camera tions remain. There is a slightly higher risk of transient
Magnifying eyepiece visual disturbances than with traditional fluid sclero-
Surgical marking pen therapy, particularly in patients with a history of
Fig. 20.2 (a) Visualization of the target vein. (b) Application of two-point couterpressure assists needle placement into vein at 30°.
(c) Steady injection produces immediate blanching of target vessel
Fig. 20.3 The Tessari method to produce foam requires two syringes and a three-way stopcock to facilitate rapid mixing of air and
detergent sclerosant
migraine headaches.5 Another consideration is the pression stockings routinely used for vessels >2 mm
presence of a patent foramen ovale, which is present in in diameter and in those with symptomatic reflux.
10% of individuals. This predisposes to the possibility Light compression hosiery (Class 0, 10–20 mm/hg)
that a foam embolus may pass through the opening and is a good adjunct when treating small fragile vessels
cause transient visual changes or more serious embolic <2 mm and can be used to enhance long term treat-
events. A recent large meta-analysis reported the ment results for patients whose occupation requires
median rate of serious adverse events in foam sclero- prolonged standing or sitting. There are no firm guide-
therapy, including pulmonary embolism and deep lines on the desired duration of compression. Some
venous thrombosis was less than 1%; the median authors suggest that duration of 2–8 weeks may be
rate of visual disturbances was 1.4% and headache required, but utilization is often limited by patient
4.2%.3 compliance.2
Compression Postoperative Care
Immediate compression applied after treatment and Postoperative instructions should include directions
sustained compression in the days to weeks following for short showers during sustained compression
sclerotherapy are critical to maximizing efficacy.5 The period and warning signs of circulatory compromise,
immediate technique diminishes the return of blood such as numbness, tingling, and swelling in the case
thereby minimizing displacement of sclerosant. of over-compression. If travel occurs in the immedi-
Compression decreases the size of intraluminal throm- ate postoperative period, frequent ambulation every
bus at site of injection, which will lessen time required 1–2 h and support hose is recommended. Further rec-
for full-thickness mural destruction, thereby reducing ommendations are to ensure adequate hydration,
the risk of recanalization. avoidance of alcohol, and consideration of aspirin
Immediate posttreatment compression is achieved supplementation if large vessels have been treated.
with application of cotton balls and tape or elastic ban- Patients are encouraged to take short daily walks with
dages at injection site. A few hours following the treat- appropriate support hose; however, intense exercise,
ment session, patients are instructed to replace bandages hot baths, or saunas should be avoided for the first
with compression hose. Class 1 (20–30 mm/hg) com- week posttreatment.
20 Sclerotherapy of Leg Veins 133
Management of Adverse Events the area with injection of warm saline may minimize
tissue damage.
Most adverse reactions from sclerotherapy are mild
and may resolve with treatment. Hyperpigmentation
occurs in 0.3–10% of cases and is seen more com- Conclusion
monly with higher sclerosant concentration and with
rapid vessel destruction in larger vessels. It regresses Sclerotherapy remains the most effective technique to
slowly and fading can be accelerated with laser treat- treat small venous varicose vessels of the lower extremi-
ment. When involution of the treated vessel is fol- ties. In skilled hands, it is relatively safe and well-toler-
lowed by distal proliferation of fine vascularity, this ated. Laser treatment of leg telangiectasias often produces
is known as matting. This unpredictable and undesir- the less desirable result of increased pigmentation.
able result may resolve spontaneously, respond to
repeat sclerotherapy, or be diminished by various
laser treatments. References
Posttreatment local thrombosis is a common
adverse outcome, heralded by the development of a 1. Alam M, Nguyen TH. Treatment of Leg Veins. Philadelphia,
tender palpable cord. Because spontaneous resolu- PA: Elsevier Saunders; 2006.
tion is prolonged, thrombectomy may be attempted 2. Green D. Sclerotherapy for the permanent eradication of vari-
as early as 2 weeks after sclerotherapy for symptom- cose veins: theoretical and practical considerations. J Am
Acad Dermatol. 1998;38:461-475.
atic thrombi. This involves incision with a No. 11 3. Jia X, Mowatt G, Burr JM, et al. Systematic review of foam
scalpel blade and evacuation of clot under local sclerotherapy for varicose veins. Br J Surg. 2007;94:925-936.
anesthesia. Skin necrosis leading to ulceration in its 4. Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins
most severe form is a rare complication that occurs – a prospective, blinded, placebo-controlled study. Dermatol
Surg. 2004;30:723-728.
most often when a paravascular injection of high 5. Rabe E, Pannier-Fischer F, Gerlach H, et al. Guidelines for
concentration sclerosant has occurred. If extravasa- sclerotherapy of varicose veins. J Dermatol Surg. 2004;
tion is suspected at the time of the procedure, diluting 30:687-693.
Chapter 21
Ambulatory Phlebectomy
Marisa Pongprutthipan, Girish Munavalli, and Simon Yoo
Introduction Contraindications
Ambulatory phlebectomy (AP) is a common, minor, • Infection in the treatment area
office-based procedure using a specially designed • Severe arterial occlusive disease
hook inserted through a minute stab incision to avulse • Bleeding tendency or coagulopathy
and completely remove superficial varicose veins. AP • Allergy to local anesthetics
is generally well tolerated and results in a high degree • Severe peripheral edema or severe lymphedema
of patient satisfaction. Advantages of AP include short • Seriously ill patients (i.e., cardiovascularly compro-
surgical time, ability to be performed under local mised, etc.)
tumescent anesthesia, low recurrence rate compared to • Very elderly patients
sclerotherapy, minimally obtrusive scars and dyschro-
mia compared to other methods, and immediate post-
operative ambulation, which helps prevent vascular
complications.1–4 Relative Contraindications
• Recent deep vein thrombosis

• Hypercoagulable states
Indications • Pregnancy
• Untreated or poorly managed diabetes mellitus
• Superficial varicose venous tributaries of the great
saphenous vein (GSV) or small saphenous vein
(SSV), perforator veins, and reticular varicose veins
when distended, visible, and palpable on the sur- Clinical Examination and Patient History
face of the skin (Fig. 21.1 and 21.2(a))
• Preferred for varicosities greater than 4 mm in Before stripping any vessels or performing extensive
diameter and flesh-colored (which are thicker wall phlebectomies, a preoperative evaluation must be
and more resistant to treatment with sclerotherapy) completed. The deep venous system should be inter-
• Large tortuous distal veins (which are difficult to rogated, and any source of venous hypertension
treat with endovascular procedures) needs to be identified by using duplex ultrasound.1

136 M. Pongprutthipan et al.
7. Instruments for creating incisions: 18-gauge

Nokor needle, no. 11 scalpel blades or 15-degree
ophthalmologic Beaver blades.
8. Mosquito clamps (6–12)
9. Postoperative washing solution (i.e., 0.9% normal
saline solution or hydrogen peroxide)
10. Absorbent dressing (i.e., Telfa, sanitary pads, etc.)
11. Inelastic compression wrap (i.e., cotton roll gauze)
12. Elastic graduated compression stockings (ABD pads,
Webril, Kerlix, Ace Wrap, Coban, Comprilan)
13. If needed, suturing material (needle holder, suture
material, suture scissors and Adson forceps)
To avoid any possible injury to superficial neurovascu-
lar structures, use caution when treating deeper super-
ficial veins along the common femoral artery,
superficial femoral artery, popliteal artery, anterior and
posterior tibial artery, and superficial nerve supplies of
the lower limb below the knees (the superficial pero
Fig. 21.1 Varicose veins. The bulging veins on the calf of an
neal nerve and saphenous nerve) (Fig. 21.2(b)). If inad-
African-American female in her 40 s. AP would be preferred to vertently hooked, patients will experience sharp
sclerotherapy due to the size of the vessels and high probability burning pain radiating proximally or distally. Special
of postsclerotherapy hyperpigmentation attention should be paid to difficult anatomical zones
such as the ankles, feet, and knees where injuries to the
superficial cutaneous nerves are common. Injury to the
If reflux is demonstrated at the saphenofemoral or sensory cutaneous nerves may cause paresthesia and
saphenopopliteal junctions, procedures such as endo- dysesthesia. In most cases, this is only temporary and
vascular radiofrequency, endovascular laser, or liga- resolves within 2–3 weeks. However, there are case
tion and short stripping should be performed.3,5 This reports of foot drop that may or may not resolve over
will decrease venous pressure, prevent recurrence, time, depending on the extent of nerve damage.
reduce the size of the superficial veins, and ease the
phlebectomy procedure. AP can be done concurrently
or several weeks after endovenous ablation.
Technique (Fig. 21.3)
1. Venous Marking: Accurate and comprehensive

Treatment Application venous marking on the skin with an indelible marker
should be done while the patient is standing
(Fig. 21.4). Marking should be done in a consistent,
Procedural Protocol standardized way, so as to highlight straight and
tortuous segments. The choice of marking pen is
Tray Setup important, as even the most tough markings can
easily wear off during the procedure as the area is
1. Indelible skin marking pen exposed to surgical prep washes and interoperative
2. Iodine prep solution blood and oozing. Marking is a critical aspect of the
3. Disposable face mask, sterile gloves procedure, allowing the surgeon to quickly locate
4. Local anesthetic, syringes, needles the desired venous segments. The standing position
5. Ambulatory phlebectomy hooks: Mueller, Oesch, increases venous hydrostatic pressure, making them
Ramaelet, Varady (Table 21.1) easily visible. Mapping may be done via visual
6. Sterile 4 × 4 gauze pads inspection and palpation. An intense point light
Table 21.1 Ambulatory phlebectomy hooks
Mueller’s hooks Oesch’s hooks Ramelet’s hooks Varady’s hooks
No. of size 4 3 2 4 hooks and 2 phlebodissectors
Left-handed Yes Yes Yes May be used by both
availability
21 Ambulatory Phlebectomy
Photographs provided by Venosan North America, Inc.

137
Fig. 21.2 Relevant anatomical structures: (a) veins and (b) nerves (Illustration by Alice Y. Chen)
source can be used to transilluminate the skin, diameter of the hook curvature. Place incisions just
making it much easier to visualize less superficial lateral to the targeted vein, and parallel to the long
segments of the vein. axis of the extremity following tension lines. This
2. Anesthesia: Tumescent anesthesia is a safe and easy allows approximation of the wound edge with the
technique for use with AP. The technique involves force of a circumferentially placed compression
infiltration of the subcutaneous fat compartment by dressing. Incisions are made by a needle for small
using an irrigation pump with a 0.05–0.1% prepara- varicose veins or a scalpel for larger ones. Horizontal
tion of lidocaine with epinephrine1,6 (Table 21.2). stab incisions, following the relaxed skin tension
Advantages of tumescent anesthesia include lines, are preferred around the knees and ankles.
elimination of multiple needle sticks, rapid-onset Incision through marking ink should be avoided to
of anesthesia, and an extensive anesthetic field. prevent tattooing the skin. Avoid stretching or trau-
Additionally, the temporary turgor and hydrodis- matizing the wound edge. The interval between
section of surrounding adventitia can facilitate vein incisions varies from 3 to 5 cm depending on the
identification and extraction, reduce blood loss, patient’s veins. Verify the location of subsequent
diminish bruising, shorten postoperative recovery, incisions by simply pulling the vein gently to observe
and allow for greater postoperative comfort.7 depression of the skin along the venous course.
3. Incisions: When the patient is in the supine position, 4. Hooking and Extraction: Vessels are grasped by
the vein may shift from the initial markings. Confirm either using a hook or using fine hemostats to elevate
the vein location with transepidermal illumination the vein. Hooks should be inserted very gently to
or Doppler ultrasound mapping. This will allow grasp veins 2–3 mm in depth to avoid unnecessary
better vein visualization, fewer incisions, and less trauma to the wound margins and avoid injury to the
operative time. Depending on vein size, incision deep structures. Ultrasound may be used to guide
lengths vary from 0.5 to 4 mm, or as long as the hooking especially for deeper or subtle veins.
21 Ambulatory Phlebectomy 139
Fig. 21.3 AP techniques: (a) incision, (b) and (c) hooking, (d) and (e) venous extraction, and (f) vein separation from surrounding
tissue using the spatula component of Varady’s hook (Illustration by Alice Y. Chen)
The authors typically use blunt dissection with the example, the Ramelet hook is more pointed and
blunt end of the Varady hook to release the vein smaller in size, thus easier in tight spaces. Once the
from the surrounding dermis prior to inserting the vein or its adventitia are hooked, the vein should
hooked end of the instrument. Due to the availabil- come out easily through the stab incision. If the
ity of a variety of hooks, it is recommended that the effort is met with resistance or requires a lot of
surgeon try each to determine which fits his style traction, it is possible that another structure has
best. Different hooks have different advantages; for been hooked; remove the hook and reattempt.
Fig. 21.5 Avulsed vein segment
applying gentle pressure over the incision site and

by placing the patient in Trendelenburg position to
reduce the venous hydrostatic pressure. Venous liga-
tion is not necessary, as stretching of the vein causes
rapid hemostasis most likely due to an increase in
Fig. 21.4 AP markings. A water-resistant, indelible marker is exposed endothelial sites for platelet aggregation.8 If
used to clearly mark the varicose veins while the patient is the vein is difficult to compress, ligation may be
standing
performed in areas such as the inner thigh.
Special attention should be paid to difficult anato
Table 21.2 Tumescent anesthesia preparation (0.05% lidocaine) mical zones such as:
In 1 L of 0.9% normal saline solution:
• Below the knee: The saphenous nerve is particu-
Lidocaine 500 mg (50 ml of 1% lidocaine solution)
Epinephrine 1 mg (1 ml of 1:1,000 solution)
larly prone to injury. If this nerve is injured, the
Sodium bicarbonate 12.5 mg (12.5 ml of an 8.4% patient may experience shooting pain radiating
NaHCO3 solution) into the foot.
• Pretibial area: This area contains many lymphatic
vessels. Accidental trauma to lymphatic vessels
Separation of the vein from the surrounding adven- will cause lymphatic pseudocysts and swelling
titia may be necessary by using iris scissors or the may follow.6
spatula component of a phlebectomy hook such as • Popliteal fossa: The skin is very soft and easily
the Varady. Veins are exteriorized by the phlebec- torn. Be very gentle when handling the wound
tomy hook. The exteriorized vein is then clamped edge, especially with the elderly.
proximally and distally and cut in between. A gentle • Ankle and foot: Superficial sensory cutaneous
rolling motion of the clamp in the same or opposite nerves and vascular structures may be easily
direction pulls and frees the vein from its surround- injured on the ankle and foot. Multiple attempts
ing tissue (Fig. 21.5). Dissection of the vein from its or traumatized manipulation in the wound may
adventitia should be done at the skin level to avoid produce swelling, hematomas, and nerve dam-
injury to the unseen structures. Lack of subcutane- age. If a sensory cutaneous nerve is avulsed,
ous tissue in the anterior of the knee and dorsum of paresthesia and dysesthesia may follow. In most
the foot may cause difficulty when extracting the cases, this is temporary.
vein. Do not forcibly pull the vein. Instead, either 5. Incision Closure: Cleanse the area postoperatively
locate and ligate the perforator, or make a larger (i.e., with 0.9% normal saline solution or hydrogen
incision. Perforators may be identified by their per- peroxide), and apply antibiotic ointment to the
pendicular course and by evaluating patient discom- puncture sites. Spontaneous wound healing facili-
fort when retracted.2 Hemostasis is achieved by tated by sterile adhesive tape to approximate wound
edges is preferred by most surgeons. This sponta- Alternative Treatment Methods

neous healing allows blood and anesthetic fluid to
drain. Sutures may be required if the surgical inci-
Sclerotherapy is the alternative treatment for truncal
sion is longer than 3 mm, or if the incision is near
varicosities or perforators especially in thin-walled
the foot and ankle, which is subject to potential
venules. It may be performed 4–6 weeks after AP to
bleeding and wound dehiscence. In some cases,
clear up residual, smaller caliber vessels. Endovascular
steristrips can be used to facilitate epidermal skin
laser and endovascular radiofrequency may be combined
approximation, while allowing for mild drainage to
with AP for maximal removal of GSV branches from
continue.
the saphenofemoral junction, or deeper GSV and SSV.
6. Dressing Compression Bandage: After applying
absorbent sterile dressings to the incision site, a com-
pression bandage is applied to prevent bleeding and
hematoma. Careful precautions must be observed to Complications
avoid ischemic nerve damage and blistering.
• Apply extra padding over the lateral fibular head Proper patient evaluation selection and operator expe-
to avoid foot drop from a pressure-induced injury rience are the most important elements to prevent com-
to the deep and superficial peroneal nerves. plications. The most common postoperative event is
• Wrap the leg circumferentially from foot to hematoma or ecchymosis (Table 21.3), which resolve
groin, first with inelastic compression dressing within 2–3 weeks. The majority of neurologic compli-
and then with an elastic compression dressing. cations is temporary and usually resolves within a few
This dressing helps to promote hemostasis, to months.
reduce swelling of the foot and leg, and to pro-
mote wound healing.
• Take heed of patient’s complaints, such as pain,
numbness, and tightness, to guide assessments Pearls
and complication prevention. These complaints
can herald nerve compression. • Use of tumescent anesthesia is key to an easy,
• Observe the patient for at least 15 min after the successful procedure.
three-layer compression bandage is in place. • Prevent recurrence by evaluating for venous reflux.
• Encourage ambulation of all patients while
still in the office to help mold the pressure
wrap, generate normal function of the calf muscle Table 21.3 Complications of Ambulatory Phlebectomy6,8
pump, and minimize potential thromboembolic Frequent complications
complications. • Transient hyper- or hypopigmentation
• Vesicles or blisters from pressure dressing
• Hematoma and ecchymosis
Uncommon complications
Postoperative Instructions • Skin: allergic contact dermatitis, infection, scar, tattoo from
marking pen, skin dimpling, skin necrosis, indurations, swelling
• Vascular: postoperative bleeding, matted telangiectasias,
Patients should return to the office 2 days after superficial thrombophlebitis
• Lymphatic: persistent edema, seroma (Fig. 21.6)
the procedure for dressing removal and follow-up.
• Neurologic: postoperative pain, transitory sensory defect or
Consideration of a duplex ultrasound to exclude dysesthesia (temporary/permanent), neuroma
the presence of deep venous thrombosis may be Rare complications
performed. Some ecchymosis or some minor leakage • Keloid and hypertrophic scar
of blood and anesthetic fluid from the open wound is • Lymphatic pseudocyst
• Infection
expected near the treated areas. After the compression • Talc granuloma
bandage is removed, class II (20–30 mmHg) graduated • Deep vein thrombosis
compression stockings are indicated during daytime • Pulmonary embolism
hours for 2 weeks. • Foot drop
Fig. 21.6 Seroma: (a) an ultrasound probe is placed on the seroma on the right thigh of a patient 1-week post-op from AP, (b) the
duplex ultrasound image shows the seroma fluid collection under the skin, and (c) an 18-G needle is being used to drain the seroma.
The clear fluid being drained from the seroma can be seen at the hub of the needle.
• Minimize the size and number of incisions and • Manage patient expectations by educating patients
decrease operative time by mapping veins with about recurrence and possible complications.
transepidermal illumination (venoscope) or Doppler
ultrasound.9
• Avoid complications such as swelling, hematoma,
and nerve damage by exercising caution when Conclusion
the procedure is performed around the knee, ankle,
or foot. Ambulatory phlebectomy is a simple, minor surgical
• Correct GSV and axial vein reflux by combining procedure for complete removal of large superficial
AP with saphenofemoral ligation or endovenous varicose veins. By combining AP with endovenous abla-
ablation prior to AP. This will reduce the vein size tion or PIN stripping, complete removal of all varicose
and make it easier to remove. veins can be accomplished in-office. With proper and
careful operation, AP is safe, effective, and achieves 4. Ramelet AA. Phlebectomy. Technique, indications and com-
successful cosmetic results. plications. Int Angiol. 2002;21:46-51.
5. Weiss RA, Dover JS. Leg vein management: sclerotherapy,
ambulatory phlebectomy, and laser surgery. Semin Cutan
References Med Surg. 2002;21:76-103.
6. Olivencia JA. Pitfalls in ambulatory phlebectomy. Dermatol
Surg. 1999;25:722-725.
1. Almeida JI, Raines JK. Ambulatory phlebectomy in the 7. Cohn MS, Seiger E, Goldman S. Ambulatory phlebectomy
office. Perspect Vasc Surg Endovasc Ther. 2008;20(4): using the tumescent technique for local anesthesia. Dermatol
348-355. Surg. 1995;21:315-318.
2. Ricci S. Ambulatory phlebectomy. Principles and evolution 8. Olivencia JA. Complications of ambulatory phlebectomy.
of the method. Dermatol Surg. 1998;24:459-464. Review of 1,000 consecutive cases. Dermatol Surg. 1997;23:
3. Sadick NS. Advances in the treatment of varicose 51-54.
veins: ambulatory phlebectomy, foam sclerotherapy, endo- 9. Weiss RA, Goldman MP. Transillumination mapping prior
vascular laser, and radiofrequency closure. Dermatol Clin. to ambulatory phlebectomy. Dermatol Surg. 1998;24(4):
2005;23(3):443–455. 447–450.
Chapter 22
Endovenous Laser and Radiofrequency Treatment of Leg Veins
Marisa Pongprutthipan and Jeffrey T.S. Hsu
Introduction This procedure can be done in-office under local anesthe-

sia. After vein treatment, patients are able to walk imme-
diately and most individuals are able to return to work the
Superficial varicosity is a common medical condition
next day. The mechanism of action is the ablation of the
that is symptomatic in 20–30% of the US population.
target vein through delivery of laser energy. Since then,
Classic symptoms of venous insufficiency are ankle
several wavelengths have been used in endovenous laser
edema, leg fatigue, aching, discomfort, and muscle
therapy (810, 940, 980, 1,319, 1320, and 1470 nm).
cramps. Some patients develop associated complica-
Shorter wavelengths (810, 940, and 980 nm) are absorbed
tions, including stasis dermatitis, lipodermatosclerosis,
by deoxygenated hemoglobin and transmit heat to the
skin atrophy, superficial thrombophlebitis, and venous
vein wall. The extent of thermal injury when using shorter
ulcers. The treatment of varicose veins reduces symp-
wavelengths depends on the energy settings, pulse dura-
toms and complications of chronic venous insuffi-
tion, presence of blood in the lumen, pullback rate, and
ciency and improves quality of life. Superficial varicose
amount of tumescent anesthesia. Since the hemoglobin is
veins are often due to failure of the valves in the
the target, endothelial destruction and thrombotic vein
saphenous vein and at the saphenofemoral junction
occlusions can occur. Thrombus may progress into the
(SFJ), causing venous reflux. Until recently, traditional
deep venous system creating a deep vein thrombosis
ligation and stripping has been the standard of care in
(DVT), which is usually asymptomatic. The likelihood of
the treatment of truncal varicosities. But there are some
DVT is less than 1%.6 With longer wavelengths (1319,
disadvantages, including a 20% recurrence rate in
1320, and 1470 nm), heat is generated when the laser
5 years, requirement of 2–6 weeks of downtime, asso-
energy is absorbed by the intracellular water of the vein
ciated risks of general anesthesia, scars, and possible
wall and the water content of the blood. Heat is produced
neurovascular and lymphatic vessel damage. As an
endoluminally and eccentrically distributed. This leads to
alternative, there are currently available endovenous
vascular contraction, venous wall (especially tunica
treatment options for superficial varicose veins: ultra-
intima) destruction, inflammation, and ultimately, fibro-
sound guided foam sclerotherapy, endovenous radiof-
sis. Some reports have suggested that this direct heating
requency, and endovenous laser treatment. These are
of the vein wall tends to be more effective, less painful,
minimally invasive in-office procedures with less pain,
and results in less incidence of vessel perforation. The
early ambulation, and less recovery time. In this chap-
reported rates of great saphenous vein (GSV) occlusion
ter, we review techniques for endovenous laser and
from endovenous laser treatments range from 84 to
endovenous radiofrequency treatments.
100%. Recanalization is rare, but may occur as early as
1 week after treatment.5 The mechanisms of recanaliza-
tion remain unclear; however, some postulated factors
Endovenous Laser Therapy1–7 include improper performance, laser fluence, anticoagu-
lant or antiplatelet medication use during the periopera-
In January 2002, an 810-nm diode laser (Diomed Inc., tive period, and patients with body mass index greater
Andover, MA) received Federal Drug Administration than 35 kg/m2. Some commercially available endovenous
(FDA) clearance for use in endovenous laser therapy. lasers are provided in Table 22.1.

146 M. Pongprutthipan and J.T.S. Hsu
Table 22.1 Some commercially available endovenous lasers

Device type Energy output (W) Fiber Target
Endovenous laser treatment 810 nm diode laser Available in 15 600 µm. EVLT® Laser fiber with Hemoglobin
(EVLT™) Delta laser and 30 SiteMarks™
Diomed, Andover, MA
http://www.evlt.com
Vari-lase 810 nm solid-state Up to 30 600 µm. Flex catheter and Hemoglobin
Vascular solution, Minneapolis, MN diode laser ceramic distal tip fiber
http://www.vascularsolutions.com (Bright Tip Fiber™)
Pro-V 1319 nm Nd:YAG Up to 12 600 µm, optical fiber Water
Sciton, Palo Alto, CA laser
http://www.sciton.com
Cooltouch endovenous (CTEV™) 1320 nm Nd:YAG Up to 10 600 µm, optical fiber, available Water
Cooltouch, Roseville, CA laser with single-use fiber or
http://www.cooltouch.com/ reusable fiber with automated
varicoseveins.aspx pullback system
Endo lase vein system painless 1470 nm diode Up to 15 ELVeS™ Radial fiber Water
(ELVeS™ PL) laser (homogenous circumferential
Biolitec AG, Jena, Germany energy emission)
http://www.biolitec.com
Endovenous Radiofrequency
Ablation3,6,8
Endovenous radiofrequency (RF) ablation (Closure®

procedure, VNUS Medical Technologies, Inc., San
Jose, California) was FDA approved for the treat-
ment of the great saphenous vein (GSV) in 1999.
This is a minimally invasive, in-office treatment
using local anesthesia with 1–2 days of downtime.
Eighty-five percent of patients return to normal activ-
ity within 1 day. Instead of using optical fibers,
VNUS technology applies RF energy directly to the
vein walls through a endoluminal catheter fitted with
metal electrodes at the tip. Radiofrequency genera-
tors (VNUS RFGplus™) create a temperature-con-
trolled delivery of heat endoluminally (85°C by
ClosurePLUS fiber or 120°C by ClosureFAST fiber)
(Fig. 22.1(a,b) and Fig. 22.2(a,b)) to optimize
endothelial denudation, collagen contraction, and
vein wall thickening for fibrotic vein occlusion. The
consistency of endoluminal temperature may be a
safety advantage over laser techniques. Several stud-
ies use thermocouple monitors to show lower mean Fig. 22.1 (a) Above is an infrared thermal camera image of a
ClosurePLUS catheter heating a vein inside a block of tissue. Note
peak perivascular tissue temperature in comparison uniformity and limited depth of heating; temperature decreases from
to endovenous laser treatments, suggesting less risk 85 to 43°C at 1.5 mm radial distance from intima. Image Copyright@
of damage to the perivascular tissue and the skin VNUS Medical Technologies,Inc. Used with permission. (b) Above
above. The ClosureFAST fiber (Fig. 22.2(b)) is the is an infrared thermal camera image of the ClosureFAST™ catheter
heating a vein inside a block of tissue. Note uniformity and limited
newest generation of this technology to shorten pro- depth of heating; temperature decreases from 95° C to 43° C at 1.5
cedure times from around 24 min to less than 5 min mm radial distance from intima. (Image Copyright@VNUS Medical
by applying segmental ablation instead of full length Technologies, Inc. Used with permission.)
22 Endovenous Laser and Radiofrequency Treatment of Leg Veins 147
Fig. 22.2 (a) ClosurePLUS™ and (b) ClosureFAST™ (Image Copyright@VNUS Medical Technologies, Inc. Used with permission.)
continuous ablation. This eliminates the pullback Table 22.2 CEAP classification: clinical class score (C)
speed variability, shortens the operating time, and Class description
simplifies the procedure. Recently, the ClosurePLUS C0 No visible or palpable signs of venous disease
fiber is no longer manufactured or distributed. C1 Telangiectases, reticular veins, malleolar flare
C2 Varicose veins, distinguished from reticular veins by a
Recurrence rates of VNUS have been reported to be
diameter of 3 mm or more.
comparable or better than endovenous laser tech- C3 Edema
niques, varying from 0.5 to 2.8% during the follow- C4 Skin changes ascribed to venous disease
ing 2 years. C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C5 Skin changes in conjunction with healed ulceration
C6 Skin changes in conjunction with active ulceration
Indications for Endovenous Ablation

Contraindications
• Reflux of the GSVs or SFJ, reflux of small saphenous
veins (SSV) or saphenopopliteal junction (SPJ), • Thrombus in the vein segment to be treated
and accessory saphenous branches. • Severe arterial occlusive disease, as evidence by an
• Varicose veins should have a Clinical Etiology Ankle–Brachial Index of less than 0.5
Anatomy Pathophysiology (CEAP) classifica- • Inability to ambulate
tion score of 2–6 in the Clinical Signs category • Large tortuous vein which catheter cannot pass through
(Table 22.2). • Allergic to anesthetics
• Preference for vessels that are at least 2.0 mm in • Seriously ill patients (e.g., cardiovascular compro-
diameter, as measured with the patient in the supine mised, pulmonary compromised)
position. • Recent deep vein thrombosis
• Preference for vessels that are at least 1 cm deep • Infection in the treatment area
from the surface of the skin (with tumescence). • Pregnancy
Relative Contraindications –– Surgical drapes: 80 × 120 in. Split Drape (patient

leg), 60 × 44 in. Half Drape (patient torso)
–– 500-cc Plastic Bowl
• Aneurismal section in the vein segment to be
–– 20 pieces of 4 × 4 in. 12 ply Gauze Sponges
treated
–– Syringe (3 cc, 10 cc, 20 cc)
• Hypercoagulable states
–– 25 Gauge, 5/8 in. and 1.5 in. needle
–– No.11 Scalpel blade
–– Skin preparation solution (i.e., iodine, etc.)
Clinical Examination and Patient History –– Surgical skin marker
–– 4 sterile towels
–– Sterile Esmarch bandage (optional)
Preoperative Evaluation
–– Graduated compression stockings (20–30 mmHg)
–– For endovenous laser treatment: Laser unit (Fig.
Patient history and physical examination should be 22.3 (b and c)), laser safety goggles, micropunc-
properly taken to include any allergic reaction to medi- ture vascular access kit, introducer sheath set,
cations, anesthetic agents, or antiseptics. Before the guidewire and standard J-wire, and laser fiber
procedure, perform a duplex ultrasound examination –– For endovenous radiofrequency treatment:
to document reflux in the system to be treated. Patency VNUS RFGplus™ Radiofrequency generator
of the entire lower extremity venous system (deep, (Fig. 22.3(a)), micropuncture vascular access
superficial, and perforator) should be explored. Once kit(18-G thin-walled or 19-G ultrathin-walled
the initial evaluation process is complete, preoperative needle), introducer sheath set and Closure®
planning is initiated, and the target vein is identified. In catheter with guidewire
general, the most proximal site of reflux should be
treated first. This may be the SFJ followed by the tribu- • Technique
tary branches, or it may be the SPJ followed by the The following pertains to the treatment of the GSV.
SSV, then the branches. Routine hematologic or other For SSV, the technique will need to be modified.
laboratory studies should be completed if indicated by 1. Venous marking
the patient history (i.e., anticoagulation therapy, preg- Position the patient in reverse Trendelenburg
nancy testing for women within reproductive age). position (5–10°) to dilate the venous system,
thus a tilting table is recommended. Slightly flex
the hip and knee, and externally rotate it to facil-
Treatment Application itate access to the saphenous vein along the
medial leg. After sterile preparation and draping
the treatment area, GSV is marked, mapped, and
Procedural Protocol
measured with Duplex ultrasound sonography.
For better vessel visualization, use a probe fre-
• Supplies and equipment needed
quency of 7.5 MHz or greater.
–– Tilt table
–– Duplex ultrasound scanner with sterile ultrasound 2. Venous access
gel and sterile ultrasound transducer cover Vascular access is generally accomplished at the
–– Tumescent anesthesia preparation: anesthetic knee level for the GSV and just above the ankle
fluid, tumescent infiltration device, 20 or 22G, for the SSV. Administer local anesthesia at the
3.5 in. spinal needle for fluid infiltration, and vein access site. Micropuncture is performed, or
Klein infusion pump insert a 19-G needle into the GSV. Place a guide-
–– Protective eyewear wire (e.g., J-tipped guidewire) into the needle,
–– Surgical gown remove the needle, and place the introducer
–– Disposable face mask and sterile gloves sheath that has been flushed with heparinized
–– Trays set up includes: (The manufacturers also saline over the wire guided by an ultrasound.
provide preassembled kits) Then remove the guidewire.
Fig. 22.3 (a) RF generator VNUS RFGplus™ (Image Copyright@VNUS Medical Technologies, Inc. Used with permission.) (b)
DELTA laser 810 nm (Copyright ©2009 AngioDynamics) (c) CoolTouch CTEV™ 1320 nm laser and automatic pullback device.
(Photograph provided by CoolTouch Inc.)
3. Catheter advancement optimal setting, recanalization and recurrence rates

If the saphenous vein develops vasospasm prior were reduced and had the highest overall success
to cannulation, adjunctive techniques include rate. Mark the laser fiber 3 cm longer than its sheath.
application of a tourniquet proximal to the site of Gently advance the laser fiber/sheath into the vein.
cannulation, placement of the leg in a more Confirm that the tip of the laser fiber is positioned at
dependent position, and/or placement of towels least 2 cm distal from the SFJ or SPJ and distal to the
moistened with warm saline along the course of inferior epigastric vein.2 After withdrawing the
the saphenous vein to enhance vein dilation.1 sheath to the marked site to reveal the laser tip, lock
For endovenous laser ablation: the laser fiber and its sheath together. Mark the point
Place a laser fiber through the introducer sheath. on the skin at which the laser treatment can be
Connect the laser fiber to the laser device and verify stopped. Carefully remove the introducer sheath.
the energy setting. The available modes of laser
delivery include pulsed and continuous. The dose of For endovenous radiofrequency ablation:
laser energy delivered can be expressed as a Joule When venous access is established, the patient remains
(J/cm), sometimes called linear endovenous energy in the reverse Trendelenburg position. Flush and fill
density (LEED). LEED is the amount of laser energy the radiofrequency ablation catheter lumen with
delivered for a given surface area (J/cm2) to achieve sterile, normal saline. Wipe the outer surface of the
the optimal setting for an individual patient. catheter with normal saline. Check the electrode
Calculating LEED requires estimation of the cross impedance in sterile normal saline solution, typically
sectional area of the vein.9 Varying settings are rec- 100–150 W for 6 Fr catheter and 40–70 W for 8 Fr
ommended by several studies either by fluence or catheter.11 Advance the catheter to the SFJ. If difficul-
LEED depending on the type of laser and extent of ties manifest when advancing the catheter due to
surgeon experience. For example, when using 810- excessive tortuosity of the vein or prior phlebitis,
nm diode laser, the recommended setting is 65–70 J/ take caution because of the increased risk of
cm per length of treated GSV and SSV.10,11 With the dislodging emboli or causing perforation. The
“skin stretch maneuver” may be performed by information, including watts, laser on-time, total
straightening the vein with external compression.3 joules, and length of the treated vein. Energy used per
Longitudinal imaging with the ultrasound probe length of the treated vein should be calculated.
will best define the location of the epigastric vein
For endovenous radiofrequency ablation:
and SFJ in relation to the catheter tip. For GSV
Place the patient in the Trendelenburg position.
ablation, the tip of the catheter is placed distal to the
Confirm the location of the device tip by ultrasono
SFJ (5–10 mm for ClosurePLUS and 15–20 mm for
graphy. When using the ClosurePLUS catheter, the
ClosureFAST) and distal to the inferior epigastric.
outcome is determined by the withdrawal rate, total
For SSV ablation, the tip of the catheter is placed at
energy delivery, and amount of contact surface due
20 mm distal to the SPJ. Check the impedance again;
to its “umbrella catheter” and continuous energy
the expected impedance for 6 Fr catheter is >200 W
delivery. While energy is being delivered, monitor
and >150 W for 8 Fr catheter.12
the probe temperature, impedance, generator output,
4. Anesthesia and elapsed time on the screen to guide the rate of
Tumescent anesthesia is preferred for endovenous withdrawal. The newer RF generator also delivers
treatment for several reasons. It provides compres- an audio tone to indicate withdrawal speed. The unit
sion of the vein to achieve better contact between the will automatically adjust the minimum power neces-
endothelium and catheter prongs or laser fiber, adds sary to maintain the desired electrode temperature.
space between the catheter tip and skin surface to pre- The impedance may rapidly rise in case of coagulum
vent skin burn, and protect the perivascular tissues formation on the electrodes; the programmed RF
from the thermal effects of intravascular energy. The generator will automatically shut off. The recom-
technique involves infiltration of the subcutaneous fat mended withdrawal rate for 85°C probe temperature
compartment by using an irrigation pump with 0.05– is 2–3 cm/min. If probe temperature reaches 90°C,
0.1% lidocaine solution. Position the 22-gauge spinal withdrawal rate should be 4–6 cm/min. During the
needle in the perivascular tissue and infiltrate, guided treatment, the expected impedance for 6 Fr catheter
by ultrasound imaging to achieve circumferentially is >150 W and >100 W for 8 Fr catheter.11 Common
compression of the vein (distribute anesthetic fluid problems causing lower and higher impedance are
approximately 10 ml/cm vein or 300 mL/limb). usually from poor contact between the electrode and
Separate the skin and catheter by at least 10 mm. vein wall, and coagulum formation at the thermo-
couple tip, respectively.12 Stop the treatment when
5. Catheter withdraw and ablation
the catheter tip enters the introducer sheath.
For endovenous laser ablation:
The ClosureFAST catheter has a 7 cm long heater
Before catheter withdrawal, have the patient shift to
element that reaches 120°C in 20 s. By conductive
Trendelenburg position, so that the leg is above the
heat transfer, the vein wall segment in contact with
heart to facilitate vein collapse, apposition, and exsan-
the catheter heating element reaches a temperature
guination. Confirm the location of the device tip by
of 100–110°C. The catheter is then moved distally
ultrasonography and visualization of the red indicator
in 6.5 cm increments (0.5 cm overlapping surface),
light through the skin. Turn on the device and with-
and the cycle is repeated.3 This catheter tip provides
draw relatively rapidly and continuously pull back at
ease of use, no required saline drip, increased effi-
about 1–5 mm/s, depending on the laser wavelength,
cacy, and faster operative time.
mode of operation (continuous or pulse), and power
(i.e., 3 mm/s for 810 nm when using the DELTA laser, For larger vessels, adjunctive strategies to improve
1 mm/s for 1320 nm when using the Cooltouch outcome include increasing tumescent fluid volume,
CTEV™ laser with automatic pullback). The amount manual compression using an Esmarch bandage, and
of energy delivered during endovenous laser therapy placing the patient in extreme Trendelenburg
is an important parameter in achieving successful position.
ablation of the GSV. Manual compression of the vein
Precaution:
aids with obliteration of the lumen and facilitates
venous closure. For safety, when you finish the treat- • Appropriate laser safety goggles must be worn
ment, turn the laser into “standby mode” then remove by the patient and all operating personnel to
the fiber/sheath from the vein. Record necessary protect from direct and reflected laser energy.
• The integrity of the fiber and/or sheath may be daily for 1 week. Perform a follow-up Duplex ultra-
compromised when using excessive energy, and sound scan 3–5 days after the procedure to confirm pro-
may result in embolization of device components. cedural success, and ensure no thrombus into the femoral
• When the laser fiber or RF catheter is inserted, it vein has occurred. Compression stockings should be
should be manipulated under ultrasound visuali continuously applied during the day and evening for the
zation. following week. Patients may experience a “string-like”
• After the catheter is moved out of the treatment pulling sensation, pain, inflammation, and bruising.
zone, it should not be re-advanced into a recently Generally, varicosity symptoms reduce rapidly in a
treated area. few days following the procedure; however, some
• Do not advance the catheter or guide the wire patients may experience persistent symptoms for up to
against resistance–vein perforation may occur. 6 weeks. Clinical improvement in the appearance of
varicosities is typically observed within 4–6 weeks.
6. Postoperative ultrasound
At the completion of the procedure, return the patient
to a horizontal position. Perform an ultrasonogra-
phy to evaluate a successful closure and to assess Alternative Treatment Methods
patency of the deep venous system. With successful
occlusion, ultrasound imaging will show a thickened
vein wall with the absence of a flow in the lumen. If Ambulatory phlebectomy, ultrasound-guided foam
there is still spontaneous flow, the procedure can be sclerotherapy and venous stripping and ligation are the
repeated. If the second attempt fails to close the alternative treatments for GSV and SSV varicosities.
vein, surgical ligation should be performed. These techniques are preferred in previously treated
varicosities, recurrent veins after surgery (i.e., neo-
7 . Compression bandage vascularization), or perforator veins. They may be
After the procedure, cover access site(s) with a performed in combination with endovenous radiofre-
sterile bandage. Apply waist high 20–30 mmHg quency/laser ablation (Fig. 22.4), or after the failure of
compression stockings. an endovenous treatment.
Postoperative Instructions
Complications
For the first 24 h after the procedure, encourage ambula-
tion of all patients to minimize potential thromboembo- The most common complaint of endovenous therapy
lic complications and continue ambulation at least 1 h (up to 90%) is the report of a “string-like” pulling
Fig. 22.4 Leg veins treated by CTEVTM combined with ambulatory phlebectomy (a) before and (b) 6 months after treatment.
(Courtesy of Girish Munavalli, MD)
sensation along the course of the ablated vein that may the treatment of GSV and SSV varicosity. This mini-
persist for 1–2 months. Other common complaints are mally invasive office-based technique has been shown
erythema, superficial and deep thrombophlebitis, to have a high technical success rate, low morbidity
vessel perforation, ecchymosis, hematoma, and hyper- rate, and high patient satisfaction. Short- and long-term
pigmentation. Skin burns are less common when using success rates are equivalent or better than traditional vein
tumescent anesthesia and when practicing caution ligation and stripping; however, the cost of endovenous
when the laser approaches the puncture site. There are approach may be higher when compared with other
a few reported cases of arteriovenous fistula causing procedures. Discussion of advantages and disadvantages
recanulization in patients who underwent endovenous of each procedure should be discussed with the patient
laser treatments. Reports of thromboembolic events prior to treatment selection.
include deep vein thrombosis, common femoral vein
clot extension, and pulmonary embolism. Prophylaxis
with low molecular weight heparin before surgery in
patients with a history of DVT or other risk factors for References
the development of DVT is controversial. Nerve inju-
ries may occur and cause paresthesia and dysesthesia. 1. Johnson CM, McLafferty RB. Endovenous laser ablation of
varicose veins: review of current technologies and clinical
The sural nerve is prone to injury when endovenous outcome. Vascular. 2007;15(5):250-254.
laser therapy is used for SSV ablation. To reduce the 2. Singh M, Sura C. Endovenous saphenous and perforator
possibility of nerve injury, perform the procedure vein ablation. Oper Tech Gen Surg. 2008;10(3):131-135.
guided by ultrasound imaging near the knee, and 3. Weiss RA, Munavalli G. Endovenous ablation of truncal
veins. Semin Cutan Med Surg. 2005;24(4):193-199.
provide good circumferential tumescent anesthesia 4. Gibson KD, Ferris BL, Pepper D. Endovenous laser treat-
around the target vein are suggested. Complications ment of varicose veins. Surg Clin North Am. 2007;87(5):
depend not just on the methods and tools used, but the 1253-1265.
experience of the surgeon. 5. Proebstle TM, Gül D, Lehr HA, Kargl A, Knop J. Infrequent
early recanalization of greater saphenous vein after endovenous
laser treatment. J Vasc Surg. 2003;38(3):511-516.
6. Nijsten T, van den Bos RR, Goldman MP, et al. Minimally
invasive techniques in the treatment of saphenous varicose
Pearls veins. J Am Acad Dermatol. 2009;60(1):110-119.
7. Mundy L, Merlin TL, Fitridge RA, Hiller JE. Systematic
review of endovenous laser treatment for varicose veins. Br
• Tumescent anesthesia is a key to improve efficacy J Surg. 2005;92(10):1189-1194.
8. Dietzek AM. Endovenous radiofrequency ablation for
and safety. the treatment of varicose veins. Vascular. 2007;15(5):
• Avoid treating small tortuous vein. With this vessel 255-261.
type, endovenous treatment may increase the risk of 9. Darwood RJ, Gough MJ. Endovenous laser treatment for
perforation and unsuccessful surgery. uncomplicated varicose vein. Phlebology 2009;24 supple
1:50-61.
• Managing patient expectation and counseling for 10. Theivacumar NS, Darwood R, Gough MJ. Neovascularisation
additional treatment. and recurrence 2 years after varicose vein treatment for
Sapheno-Femoral and Great Saphenous Vein Reflux: a com-
parison of surgery and endovenous laser ablation. Eur J Vasc
Endovasc Surg. 2009;38(2):234-236.
11. Hamel-Desnos C, Gérard JL, Desnos P. Endovenous laser
Conclusion procedure in a clinic room: feasibility and side effects study
of 1700 cases. Phlebology. 2009;24(3):125-130.
12. Zimmet SE. Endovenous ablation. In: Ngyugen T, Alam M,
Endovascular ablation has many advantages over the eds. Procedures in Cosmetic Dermatology Series- Leg Veins.
traditional high ligation and stripping procedures for London: Elsevier; 2006:147-163.
Part VI
Abdomen, Thighs, Hips, and Buttocks
Chapter 23
Noninvasive Body Rejuvenation
Amy Forman Taub
Introduction 1.9 cm 12 weeks after one treatment8 (Fig. 23.6), whereas

after three treatments, the mean was up to 3.95 cm.9
Reports of tissue tightening of body areas have been
Noninvasive body rejuvenation is a nascent area of
limited to case reports and anecdotal reports, except
aesthetic medicine. Dominant past invasive procedures
for one large multicenter study on upper arm laxity and
include liposuction, body lifts, and tummy tucks. The
monopolar radiofrequency, with the TC tip revealing
success of tissue tightening on the face in the past 5
56% of patients achieving positive results10 (Fig. 23.7).
years has led practitioners and researchers to explore
Another study utilizing unipolar radiofrequency for the
this new frontier of body shaping. The main focus of body
buttocks and thighs revealed a 20% volume reduction as
shaping is fat, whereas the focus of facial contouring is
measured by real-time ultrasound after two treatments
dermal. Thus, body shaping presents unique technical
(Fig. 23.8),11 and an average of 2.45 cm thigh circum-
challenges that have not been encountered before. In
ference reduction and suggested that skin tightening
addition, cellulite is a different pathophysiologic entity
was responsible for the improvement.12
(Fig. 23.1) than either laxity or excess fat and cannot
be addressed in the same fashion.
Most of the published literature on body shaping has
focused on demonstration of increased compactness of Patient History and Clinical Examination
an extremity, abdomen, or buttocks via circumferential
reduction. Difficulty is encountered in objective photo-
Historically, important factors to note would be recent
graphic assessment of subtle topographical changes
weight changes, prior surgery or liposuction in the
(Fig. 23.2).
proposed treatment area, presence of scars and/or
The literature reveals a range of 0.8–3.5 cm circum-
hernias, and history of mastectomy if arm rejuvenation
ferential reduction per thigh with a device utilizing
is considered.
infrared light, suction, and bipolar radiofrequency.1–5 The
When approaching a patient for examination for
second-generation device (Velashape, Syneron Corp.)
body rejuvenation, there are four factors to consider:
(Fig. 23.3) was the first to achieve FDA clearance
cellulite, contour, laxity, and excess fat. Body rejuve-
for circumferential reduction of body areas (Fig. 23.4).
nation is focused on noninvasive three-dimensional
In a study comparing the latter with a device utilizing
changes that include circumferential reduction (shaping),
diode laser, suction, and massage in a split thigh study,
improvement in topography/cellulite (smoothing),
there was no significant difference in efficacy although
reduction of laxity (tightening), and reduction of fat
more bruising was associated with the former.6 In a
(Table 23.1).
study looking at a dual wavelength laser with suction
The anatomical areas that are commonly treated are
and massage, 80% of patients experienced improvement
the abdomen, thighs, arms, and buttocks.
as measure by high-frequency ultrasound imaging of
Physical Examination:
treated thighs (Fig. 23.5).7
Focused ultrasound has been shown to reduce Abdomen (Figs. 23.9 and 23.10). Most common
circumference of abdomen and thigh an average of unwanted features of the abdomen include striae, laxity,

156 A.F. Taub
Fig. 23.1 Diagram of normal fat architecture (a) and cellulite architecture (b). Note in the normal (a) architecture the surface is flat
and the fat globules are positioned well below the surface. In the cellulite architecture (b), the surface is irregular due to fat globules
protruding into a more superficial area of skin. Schematic courtesy of Syneron Corp
Fig. 23.2 Before and after one treatment with Thermage CL tip. Photo taken with three-dimensional image (Vectra, Canfield
Scientific Corp, New Jersey), in order to better capture changes in the topography of the skin
and excess adiposity. Data would include degree of lax- pinching the skin, (3) dimples present on standing at
ity, area(s) of laxity, presence or absence and degree of rest, and (4) dimples present when laying flat and
striae and contour. at rest (Fig. 23.13). Ask the patient to stand with their
back to you and clench their buttocks in order to grade
Thighs and buttocks (Figs. 23.11 and 23.12). Common
appropriately.
problems in these areas include cellulite, irregular con-
tour (either genetic or postliposuction), fat pockets, Arms. The arms are usually a combination of skin
and large diameter. Cellulite has four grades: (1) not laxity overall and surface wrinkles with atrophic
present, (2) dimples present only when standing and skin and excess fat. Examination should be in the frontal
Fig. 23.3 Velashape device. Photograph courtesy Syneron Corp
Fig. 23.4 Graph showing circumferential Circumferential Reduction 1-FU

reduction at follow-up of subjects after 5
weekly treatments with Velashape. Areas 25% 24%
treated included abdomen, thighs, and 21% 21%
buttocks. Data courtesy Syneron Corp 18%
% of areas (n=38)
20%
16%
15%
10%
5%
0%
0%
0 up to 2cm up to 4cm up to 6cm up to 8cm >10cm
Fig. 23.5 Before (a) and (b) 12 weeks after 10

treatments with Smoothshapes dual wavelength laser
device. Photo courtesy Elemé Medical
158 A.F. Taub
Fig. 23.6 Clinical responses to a single Contour I treatment in three cases. Reprinted with permission from: Teitelbaum SA, Burns JL,
Kubota J, Matsuda H, Otto MJ, Shirakabe Y, Suzuki Y, Brown SA. Noninvasive body contouring by focused ultrasound: safety and efficacy
of the Contour I device in a multicenter, controlled, clinical study. Plast Reconstr Surg. 2007; 120(3):779-789; discussion 790
Fig. 23.7 Pre (a) and 2 months post 1 Thermage treatment of the upper arm (b). Photo courtesy of Martin Safko, MD and Thermage Corp
Fig. 23.8 Pre (a) and 15 days after one treatment (b). Parameters: unipolar, three passes at 150–160 W. Photo courtesy Emilia del
Pino, MD and Ramon Rosado MD and Alma Corp
Table 23.1 Categorization of methods of body contouring according to components

Excess Irregular
Cellulite Laxity adiposity contour
Suction massage [Endermologie (LPG, valence, France)] + − − +
Liposuction − +/− +a +
Chemical lipolysis (Mesotherapy) − − +a +
Laser lipolysis [SmartLipo (SmartLipo, Deka, Florence, Italy), CoolLipo − + +a +
(CoolTouch Corp., Roseville, CA), Lipotherme, Osyris, Lille, France]
Combo suction, rollers, IR light, bipolar RF (Velasmooth) + +/− − +
Diode laser + suction massage [Triactive (Cynosure, Inc. Westford, MA, USA)] + +/− − +
Velashape (Syneron medical Ltd, Yokneam, Israel) + + +b +
Focused ultrasound (Ultrashape) − +/− +a +
Tissue tightening [Thermage, Titan, Lux IR (Palomar medical technologies, − (+ for + − +
Burlington, MA, USA), ReFirme (Syneron Medical Ltd.), Accent Thermage
(Alma Lasers, Buffalo Grove, IL, USA)] CL tip)
a
Physical reduction of fat quantity
b
Redistribution of fat quantity
Fig. 23.9 This abdomen needs contouring and fat reduction. Fig. 23.10 This abdomen needing skin tightening only. Photograph
Photograph courtesy Thermage Corp courtesy Thermage Corp
160 A.F. Taub
Fig. 23.11 Thighs and buttocks in need of circumferential

reduction and shaping. Photo courtesy Thermage Corp Fig. 23.12 Thighs in need of cellulite reduction. Photograph
courtesy Thermage Corp
Fig. 23.13 Grading scale for cellulite

or gynoid lipodystrophy. Photo Courtesy
Thermage Corp
23 Noninvasive Body Rejuvenation 161
standing position with arms outstretched perpendicular Treatment Techniques by Device

to the body. Note preexisting scars.
Velashape (Syneron Medical Ltd, Yokneam, Israel).
An area is treated that is 25–40 cm2 on each side. Fifty
Method of Device or Treatment percent overlap of pulses treating in the direction of
Application lymphatic drainage and doing a total of 10 min on each
side, with extra pulses for problem areas, vectors or to
create symmetry.
Dosages and Settings
Smoothshapes (Elemé Medical, Merrimack, NH, USA)
(Fig. 23.14). Passing motions with the handpiece are
Dose and setting selections vary by make of equipment
made over the area in the direction of lymphatic drain-
and method of action. These would also vary depending
age. Approximately 10 min of repetitions of this are
on body area being treated (arms, abdomen, thighs,
included per area.
buttocks). Therefore, only a range of settings/doses for
each instrument will be given, based on their brand Thermage (Solta Medical Inc., Hayward, CA, USA).
names. Number of recommended treatments and mech- After applying the grounding cable and grid, areas of
anism of action are listed in Table 23.2. directional laxity or excess tissue are marked with the
Table 23.2 Categorization of methods of body contouring according to technology, mechanism of action, number of treatment and
frequency
No. of treatments Need for maintenance
(frequency) Type of energy Mechanism of action therapy
Suction massage 14+(2×/week) Vacuum and mechanical Redistribution of fluids Yes
(Endermologie) manipulation
Liposuction 1 Heating from ultrasound, Removal of fat No
suction, human exertion
Chemical lipolysis 4–6 (every 3 Heat from chemical Necrosis of fat cells No
(Mesotherapy) weeks) reaction
Laser lipolysis (Smart 1 Laser fiber induced heating Ablation of fat No
Lipo, Cool Lipo)
Combo suction, 12–16 Vacuum, mechanical Redistribution of fluid, Yes
rollers, IR light, (biweekly) manipulation, broadband alteration of fibrous
bipolar RF infrared light, bipolar tissue, increased
(Velasmooth) radiofrequency metabolism of fat cells
Diode laser + Suction 10–14 Diode laser, mechanical Redistribution of fluid, Yes
massage manipulation and alteration of fibrous tissue
(Triactive) vacuum
IR light, suction, 4–6 Same as Velasmooth Same as Velasmooth Yes
massage, bipolar
RF (Velashape)
Focused ultrasound 1–2 Focused ultrasound Photoacoustic lipolysis No
(Ultrashape)
Tissue Tightening 1–5 Monopolar, bipolar or Alteration of connective tissue No
(Thermage, Titan, unipolar radiofrequency,
Lux IR, ReFirme, broadband infrared light,
Accent) combination infrared light
and bipolar radiofrequency
Photomology 8 Dual wavelength laser light “Photomology,” laser induced Yes
(Smoothshape) (630 and 900 nm), release of lipids from fat
suction, massage cells, liquification of fat,
redistribution of fluid,
tightening
162 A.F. Taub
patient standing up (Fig. 23.15). Treat entire grid with

staggered passes (Fig. 23.16) 2–3 times, then treat vectors
and problems areas with 1–4 passes. Treat distal to proxi-
mal and medial to lateral (legs or arms). Treatments are
performed (Fig. 23.17) to visual tightening/smoothing
(typically 900–1200 pulses, depending on area utilizing
the TC, CL, or DC tip, or 300 pulses with the 16.0 tip).
Titan (Cutera Inc, Brisbane, CA, USA). Same as
Thermage except for no placement of grid or grounding
cable. Treatments are more effective if an area the
size of approximately two decks of cards are treated
at one time, which decreases the number of pulses
Fig. 23.14 Application of Smoothshapes handpiece. Photo necessary to bring a given area to temperature yield-
courtesy Eleme Corp ing tissue conformational change. Ultrasound gel is
Fig. 23.15 Designing appropriate and different treatment approaches to three different abdomens for tissue tightening. Photo courtesy
Thermage Corp
Fig. 23.16 Staggered passes design for abdominal treatment Fig. 23.17 Application of Thermage handpiece to patient.
with Thermage. Photo courtesy Thermage Corp Photo Courtesy Thermage Corp
necessary. Two to four treatments over 2–5 months are Postoperative Care
performed.
Refirme (Syneron Medical Ltd, Yokneam, Israel).
None of the noninvasive procedures discussed in this
Essentially the same as Titan.
chapter require postoperative care, unless there is a
Accent RF (Alma Lasers Ltd, Caesarea, Israel). Utilizing complication.
the monopolar handpiece that has a rolling ball, an area
on the skin the size of the dorsal hand is continuously
contacted using circular motions. The area is treated
until the external temperature (monitored with a radar Management of Adverse Events
temperature gun) reaches 40–42°C, and then the next
area is heated in like fashion. Most adverse events with these devices are mild and/or
Ultrashape (UltraShape Ltd., Tel Aviv, Israel). transient. These could include discomfort during or
(Fig. 23.18). During treatment, a video camera cap- after the procedure which is short-lived, erythema,
tures the treatment area and the transducer in real time and/or radiating heat from the area which can last min-
and guides the user, by means of graphic overlays dis- utes to hours. Blisters require conservative care and
played on the system monitor, to place the transducer on usually heal without incident. The main cause of
the next treatment spot (“node”). The nodes homoge- adverse events is excessive heating of an area or lack
neously cover the treatment area, which is detected by of adequate coverage with medium (such as gel or con-
the system, without overlap and without extension beyond ductive fluid, if required). It is important to discontinue
the marked boundaries of the treatment area. Any area any treatment that causes excessive discomfort or
where the fat compartment is more superficial than 2 cm severe heat sensation and to immediately discontinue
is not appropriate for treatment with this device. the procedure and/or increase cooling. If overheating
were severe enough, a first or second degree burn
could occur with subsequent hypo- or hyperpigmen-
tation and/or scarring. If pulses are stacked in tissue
tightening procedures, or an area is significantly
overheated, fat necrosis and permanent concavity
could occur. This type of result is less common with
newer protocols of more frequent passes and mode
rate temperatures. Bruising can also occur with
devices, which include mechanical manipulation
and/or suction. This is usually managed via discon-
tinuation of any blood thinning medications if not
necessary, and/or time. Many of the early studies of
these devices found no perturbations of serum lipids
or liver function tests. However, in devices that utilize
suction and massage, increased frequency of urina-
tion and defecation without known metabolic or
infectious abnormalities have been not uncommonly
reported.
Fig. 23.18 Ultrashape treatment area (abdomen) homogeneously

covered by individual treatment nodes, as guided by the Contour
I real-time video monitoring and guidance system as it appears
at the completion of treatment. Reprinted with permission from: Conclusion
Teitelbaum SA, Burns JL, Kubota J, Matsuda H, Otto MJ,
Shirakabe Y, Suzuki Y, Brown SA. Noninvasive body contouring
by focused ultrasound: safety and efficacy of the Contour I Body shaping technologies are in their infancy. Focused
device in a multicenter, controlled, clinical study. Plast Reconstr ultrasound is not approved for use in the US, whereas
Surg. 2007; 120(3):779-789; discussion 790 tissue tightening devices such as uni and monopolar
164 A.F. Taub
radiofrequency move forward with second-generation (Fig. 23.21), while new devices (Smoothshapes) are
devices (Accent XL, Velashape II, Thermage NXT) or being introduced. These devices will continue to
new tips (DC and CL and 16.0 tips on the Thermage) become more specific for fat reduction, utilize lesser
(Figs. 23.19 and 23.20) and combination therapies treatments and result in greater improvements as tech-
have added increased energy and utility (Velashape) nological advances continue. Combination therapies
Fig. 23.19 Before and 2 months after two treatments with the Thermage DC tip. Photo courtesy Amy Forman Taub MD
Fig. 23.20 Pre (a), 6 months after one treatment with Thermage CL tip (b) and 14 months after treatment (c). Photo courtesy Silvia
Cuevas, MD and Thermage Corporation. postcellulitethermage14mossilviacuevas.jpg
Fig. 23.21 Before (a) and after four treatments with the Velashape device (b). Photo courtesy Gerald Boey, MD and
Syneron Corp
Fig. 23.22 “Velafirme” – before (a) and after four treatments with both Velasmooth and Refirme (b). Photo courtesy B. Niemann,
MD and Syneron Corporation
are being explored to create synergistic changes 2. Sadick N, Margo C. A study evaluating the safety and efficacy
(Fig. 23.22). Noninvasive body contouring and shaping of the VelaSmooth system in the treatment of cellulite. J Cosmet
Laser Ther. 2007;9(1):15-20.
is the new frontier for aesthetic medicine. 3. Kulick M. Evaluation of the combination of radiofrequency,
infrared energy and mechanical rollers with suction to improve
skin surface irregularities (cellulite) in a limited treatment
area. J Cosmet Laser Ther. 2006;8:185-190.
References 4. Boey G. Cellulite treatment with a radiofrequency, infrared
light, and tissue manipulation combination device. Abstract.
American Society of Dermatologic Surgery Annual Meeting,
1. Wanitphakdeedecha R, Manuskiatti W. Treatment of cellulite Oct. 2006.
with bipolar radiofrequency, infrared heat, and pulsatile 5. Alster TS, Tanzi EL. Cellulite treatment using a novel combi-
suction device: a pilot study. J Cosmet Dermatol. 2006;5(4): nation radiofrequency, infrared light, and mechanical tissue
284-288. manipulation device. J Cosmet Laser Ther. 2005;7(2):81-85.
166 A.F. Taub
6. Nootheti PK, Magpantay A, Yosowitz G, Calderon S, Goldman 9. Moreno-Moraga J, Valero-Altes T, Riquelme AM, Isarria-
MP. A single center, randomized, comparative, prospective Marcosy MI, de la Torre JR. Body contouring by non-invasive
clinical study to determine the efficacy of the VelaSmooth transdermal focused ultrasound. Lasers Surg Med. 2007;39(4):
system versus the Triactive system for the treatment of cellulite. 315-323.
Lasers Surg Med. 2006;38(10):908-912. 10. Atkin D, Goldberg D, Kilmer S, et al. A multicenter study to
7. Khatri KA, Stol ML, et al. Effectiveness of Smoothshapes assess the effectiveness of monopolar radioFrequency energy
cellulite treatment as monitored with high-frequency ultrasound on the upper arm. Poster World Congr Dermatol. 2007.
laser. Presented at the American Society of Laser Medicine 11. del Pino Emilia M, Rosado RH, Azuela A, et al. Effect of
and Surgery 2008 Annual Meeting, Orlando, FL. controlled volumetric tissue heating with radiofrequency on
8. Teitelbaum SA, Burns JL, Kubota J, et al. Noninvasive cellulite and the subcutaneous tissue of the buttocks and
body contouring by focused ultrasound: safety and effi- thighs. J Drugs Dermatol. 2006;5(8):714-722.
cacy of the contour I device in a multicenter, controlled, 12. Goldberg DJ, Fazeli A, Berlin AL. Clinical laboratory, and
clinical study. Plast Reconstr Surg. 2007;120(3):779-789. MRI analysis of cellulite treatment with a unipolar radiofre-
discussion 790. quency device. Dermatol Surg. 2008;34(2):204-209.
Chapter 24
Reduction of Cellulite with Subcision®
Doris Hexsel, Taciana Dal’ Forno, Mariana Soirefmann, and Camile Luiza Hexsel
Introduction: Evidence from Literature Clinical Examination and Patient

Selection
Subcision® is a simple surgical technique used for the
treatment of cutaneous depressions. It was originally The ideal candidates for Subcision® are healthy patients
described by Orentreich and Orentreich for the treat- who present one or more evident depressed lesions
ment of cutaneous scars and wrinkles in 1995.1 (level of cellulite on the buttocks and/or upper thighs.
of evidence *C) Subsequently, Subcision® was reported According to the current classification of cellulite
for the treatment of cellulite and liposuction sequella (Gynoid Lipodystrophy Scale), ideal candidates are
by Hexsel and Mazzuco in two series of cases with 462 those presenting 2nd and/or 3rd degree of cellulite
(*C) and 2323 (*C) patients.3 Subcision® has also been (Table 24.1).3
reported for the treatment of atrophic depressed scars4 Patients should be evaluated in a standing position
(*C), acne scars5 (*C), stretch marks6 (*B), and auricu- with relaxed muscles, and only the evident depressed
lar deformities in rabbits7 (*C). lesions are selected for the treatment. This means that
The most frequent cellulite lesions are depressions in lesions should be independently visible of pinch test or
the cutaneous surface of the affected areas. These lesions muscular contraction. Lesions up to 3 cm in diameter
are related to the subcutaneous septa, which pull the skin or less, or even parts of larger lesions, are eligible
down8 (*C). Interestingly, a study demonstrated that sig- for the procedure.3 A light source in a downward
nificantly thicker subcutaneous fibrous septa are present in position is helpful to visualize and mark the lesions to
areas with cellulite compared to areas without cellulite.9 be treated.10
Subcision® works for specific degrees of cellulite by
a multistep process. The first mechanism is the section of
the fibrous dermal and subcutaneous septa with the pur-
pose of releasing traction to the skin.1 The subsequent
hematoma formation is followed by secondary connec- Contraindications
tive tissue deposition, which fills the depression.1
The following conditions are contraindications for the
treatment of cellulite with Subcision®:
*Levels of Evidence
• Relative contraindications: history of hyperthophic
A. Literature on randomized and meta-analyses or keloid scars, active local or systemic infections,
of clinical trials and use of drugs that interfere with coagulation or
B. Well-designed clinical and observational with local anesthetics.
studies • Absolute contraindications: pregnancy, 1st degree
C. Reports and case series of cellulite, cottage cheese or orange peel lesions,
D. Publications based on consensus and opinions coagulation disorders, severe illnesses, and patients
of specialists who will be unable to follow postoperative recom-
mendations or with unrealistic expectations.3

168 D. Hexsel et al.
Table 24.1 Classification of cellulite on the basis of clinical the marked area, and an intradermic anesthetic
criteria button should be left in the locations where the
Degree or stage Clinical characteristics Subcision® needle will perforate the skin;
0 (zero) There is no alteration to the skin surface • After the maximum vasoconstriction (Fig. 24.1), the
I The skin of the affected area is smooth
skin should be punctured using an 18-G BD Nokor
while the subject is standing or lying,
but the alterations to the skin surface Needle or a common needle. The needle is inserted
can be seen by pinching the skin or into the subcutaneous tissue to a depth of 1.5 or
with muscle contraction 2 cm, and then parallel to the cutaneous surface;
II The orange skin or mattress appearance • At the subcutaneous level, it is possible to press the
is evident when standing, without the
use of any manipulation (skin needle against the septa, facilitating the detection of
pinching or muscle contraction) the septa responsible for the skin depression. Only
III The alterations described in degree or septa responsible for depressions to the skin surface
stage II, are present together with should be cut. Subsequently, the needle is pressed
raised areas and nodules
against the septa and the cut is made in the same
direction in which the needle will be withdrawn
Method of Device and Treatment (Fig. 24.2).
Application • A gentle pinching of the skin helps to determine the
presence of residual septa which still pull the skin;
Preoperative Recommendations
The preoperative care for Subcision® includes coagula-

tion studies. The following recommendations are given
to the patients undergoing to the procedure:
1. Seven days prior to the procedure, discontinuation
of drugs that may interfere with blood coagula-
tion, such as anticoagulants, analgesics, and anti-
inflammatories;
2. Discontinuation of iron supplements one month
prior to the procedure;
3. Prophylactic antimicrobial therapy with cipro-
floxacin 500 mg should be started 6 h prior to the Fig. 24.1 A patient during Subcision® showing paleness and
hair erection due to vasoconstriction after local anesthesia
procedure;
4. Identify the patients who are in use of any drug that
may interfere with the results of the procedure (e.g.,
beta-blockers, immunosuppressants, neuroleptics,
and oral isotretinoin).
Treatment of Cellulite with Subcision®

Technique
After marking the lesions, the following steps are

recommended:
• Antisepsis of the skin with 70% alcohol;
• Infiltrative local anesthesia with 2% lidocaine plus a
vasoconstrictor agent (epinephrine or phenylephrine); Fig. 24.2 The needle is pressed against the septa during the
local anesthetics are injected beyond the limits of Subcision®
24 Reduction of Cellulite with Subcision 169
if that is present, the needle can be reinserted to cut intervention is necessary, the procedure can be
these specific septa; repeated, as long as there are no sequelae from the pre-
• The blood vessels that accompany the septa are also vious procedure, after an interval of two or more
bisected, promoting the formation of hematomas; months.9 The number of procedures necessary to cor-
• Compression of the treated areas with specifically rect a specific depression or lesion will depend on the
designed pillows, weighing around 10 pounds for size, depth, and location of the defect as well as
5–10 min and wrapped in a sterile sheet guarantees the ability of the individual’s body to form and deposit the
a homogeneous compression, hemostasis, and con- necessary amount of collagen to fill the depression.
trol of the size of the hematomas formed by the
procedure.
• The procedure is finalized with the application of
micropore bandages and compressive garments. Complications, Postoperative Care,
and Management of Adverse Events
If the procedure has been accurately carried out, com-

Postoperative Recommendations
plications resulting from the treatment with Subcision®
are rare and easily treated.2,3 These complications are
Ciprofloxacin 500 mg should be taken twice a day during described as follows:
the first 3 days. Moreover, patients may take acet-
aminophen 750 mg once every 6 h, as needed for pain. • The resulting hematomas and ecchymosis are
Compressive garments are recommended to be worn both expected and needed for the formation of the new
day and night and encouraged during the day for 30 days. connective tissue, acting as an autologous filling
Light physical activity is allowed in the first 30 days. (Fig. 24.7); they tend to regress spontaneously
within a period varying from 30 to 60 days. If the
surgical area has been sufficiently compressed
by the recommended compressive garments, the
Results hematomas will have a better evolution;
• Seromas can occur in some treated lesions. They
The final result can be observed 30–60 days after the usually appear as hardened nodules that are sensitive
procedure, when the hematomas have completely to the touch. They tend to regress spontaneously in
resolved (Figs. 24.3 and 24.4, 24.5 and 24.6). If further 3–4 months;
Fig. 24.3 Patient showing cellulite depressions on buttocks

before Subcision® Fig. 24.4 Same patient as in Fig. 24.3, 20 days after Subcision®
170 D. Hexsel et al.
Fig. 24.6 Same patient as in Fig. 24.5, 4 months after Subcision®

Fig. 24.5 Patient showing cellulite depression on buttocks
before Subcision®
• Pain may occur during the first days of the postop-

erative period. It can be controlled with common
analgesics such as acetaminophen;
• Infections can be prevented by a careful clinical exam
and by administration of prophylactic antibiotics.
If an infection occurs, treatment is recommended;
• Brownish spots may occur in the areas of the hema-
tomas due to iron deposition, which is more intense
and persistent in patients who had ingested large
amount of iron in medicines or diet or patients with
high baseline hemoglobin. These spots may take
over one year to fade. Restriction in iron intake from
diet or supplements one month prior to the procedure,
as well as other measures mentioned before is quite
efficient in preventing this complication;
• Suboptimal response may occur, but a new interven-
tion can be done as long as there are no sequelae
from the previous procedure;
• Excessive response may occur in 5–10% of all
cases. A true excessive response is due to formation
of excessive fibrosis resulting from the procedure. Fig. 24.7 Hematomas in the third postoperative day of Subcision®
This condition can be treated with intralesional
triamcinolone;
• A false excessive response may also occur.3 This is in the treated area. This particular condition can be
due to herniating of the fat, causing by cutting unnec- prevented by avoiding Subcision® over large lesions
essary additional septa and causing detachment of a or extensive areas and concomitant section of all
fat layer and projection of the fat to the skin surface septa. It is important to keep in mind that some of the
24 Reduction of Cellulite with Subcision 171
septa that are not exerting excessive skin retraction scars and wrinkles. Dermatol Surg. 1995;21(6):543-
should remain intact; 549.
2. Hexsel DM, Mazzuco R. Subcision: Uma alternativa cirúrgica
• Although formation of keloid scars has not been para a lipodistrofia ginoide (“celulite”) e outras alterações do
observed in our experience of the treatment of relevo corporal. An Bras Dermatol. 1997;72: 27-32.
more than 2,000 patients, this may happen, as their 3. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite.
occurrence is related to individual factors. Int J Dermatol. 2000;39(7):539-544.
4. Goodman GJ. Therapeutic undermining of scars (Subcision).
Australas J Dermatol. 2001;42(2):114-117.
5. Alam M, Omura N, Kaminer MS. Subcision for acne scar-
Conclusion ring: technique and outcomes in 40 patients. Dermatol Surg.
2005;31(3):310-317; discussion 317.
6. Luis-Montoya P, Pichardo-Velázquez P, et al. Evaluation of
Subcision® is a useful technique for the correction subcision as a treatment for cutaneous striae. J Drugs
Dermatol. 2005;4(3):346-350.
of depressed alterations and lesions of the skin, 7. Karacalar A, Demir A, Yildiz L. Subcision surgery for the
including cellulite, liposuction sequela, scars, and correction of ear deformities. Aesthetic Plast Surg. 2004;
other alternations in the skin relief. It is an outpa- 28(4):239-244.
tient surgical intervention that produces long-last- 8. Nürnberger F, Müller G. So-called cellulite: an invented
disease. J Dermatol Surg Oncol. 1978;4(3):221-229.
ing results. 9. Hexsel D, Soirefmann M, Rodrigues TC, Lima MM.
Anatomy of subcutaneous structures in areas with and with-
out cellulite by magnetic resonance images. (Poster – 66th
Annual Meeting – American Academy of Dermatology, San
References Antonio, February 1-5, 2008).
10. Hexsel D, Mazzuco R. Subcision. In: Goldman, Hexsel,
1. Orentreich DS, Orentreich N. Subcutaneous incisionless Baccci, Leibashoff, eds. Cellulite: Pathophysiology and
(subcision) surgery for the correction of depressed Treatment. Marcel Dekker, Inc. New York.
Chapter 25
Body Contouring with Tumescent Liposuction
Carolyn I. Jacob
Introduction may be an indicator that the patient will have redundant

skin folds or surface irregularities after liposuction.
In some cases, a combination of procedures may enable
Liposuction is the aesthetic removal of undesirable,
the patient to obtain results they were anticipating.
localized collections of subcutaneous adipose tissue.1
Locations that are at particular risk for poor skin
An individual may be near his or her ideal body
retraction (in the patient with poor skin tone) are the
weight, yet still have disproportionate, localized
neck, upper arms, lower abdomen, and inner and outer
adipose deposition. Such a patient is an ideal candidate
thighs. I refer to patients with less than optimal skin
for tumescent liposuction. This technique of infiltrating
elasticity as having soft skin. This can be recognized as
large volumes of dilute lidocaine and epinephrine
the preoperative appearance of cellulite and dimples
obviated the need for general anesthesia, virtually elim-
on the outer thigh, ridges or folds on the abdomen,
inated the need for blood transfusions, and decreased
hanging neck skin, or wrinkled inner thigh skin. Patients
patient recovery time.2–4 Lidocaine toxicity is the most
with soft skin must be treated with caution, and they
significant factor that limits the amount of anesthesia
should be counseled as to the expected outcome of
used in tumescent liposuction. Using the tumescent
surgery. However, even patients with good skin tone
technique, lidocaine dosages up to 55 mg/kg can be
and elasticity can experience poor skin retraction, most
used with minimal risk of lidocaine toxicity.5
commonly on the upper abdomen, distal anterior thighs,
and the anterior axillae.
A thorough medical history is essential to evaluate
undue risk of bleeding, infection, emboli, thrombophle-
Clinical Examination and Patient History bitis, edema, and a history of past surgeries, which may
complicate the technique.1 Patients should be screened
The physician should take the patient’s wishes into for concomitant use of medications, which are known
consideration, as well as the overall proportions of the as P450 CYP3A4 inhibitors, such as erythromycin,
patient. Not only is proportion important, but contour, ketoconazole, or serotonin reuptake inhibitors.6 These
flow, and symmetry of body lines are an essential part medications should be avoided 2 weeks prior to the
of liposuction planning. Patients with localized irregular procedure (Appendix A), and patients should be given
contours or localized fat deposits are superb candidates information regarding what to expect on the day of the
for liposuction. Identify those body areas that can be procedure. This helps alleviate anxiety and minimize
contoured with liposuction to create an overall aesthetic confusion. Not only should current medications and
and contour improvement. medication allergies be recorded but also any history
For some patients, skin laxity, muscle flaccidity or of hepatitis, hepatotoxic chemotherapy, and use of birth
location of fat pads deeper than the subcutis (i.e., control pills or cytochrome P450 competitors. A com-
intra-abdominal) may not make them good liposuction plete skin examination includes adipose distribution,
candidates. One judges skin laxity by the “snap test.” quality of skin tone, and elasticity as previously
To perform this test, the surgeon pinches 1–3 cm of mentioned (i.e., snap test). All treatment sites should
skin, retracts and releases. Slow recoil or excess laxity be evaluated for preexisting hernias, varicosities, scars,

174 C.I. Jacob
Box 25.1
Liver function tests
Hepatitis profile
Electrolytes
Complete blood count
Prothrombin time
Partial thromboplastin time
Pregnancy test for premenopausal women
Other tests may include urinalysis, bleeding
time, or infectious disease studies such as
for the human immunodeficiency virus1
asymmetry, or other findings. Laboratory studies are

done to screen patients for general health, bleeding
disorders, and underlying disorders, which may affect
the metabolism of medications used throughout the
procedure. Typical studies are shown in Box 25.1.
To minimize local bacterial flora, some physicians Fig. 25.1 Preoperative markings for abdominal liposuction.
have the patient wash at home with antibacterial soap Note use of flow lines and markings (large “X” to denote areas
(Hibiclens, Zeneca Pharmaceuticals, Wilmington, DE) of adipose concentration) to aide surgeon intraoperatively
prior to the procedure.8
Before surgery, laboratory examinations should be Sharpie (Sanford, Bellwood, IL) pen as it works well,
reviewed and confirmed, and informed operative con- does not come off during the procedure, and fades
sent signed and last minute questions answered. The during the following few days. Because the marking
initiation of preoperative antibiotics as well as the dis- procedure relies on the patient being cognitively
continuation of medications that can promote bleeding alert, the treatment zones are delineated and confirmed
(Appendix B) should be confirmed. The patient’s weight with the patient.
should be obtained on the day of surgery, and used The patient is prepped in a sterile manner with a
both as a reference for postoperative visits as well as to surgical scrub (Betadine®, Purdue Fredrick Co.,
calculate maximum lidocaine dosage for the procedure. Norwalk, CT or Hibiclens®, Zeneca Pharmaceuticals,
If preoperative calculations are performed by nursing Wilmington, DE) to minimize skin flora and risk of
staff or assistants, the surgeon should be certain to infection. Areas not to be treated are covered with ster-
verify calculations, including the conversion of pounds ile drapes, exposing only the treatment area(s). Many
to kilograms and the calculation of lidocaine dosage. patients become chilled during the procedure, so it is
helpful to have a table heating device in place under
the patient (Gaymar hydrocollator heating pad, George
Method of Treatment Tieman Co., New York, or the Bear Hugger Warmer,
Augustine Medical Inc., Minnesota), as well as careful
A set of preoperative photographs should be taken control of room temperature. Additional options are
from at least two angles of the area being treated. While stocking caps to contain body heat and prevent loss
the patient is alert, and utilizing a standing position, the through the scalp, warm socks, and the LipoSat infusion
physician should mark the treatment areas. The physician device (LaserPoint AG, Nordkirchen, Germany), which
needs to be able to clearly denote areas to be aggressively allows heating of the tumescent solution to 37°C for
treated, areas not to be treated, and areas to be “feathered” patient comfort. Warm solution has also been shown to
or lightly treated (Fig. 25.1). Use a fine point black be more comfortable during infusion.
25 Body Contouring with Tumescent Liposuction 175
The equipment used for tumescent liposuction

varies greatly between practitioners, depending on style, Box 25.2 (continued)
training, treatment site, patient factors, and desired
aggressiveness of liposuction. Common items are an Least aggressive – small diameter, distal holes
infusion mechanism and cannula for infusion of the oriented away from dermis
tumescent anesthetic solution, suction apparatus, and Capistrano 16 gauge
suction cannulas of specified diameters and tip designs. Klein (dual port) 14–16 gauge
Some cannulas are coated with zirconium nitride or Spatula 2–3 mm
polytetrafluoroethylene to enhance slickness and reduce 1-Hole standard 2 mm
resistance. Tip shapes vary and include blunt, bullet,
spatula, and “V” shapes. Standard cannula lengths range
from 10 to 35 cm. The length of the cannula should be
Table 25.1 Gauge-Millimeter equivalents
sufficient to effectively cover the entire area to be for liposuction cannulas
treated. This is necessary to ensure proper feathering Gauge Equivalent
of edges, and allow for complete triangulation of the 8 4.2 mm
treated area. Suction cannulas vary in length, diameter, 10 3.4 mm
tipstyle, and orifice placement. All of these components 12 2.8 mm
factor into the aggressiveness of the suction cannula. 14 2.2 mm
More aggressive cannulas are wider in diameter, shorter,
have an open or pointed tip rather than blunt tip, and Cannulas may be purchased with or without handles.
have more and larger orifices for aspiration. Nearly all Those without handles use either standard luer lock or
cannulas are designed to be used with the suction deluxe luer-lock tip bases to fasten them to the handles.
holes directed away from the underside of the dermis A recent study evaluated the variety of cannula handles
(Box 25.2 and Table 25.1) (Fig. 25.2a–c). available, testing them for ergonomic ease. The most
ergonomic was found to be the biplane handle, whose
construction allows a full two plane grip with a trap of
the two planes allowing a more relaxed grip (Fig. 25.3a
Box 25.2 Cannulas
and b).9
Aggressive – large diameter, numerous holes, Many infusion devices and aspirators are available
holes placed toward tip of cannula for use (Box 25.3) (Fig. 25.4a–e).
Keel Cobra 3–3.7 mm Saline is used as the foundation for liposuction
Capistrano 10–12 gauge
anesthesia, and when placed in the subcutaneous space,
Mercedes 10–12 gauge it is absorbed slowly into the microvasculature.
Pinto 10–12 gauge This form of volume replacement, known as hypoder-
Toledo 10–12 gauge moclysis, is the mechanism for volume replacement
during tumescent liposuction surgery. Since the fluid
Intermediate – medium diameter, distal holes
is absorbed slowly over hours and not minutes
oriented away from dermis
(as with intravenous fluids), it allows the patient to
Accelerator/triport 3 mm mobilize and excrete fluids at a rate controlled by
3-Port radial or standard 3 mm normal homeostatic mechanisms. This allows for long
Pyramid 3 mm
term hydration of the patient over the immediate
Klein (dual port) 12 gauge
postoperative period, yet virtually eliminates the risk
Capistrano 14 gauge
Keel Cobra 2.5 mm of fluid overload.
Texas 2.5 mm Epinephrine has a threefold importance for tumescent
Dual port standard 2.5 mm liposuction. It provides excellent hemostasis, slows
Fournier 2.5 mm the rate of lidocaine absorption, and prolongs local
Sattler 2 mm analgesia. Unlike lidocaine, there is no described
limitation for epinephrine dosing.7 When utilizing the
(continued) tumescent technique for liposuction, total epinephrine
176 C.I. Jacob
Fig. 25.2 (a–c) Cannula varieties
Fig. 25.3 (a and b) Cannula handles and the biplanar grip. The handle furthest right has the most ergonomic biplanar hold
doses as high as 10 mg have been used without adverse

effects. 7 The author recommends limiting total
Box 25.3 Commonly Used Infusion and epinephrine dose to 5 mg to avoid toxicity. Without
Aspiration Pumps the addition of sodium bicarbonate, the tumescent
solution will be acidic, which may cause burning
Wells Johnson Single or Dual Infusion Pump
during infusion. The tumescent solution is also buffered
(Wells Johnson, Tuscon, AZ)
because sodium bicarbonate added to lidocaine in vitro
HK Infusion pump (HK Surgical, San Juan
augments the bacteriocidal activity of lidocaine.10
Capistrano, CA)
In dilutions of 0.05%, lidocaine is bacteriostatic for
Hercules aspirator (Wells Johnson, Tuscon,
staphlococcus aureus.11 Therefore, when tumescent
AZ)
anesthesia is used, infection is a rare complication.12
Reliance aspirator (Bernsco, Hauppauge, NY)
A higher concentration of lidocaine (0.1%) is used for
Byron Psi-Tec III (Byron Medical, Tuscon,
more sensitive areas, such as the abdomen, lateral thighs,
AZ)
knees, inner thighs, periumbilical area, neck, flanks
LipoSat (LaserPoint AG, Nordkirchen,
and back.5,13 When treating a large area, one may use a
Germany)
0.075% solution, which retains much of the anesthetic
Titan (Miller Medical, Mesa, AZ)
activity of the 0.1% solution but with 25% less lido-
caine, allowing the areas to be treated in one session.
Fig. 25.4 (a) Wells Johnson infusion pump. (b) HK aspirator. (c) Wells Johnson Hercules aspirator. (d) Reliance aspirator. (e) Psitec
III infusion pump and aspirator. (f) LipoSat infusion and aspiration pump
Table 25.2 Tumescent anesthetic solution deliver up to 5–6 l of fluid in 15–20 min. However, a

Strength 0.1% 0.075% 0.05% rate of less than 100 cc/min is commonly used.4
2% Lidocaine 50 cc 37.5 cc 25 cc Tumescent anesthesia fluid is delivered by blunt-tipped,
0.9% Normal saline 1 L 1 L 1 L 6–12 in., small diameter cannulas (12–14 gauge). These
Epinephrine 1:1,000 1 mg 1 mg 1 mg
are less traumatic than conventional sharp-tipped
Sodium bicarbonate 8.45% 12.5 mL 12.5 mL 12.5 mL
Triamcinolone 10 mg/cc 1 cc 1 cc 1 cc
needles and preserve the neurovascular structures.14
They also minimize risk for penetrating deeper struc-
tures. In skilled hands, 18–20 gauge spinal needles can
The following table (Table 25.2) lists the standard also be used for infusion. Appropriate incision sites
tumescent anesthetic preparations. should be planned to account for the length of the
There are many ways to deliver the tumescent liposuction cannula to be used, to provide adequate
anesthesia. Peristaltic mechanical pumps are able to access to all treatment areas, and to facilitate draining
178 C.I. Jacob
of the tumescent fluid during the postoperative period. creating a plane for the cannula to move in.4 Trying to
The surgeon can maximize the use of anatomic landmarks change directions, or angling the cannula while in
during this phase of the procedure, such as hiding an mid-stoke should be avoided. A change in cannula
incision adjacent to the umbilicus. direction during its motion can cause tenting or dimpling
Using a 30 gauge needle with a 3 cc syringe, each of the overlying skin. This can be particularly problem-
cannula incision site should be anesthetized. Some atic during the suctioning phase and produce contour
physicians use buffered 1% lidocaine with epinephrine, irregularities.
but I prefer to use the same solution as that will be used The endpoint for infusion is reached when the tissue
to provide tumescent anesthesia. A 3–4 mm incision becomes firm to hard, and indurated. For both infusing
with a No. 11 blade serves as a cannula insertion site.4 tumescent anesthesia fluid and suctioning, one hand
Insert the No. 11 blade only partially and at an angle to moves the cannula and the other serves as a “smart
avoid trauma to deeper tissues. The blunt-tipped small hand” to guide and feel the cannula position. This usually
diameter infusion cannula is inserted, attached to either nondominant hand lies on the skin and palpates, con-
the peristaltic motorized pump, pressurized infusion stantly assessing the movement of the cannula, depth
bag, or other delivery system. As discussed earlier, the in the tissue, and degree of tissue induration. This same
infusion rate may vary and is titrated to the comfort hand can be used to massage the areas as the anesthesia
of the patient, most commonly less than 100 cc/min is infused, thereby decreasing discomfort via distrac-
(a setting of 2–3 on the Klein Pump). tion. The endpoint for infusion can also be assessed by
Varying combinations of sedatives and analgesics blanching as a result of vasoconstriction. The amount
are given (Box 25.4), however, each patient will respond of tumescent anesthesia fluid infiltrated will depend on
to and metabolize medication at varying rates. the anatomic location (Table 25.3). The surgeon must
Therefore, dosages and choice of medications used be cautioned that there is no absolute rule as to how
should be titrated to each patient individually. much anesthesia is required to fully treat an area.
It is best to criss cross paths of anesthetizing both Factors that can affect volumes of infiltration include
horizontally and vertically within the depth of the body weight and the amount of fat in a particular
adipose tissue to ensure complete anesthesia. The infu- anatomic area, and the amounts listed in Table 25.3
sion cannula is moved slowly within the subcutaneous represent averages based on the author’s experience.
space to thoroughly anesthetize each region. Areas A minimum of 30–45 min is required to establish
closer to the infusion incision are anesthetized first to the profound anesthesia that is essential for performing
allow the cannula to move comfortably to distal regions. adequate and careful suctioning. The areas anesthe-
The anesthetic fluid also serves to hydrodissect the tissue tized should extend beyond the border of the intended
liposuction sites to prevent tenderness at the periphery,
and allow for feathering.
The concept of liposculpture is evolving as physicians
Box 25.4 Commonly Used Sedatives and treat not just one cosmetic unit but adjacent cosmetic
Analgesics15
Table 25.3 Approximate volume of anesthesia used
Diazepam (5–15 mg PO)
according to body site
Lorazepam (1–2 mg PO) Site Volume (liters)
Triaxzolam (Halcion: 0.25 mg PO)
Neck 0.4
Hydroxyzine Hydrochloride (Vistaril 25–50 mg Arms 1.0 per side
IV or IM) Upper abdomen 0.75
Midazolam Hydrochloride (Versed: 2.5–5 mg Lower abdomen 1.0
IV or IM) Hips 0.75 per side
Promethazine Hydrochloide (Phenergan: Love handles 1.0 per side
25 mg IV or IM) Flanks 0.75 per side
Outer thighs 1.0 per side
Meperidine Hydrochloide (Demerol: 50–75 mg
Inner thighs 0.75 per side
IV or IM) Knees 0.5 per side
Calves and ankles 1.0 per side
units (Box 25.5), blending the treatment sites to result in monitoring the aspirate for quantity and quality of
a more natural symmetry of proportions. Preoperative adipose.
markings help the surgeon to delineate areas to be treated, Adequate tumescent anesthesia should make the
with an improvement in the overall aesthetic appearance procedure nearly painless. The use of large cannulas
as the goal of surgery. However, it is the intraoperative initially takes advantage of the period of maximal
technique that ultimately determines the final result. The anesthesia. Smaller cannulas cause less pain as they
surgeon must pinch, feel, inspect, move, and contour the are advanced through the adipose tissue and offer more
subcutaneous tissue in a manner that will produce an options for fine-tuning and removing the remaining
improved skin contour. As liposuction surgeons, we rely adipose tissue (Box 25.6).
on the skin’s remarkable ability to contract and drape
over the underlying soft tissue. It is imperative to keep
the patient’s unique physical characteristics and skin Box 25.5 Liposuction Cosmetic Units
type in mind while suctioning. Skin that has poor elastic- Neck, submental region, and jowls
ity as well as skin with good tone will not recontour Posterior upper arm
without good suction technique, and this is part of the art Posterior axillary line and upper back
of liposuction/liposculpture. The surgeon factors in all of Upper abdomen
these issues to determine just how much fat to remove Lower abdomen
and from which areas, to produce the final result. Hip or Love Handles
The physician should use all sides of the operative Waistline and mid back
table to examine and treat the patient, accessing areas Outer thigh
from a minimum of two directions, preferably three. Inner thigh extending to knee
I refer to this method of suctioning as triangulation. Anterior thigh
Patient position should also be changed during surgery Posterior thigh
if the physician needs to access the fat. An advantage of Calve and ankle
tumescent liposuction surgery is that the patient is Breast
awake and therefore able to follow commands. The
patient can be asked to change body position during the
procedure to make it easier for the surgeon to treat an
area of the body. The central premise is that the surgeon
must be certain to treat all marked areas in a manner
Box 25.6 Anatomic Sites and Liposuction
that will yield smooth contours. If an area is suctioned
Aggressiveness17
from one direction, it is possible to leave ridges, as
small areas of fat between the cannula tunnels remain. Aggressive Love handles
Suctioning from two directions helps to reduce this 80–100% removed Back/flank
risk, but the third vector dramatically reduces the Male breast
appearance and feel of residual fat and ridges. Medial knee
The nondominant smart hand is one of the most Upper and lower abdomen
important elements of liposuction surgery. This hand is Moderate Hips
used to guide the cannula as well as assess cannula 50–80% removed Arms
Outer thighs
position and depth within the fat, bring fat into the
Buttock
cannula path, stretch or stabilize skin, and in general, Inner thighs
serve as the sensory input from the patient back to the Calves/ankles
physician. Visual clues are also extremely helpful for Neck
liposuction contouring, but the smart hand is an invalu- Jawline
able link between the surgeon and patient. A surgeon’s Light Mid inner thigh
mastery of the smart hand concept is likely to improve Less than 50% removed Jowls
Anterior distal thigh and knee
liposuction results significantly.
Posterior knee
With the use of tumescent anesthesia, blood
loss is minimal. The physician should continuously be
180 C.I. Jacob
Liposuction of the Arms pressure from the smart hand is not necessary in this
area, and may increase the risk for subdermal fibrosis,
adhesions, puckering, and indentations. The 3 mm
Liposuction of the arms is performed almost exclusively
Accelerator (Eliminator) or 12 gauge Klein cannulas
on women, with the posterior and posterolateral aspects
have a relatively nonaggressive tip, and with their
of the arm involved more often than the anterior and
recessed openings placed away from the dermis, they
medial upper arms. On occasion, a localized fat deposit
are ideal for fat removal of the arms. Particular atten-
on the ulnar side of the proximal forearm requires
tion must be paid to thoroughly treat the proximal
treatment as well. Conservative but thorough fat extrac-
upper arm and fat overlying the medial epicondyle, as
tion is obtainable without undue trauma due to the
incomplete treatment of these areas are the most
soft quality of the fat in the area. In some patients,
common causes of patient dissatisfaction. An incision
radiofrequency skin tightening can be a useful adjunct
site just distal to the fat overlying the medial epicon-
to upper arm fat removal.
dyle provides access to that area as well as the more
The patient is evaluated in a standing position with
fibrous fat just proximal to the elbow. Postoperative
arms extended horizontally with the thumb pointing up,
pain of the arms is minimal compared to other areas,
or elbows bent, to maximize the laxity of the posterior
and increase with poorly fitting compression garments
and posterolateral compartments. If skin tone is poor
(Fig. 25.5a–d).
preoperatively, the patient may still achieve significant
skin contraction if thorough fat removal is performed,
but texture will often not improve. For some patients,
concurrent treatment of the upper back and anterior/ Liposuction of the Trunk
posterior axillary regions is performed as well.
At least two incision sites are needed for infusion of Upper and Lower Abdomen
0.1% tumescent anesthesia. For infiltration of the
posterior and posterolateral arm, incision sites are Prior to suctioning, the patient must be evaluated for
just proximal to the elbow and at the apex of the abdominal hernias and scars. Ventral hernias including
posterior axillary line. Pinching, lifting, and downward umbilical, postsurgical, and Spigelian (lateral rectus sheath)
Fig. 25.5 Forty-two year old female (a) before and (b) after arm liposuction. Fifty year old African American patient (c) before and
(d) 6 months after arm liposuction
should be ruled out through clinical exam. Preoperative abdomen. Many patients will have well-defined
markings should reflect the extent of suctioning, areas adipose collections that lie on the rectus sheath deep
to be suctioned, and localized collections of adipose to Camper’s and Scarpa’s fascia, both superior to
tissue. The lower abdomen, when suctioned alone, is the umbilicus and inferior/lateral to the umbilicus.
often clearly demarcated and easily outlined. When the Suctioning of these areas is essential to produce a flat
lower and upper abdomen are to be treated together, abdomen (Fig. 25.6). It is often necessary to lift the
the extent of suctioning extends from under the breasts skin with the smart hand and carefully advance
to the suprapubic region. the cannula into a deep adipose plane to access this
Anesthesia is obtained through two incisions fat. Clearly, caution is needed to prevent subrectus
placed along the suprapubic region, as well as from suctioning. I have found it helpful to use short
mid-abdominal sites along the lateral aspect of the cannula strokes, and avoid any cannula motion lateral
area to be treated. Anesthesia is placed in the mid- to the rectus sheath when attempting this deep fat
subcutaneous space, and allowed to sit for a minimum maneuver. By avoiding cannula motion lateral to the
of 30 min prior to suctioning. Tumescent 0.075–0.1% rectus, it reduces the chances of becoming subrectus
lidocaine anesthesia is used for the upper abdomen, with cannula position. It is also imperative that
especially the areas over the costal margin. Suctioning cannula position be superficial when crossing the
is performed with the 3.7 mm swan neck Keel costal margin to prevent injury in that location.
Cobra cannula for debulking larger patients. The
3 mm Accelerator cannula can be used to debulk
smaller patients. The 12 gauge Klein cannula is used Hips
to feather treatment sites and ensure maximal smooth
fat removal. The hips are either treated alone or in combination
It is essential to thoroughly suction the periumbilical with the upper back and waistline. Some women
region as well as the deep fat of the upper and lower will also have the outer thighs treated in combination
Fig. 25.6 Forty year old female (a) before and (b) 6 months after upper and lower abdominal liposuction
182 C.I. Jacob
with the hips to recontour the lateral silhouette easily recognized as a distinct junction between hip
(Fig. 25.7). Correction of the double-bulge violin and upper lateral thigh. This pseudo-groove should
deformity of the hips and outer thighs can have a not be treated, even when combining hip and lateral
profound impact on body shape. The hip is outlined thigh liposuction, since this can produce disfiguring
bilaterally with the patient in the standing position. depressions. The anterior and posterior hip are also
The inferior border of the area to be treated is often usually distinct, and the surgeon can feel for the
boundaries of the hip with the pinch technique.
Typically, the amount of fat one can pinch diminishes
substantially as you move away from the central area
of hip adipose tissue. The superior hip can have an
indistinct border, and it is for this reason that hip lipo-
suction is often combined with treatment of the waist-
line. When treating the hip alone, it is important to
feather suctioning up into the waistline.
The right hip is anesthetized (and suctioned) with the
patient lying on the left side, and vice versa for the left
hip. Initial debulking can be performed with the 12 gauge
Klein or 3 mm Accelerator cannulas. Final blending is
done with the 12 gauge Klein cannula. Sufficient fat is
removed to achieve this result, and can vary significantly.
For most patients, 50–80% fat removal from the hip is
adequate. Occasionally, near 100% fat removal is needed
to obtain the desired contour (Fig. 25.8a and b).
Mid-lower Back and Waistline
Contouring of the waist can produce beautiful aesthetic

results, and a shapely waistline is one of the things appre-
Fig. 25.7 Hip and waist markings, posterior view ciated most by patients after their liposuction surgery.
Fig. 25.8 Thirty-five year old female (a) before and (b) after hip liposuction
The patient is marked in the standing position, with inferior gluteal crease where the buttock meets the upper
vectors of suctioning clearly marked. It is important to posterior thigh. Suctioning of the inferior buttock/
suction along intended vectors of skin retraction to upper thigh crease can disturb the fibrous junction in
promote skin redraping postoperatively. The surgeon that region and lead to an unnatural ptosis of the
can pinch the lower back fat to localize it, and this area buttock. Oversuctioning can produce a flattened
is marked. Incisions along the mid-waist, posterior buttock with irregular contours, which is not desirable.
mid-back, and under the lateral breast are used for The patient is often positioned in the prone position
anesthesia and suctioning. Additional incisions are for anesthesia, occasionally rocking gently onto one
placed as needed at the inferior zone of treatment to hip to allow anesthesia of the contralateral buttock.
promote triangulation and facilitate drainage. Anesthesia Incision sites should be placed in the lateral infragluteal
is obtained with 0.075–0.1% lidocaine and allowed to crease, the upper medial buttock, and the upper lateral
sit for 40–45 min. It is advisable to allow the tumes- buttock to promote triangulation. Anesthesia is placed
cent solution in this region to sit for slightly longer predominantly in the mid and deep fat of the buttock.
than other areas to provide maximal anesthesia. The Caution must be used to remain in the mid and
waistline and mid-lower back can be a particularly deep fat of the buttock, avoiding superficial suctioning.
sensitive area to treat due to the very fibrous nature of Treatment of the superficial fat can quickly lead to
the fat. Some surgeons prefer to use external ultrasound contour irregularities in this very technique-sensitive
in this area (and other areas with fibrous fat) to make region. The main theme that should guide the surgeon
fat removal easier, but I have found this to be cumber- is to retain the contour and convexity of the buttock
some and unnecessary.15,16 while decreasing size and improving contours. Mid
The goal of waistline and upper back suctioning is and deep fat liposuction are essential tools for the
near 100% fat removal. Initial debulking is performed physician. Initial gentle debulking can be done with
with either the 3.7 mm Keel Cobra or 3 mm Accelerator a 3 mm Accelerator cannula in most patients, while
cannulas. The surgeon must be certain to suction the very larger patients can be treated with the more aggressive
deep fat that lies just superficial to the muscular fascia, 3.0 or 3.7 mm Keel Cobra cannula. Following debulk-
similar to the technique for the upper and lower abdomen ing, the mid-fat is contoured with a 12 gauge Klein
deep fat. The smart hand is sometimes used to lift the cannula (Fig. 25.9a and b).
skin of the waistline to allow the cannula to access the
deeper fat. Final blending and contouring can be done
with a 12 gauge Klein cannula, but for many patients,
the 3 mm Accelerator is adequate for this task. It must Liposuction of the Legs
be emphasized that triangulation and aggressive
suctioning are needed to fully contour the waistline. Localized adipose deposits of the legs are particularly
A few extra minutes of attention to detail in this region well-suited to liposuction surgery. Although some
can produce dramatic improvements in results. people (usually women) have diffusely large legs with
abundant adipose tissue, many have well shaped legs
with discrete collections of fat. It is for these women
that liposuction is ideal. Thorough contouring of these
Liposuction of the Buttock localized fat deposits can dramatically change the shape
and flow of leg lines. Clothing fits better, and the patient
The goal here is to treat the buttock so that it fits in usually feels much more comfortable with their shape
harmony with the shape and silhouette of the patient. in general. As opposed to truncal obesity, many women
For these reasons, treatment of the buttock is often struggle with the shape of their thighs for years, even
combined with treatment of the hips and lateral thighs, when close to their ideal body weight. Genetics plays a
considering this to be an extended cosmetic liposuction significant role in determining leg shape.
unit. Caution must be used to avoid the inferomedial Women with generalized leg obesity can be improved
buttock in the vicinity of the sciatic nerve as well as with liposuction surgery, but many have underlying
the medial buttock near the gluteal cleft. In addition, bone and muscle anatomy that will not support the
suctioning and cannula motion should never cross the appearance of a thin, shapely leg. These women must
184 C.I. Jacob
Fig. 25.9 Female 43 year old patient (a) before and (b) 6 months after liposuction of the abdomen and buttocks
be counseled preoperatively that although liposuction Outer Thighs

can alter leg contours and perhaps thin their legs, it is
unlikely that they will convert from someone with an The goal of therapy is creating a flow of skin that
obese leg to one with a thin leg. Naturally, there are allows the outer leg to blend naturally with the hip,
exceptions to this rule, but we have found this to be buttock, and trunk. Suctioning of the outer thigh must
true in general. Also, there is a subset of women who be approached with caution, as taking too little fat will
have soft skin. This term refers to women who have yield a disappointed patient and taking too much a dis-
abundant cellulite in the setting of a relatively obese figured patient. The outer thigh is a landmark area, one
leg. The limiting factor for women with soft skin is that is used as a reference point by those casually
that overaggressive suctioning can produce rapid and observing a woman’s shape to determine overall body
dramatic skin depressions. Caution, and if anything type, thinness, and aesthetic contour. When the outer
undertreatment, are the rules for such patients. thigh is large or unnatural in shape, it tends to stand out
It is useful to think of the leg as having discrete and be noticeable to the eye. Therefore, improvement
cosmetic liposuction units. These include the (1) outer in outer thigh contours can have a profound effect on
thigh, (2) inner thigh extending down to and including body shape and patient self-image.
the knee, (3) anterior thigh, (4) posterior thigh, and (5) The patient is marked in the standing position
the calves/ankles. With lidocaine toxicity as the limiting (Fig. 25.10). Anesthesia is obtained with 0.075 or 0.1%
factor, the surgeon must factor in anatomy, patient lidocaine and allowed to sit for 30 min. Each leg is
desires, and surgical reality in determining which anesthetized and treated with the patient lying on
cosmetic units to treat. The outer thighs, inner thigh, and the contralateral thigh. Three to four incisions are
knee are commonly treated in one session together. used, the most common in the lateral aspect of the
Occasionally, the outer thigh is treated alone in the gluteal crease. The other incisions are placed at 2, 8, and
absence of other leg obesity, but in many cases, the outer 10 o’clock around the typical oval drawn to mark the
thigh and hip are treated together. outer thigh.
Initial debulking is performed with the 3 mm

Accelerator cannula in most individuals, but with the
12 gauge Klein in thin women. The 12 gauge Klein is
then used to suction more superficially and to perform
final blending and triangulation. Although relatively
superficial liposuction is performed, it is advisable to
leave a narrow zone of intact subdermal fat to retain
optimal contours.
Areas to be cautious include the upper lateral thigh,
distal lateral thigh, and Gasparotti’s point.17 The upper
lateral and distal lateral thigh are susceptible to
oversuctioning and ridging or dimpling, particularly
around cannula insertion holes. It is important to move
the cannula from one insertion hole to the next with
regularity to avoid oversuctioning through one incision
and creating a dimple under that incision. Gasparotti’s
point is just posterior to the greater trochanter, and
depressions in this location result from aggressive
suctioning of the deep fat (Fig. 25.11a and b). Abduction
and internal rotation of the leg are useful to drop the
greater trochanter out of the surgical field, and thus
protect against a Gasparotti point depression. Numerous
devices are available, including the triangular wedge
pillow (Wells Johnson, Tuscon, AZ), which promote
Fig. 25.10 Preoperative markings of the waist, hip, and outer
this leg position and aid the surgeon. The author
thighs prefers to have an assistant abduct the leg.
Fig. 25.11 (a and b) Indentation due to oversuctioning at Gasparotti’s point

186 C.I. Jacob
Fig. 25.12 Female 35 year old patient (a) before and (b) 3 months after liposuction of the outer thighs
The endpoint for outer thigh liposuction is the leg, and is often 1–1.5 finger-widths. The goal
subjective. Contour and flow are the most important of outer thigh suctioning becomes bringing the
concerns, and the smart hand pinch technique is outer thigh pinch test to match that 1–1.5 finger-
invaluable. The surgeon pinches other areas of the leg widths. But the surgeon must use the pinch test in
that appear to be well contoured, and determines how conjunction with visual and other tactile clues to deter-
many finger-widths (using the index finger) of skin is mine the optimal liposculpture endpoint (Fig. 25.12a
contained in the pinch. This becomes the set-point of and b).
Inner Thighs and Knees treated should also be marked, and are loosely used as
feathering guides into the anterior and posterior thigh.
For many women, the inner thigh region is a difficult Careful feathering is essential to maintain normal thigh
place to lose weight and improve contours. Diet and contours and flow.
exercise programs can have some limited success, Anesthesia is obtained with 0.075–0.1% tumescent
but liposuction is a superb treatment option for this lidocaine anesthesia through multiple incision sites.
anatomic region. When evaluating the inner thigh and Incision sites below the knee should be avoided since
knee, the surgeon must determine both the amount of they often heal less well than those above the knee.
fat removal to be performed as well as the extent of Thorough anesthesia of the fibrous posterior knee and
surface area to treat. Specifically, a decision must be inner thigh regions is helpful for improving patient
made to either treat the entire inner thigh and knee comfort. Anesthesia should be placed 2–3 cm beyond
region as one unit, or to treat the upper inner thigh and/ the anterior and posterior markings to allow for feath-
or knee as separate cosmetic units. ering. Anesthesia should sit for a minimum of 30 min
The difficulty with treating the inner thigh or knee prior to suctioning.
as distinct entities is that the risk of contour irregularities The knee is suctioned first, with the patient in the
and step-offs increases. Blending of the knee or inner frog-leg position and slightly rotated onto the side
thigh with the mid-thigh can be challenging, and the being treated. The degree of convexity of the medial
amount of fat that can be removed from these regions femoral condyle and the tibial plateau may create a
is limited if the surgeon must prevent a line of demar- pseudo-lipodystrophy in an area devoid of fat. Palpation
cation at the junction with the mid-thigh. Suboptimal upon physical examination will differentiate the depth
cosmetic results can be more frequent when the mid of the fat pad from the underlying bony prominences.
thigh is not treated. A 12 gauge Klein cannula is used to treat the knee,
For these reasons, the author has developed a with near complete fat removal as the goal. The surgeon
preferred method for treating the entire inner thigh should feather this treatment area into the proximal
and knee as one cosmetic unit, extending from the calf and the mid-thigh. It is useful to perform the
inguinal crease down to the superomedial calf. Very feather maneuvers during the initial phases of suction-
gentle suctioning of the mid-thigh region allows more ing, as this can allow for more thorough and even fat
thorough fat removal from the upper inner thigh and removal from the knee and upper inner thigh. Early
knee, improves blending and feathering into the feathering tends to improve the surgeon’s feel during
mid-thigh, and increases patient satisfaction by the procedure, often eliminating the need to “chase” a
contouring and debulking the entire medial upper leg. persistent ridge or depression. Treatment of the poste-
The patient is marked in the standing position with rior fibrous knee fat is performed with the 12 gauge
the knee fully extended, the leg advanced forward Klein cannula, but in some patients, a more aggressive
(a modified lunge position), and externally rotated. cannula such as the 12 or 14 gauge Capistrano cannula
The fat pads of the medial knee and upper inner thigh is needed to debulk this area.
are identified and delineated, as is the inguinal crease. The proximal inner thigh is initially gently
Markings should include the proximal medial calf as debulked in the deep fat with the Capistrano cannula.
treatment of this area helps to define knee contours and The 12 gauge Capistrano is used for most patients, but
improve the flow of skin lines. The surgeon should be thinner patients can be debulked with the 14 gauge.
certain to mark and identify the posterior knee and Caution is a must when using the Capistrano cannula
posterior upper thigh fat pockets, as failure to treat in this region. Its benefit is that it can quickly and
these areas will lead to less than optimal postoperative thoroughly debulk the upper inner thigh, including the
contours. Adequate contouring of these posterior very fibrous and resistant posterior inner thigh fat.
adipose collections is essential since these fibrous However, overzealous or superficial use of this
areas will dominate the postoperative appearance if cannula can produce persistent ridges and contour
not removed. Also, reduction of these compartments irregularities. The surgeon should limit the number of
allows the remainder of the inner thigh and knee skin cannula strokes performed from any single incision
to fall into position after suctioning rather than being with the Capistrano cannula, so triangulation is essen-
tented by these posterior fibrous adipose collections. tial with this instrument. The upper thigh is then fine-
The anterior and posterior borders of the region to be tuned with the 12 gauge Klein cannula, with blending
188 C.I. Jacob
and feathering into the mid-thigh. Fat removal from Careful treatment of the superficial fat compartment
the upper inner thigh should not be 100%, but more is often essential in these regions, as failure to remove
in the 50–80% range. This is one area where flow and this tissue can lead to persistent fullness.
the surgeon’s aesthetic sense are essential determinants The love handles can be treated alone, or com-
of the end point of treatment. bined with treatment of the upper and lower abdomen.
The mid-thigh is the medial region located between Evaluation for hernias is essential preoperatively
the upper inner thigh and the knee. It should be (see section on liposuction of the female abdomen).
viewed as a connector, essentially a bridge between Many men have intraabdominal fat that causes a
the upper and lower inner thigh region. For this protuberant abdomen. It is essential to identify
reason, treatment of the mid-thigh helps the surgeon this during the initial consultation and educate
to blend and contour the inner leg. The overall patients about the location of their adipose tissue.
contour changes of the inner leg come from suctioning Fat that is deep to the rectus muscle cannot be treated
of the upper inner thigh and knee, but the mid- with liposuction. Patients who have fat superficial
thigh is the glue that holds the cosmetic unit together. and deep to the rectus will often be disappointed
Suctioning of the mid-thigh should be performed with their results if they are not counseled preopera-
gently in the mid-fat with a 12 gauge Klein cannula, tively as to the limitations of treatment. The ideal
taking only what comes very easily. The endpoint of patient has little to no intraabdominal fat and well-
treatment is when the upper thigh and knee blend defined adipose collections superficial to the rectus
smoothly with the mid thigh, as well as when the and oblique muscles.
entire inner thigh blends smoothly with the anterior Multiple incision sites are used, hiding them in the
and posterior thigh. Caution should be exercised in suprapubic, periumbilical, and hair bearing regions
the vicinity of Hunter’s canal and the femoral artery, when possible. Initial suctioning can be performed
since aggressive suctioning in this area can produce a with the 3.0 or 3.7 mm Keel Cobra cannula in larger
very unnatural postoperative fullness (lump) in the individuals, as well as 10–12 gauge Capistrano
area. Final blending with the upper inner thigh, cannulas. Caution must be used to prevent ridging
posterior upper thigh, and knee is performed during when using these aggressive instruments despite the
the final stages of mid-thigh suctioning. The rule of fact that men tend to have resilient skin. Further
thumb is that it is better to remove too little rather suctioning is performed with the 3 mm Accelerator
than too much fat from the mid thigh. cannula, and superficial fat removed with either the
It is useful for the surgeon to think of the inner leg Accelerator or 12 gauge Klein cannulas.
as an entire cosmetic unit during the final stages of The abdomen is treated with the patient in the
suctioning. Taking a literal step back to view the flow flat supine position. Caution should be used when
and contours of this region can help the surgeon see crossing the costal margins. Each love handle is best
areas that require further treatment and blending. treated with the patient lying on his contralateral
Post operative compression of the upper inner thigh is side. Very aggressive suctioning of the deep fat in the
especially important, and the surgeon should be certain love handles is essential for contouring. Many men
to choose garments that provide adequate support in have firm, fibrous fat in the posterior love handle/
this area (Fig. 25.13a–d). lower back region, and this can be a challenge to
maximally debulk (Fig. 25.14a and b). Use of aggressive
cannulas such as the 10–12 gauge Capistrano can be
useful.
Love Handles and Abdomen on Men Postoperative compression is obtained with 9 or
12 in. elastic abdominal binders. Male patients are
Fat removal from the abdomen and love handles encouraged to wear these garments as much as
should be thorough for men. Most male patients desire possible to compress and contour the treated areas.
and benefit from near 100% fat removal in these Lycra bicycle shorts may also be beneficial for
areas. However, adipose tissue in these areas is the first 1–3 days to prevent fluid collections in the
quite fibrous, and aggressive suctioning is indicated. scrotal area.
Fig. 25.13 Nineteen year old female (a) before and (b) 6 months after inner thigh, knee, and outer thigh liposuction. Forty year old
female (c) before and (d) after inner thigh, knee, and outer thigh liposuction
190 C.I. Jacob
Fig. 25.14 Forty year old male (a) before and (b) 6 months after liposuction of the love handles. Note the persistence of some
subdermal adipose
Postoperative Clinical Considerations absorbent pads are applied over incision sites under
the support garment. Additional pads may be placed
Patients may be greatly distressed by the quantity of over the garment to facilitate changing by the patient.
drainage during the postoperative period unless they These may be changed as frequently as necessary to
have been adequately prepared by the medical team. absorb discharge. Some patients have found sleeping
Placement and changing schedules for the various pads the first two nights on a plastic mattress cover facili-
and support garments may be easily confused by the tates clean-up.
sedated patient, and should be provided in writing. The patient is asked to wear the compression gar-
Any instructions regarding medications (antibiotics ment for 23–24 h a day for the first 7 postoperative
and analgesics), and continued avoidance of certain days, removing it to shower when needed. After the first
products, should also be provided in writing. week, the patient is instructed to wear the compression
Most patients’ post operative pain is well-controlled garments for 8–10 h a day for the following 3–4 weeks.
with acetominophen, requiring acetominophen with Compression is particularly important for the neck,
codeine or other narcotics only the first few days, if at all. upper arms, upper inner thighs, and the abdomen.
Support garments applied by the medical team in the If preoperative antibiotics were initiated, they are
operating room will facilitate drainage of the tumescent usually continued for 5–7 days postoperatively. The
fluid, provide significant pain control, improve final patient is instructed not to shower for the first 24–48 h
outcomes and contours, and reduce the risk of seroma to decrease the risk of infection. For the same reason,
formation. These garments should compress all surgical they should not bathe in a tub or sit in a jacuzzi until
areas; multiple garments may be needed. A compres- all incision sites have healed. They should be informed
sion level between 17 and 21 mm of mercury is of the signs of possible infection, such as fever, chills,
desired.18 Adequate circulation and perfusion must be increased pain or redness and told to notify the physician
ensured before the patient is discharged. These gar- immediately if there is concern.
ments should not be removed by the patient for the first Since the lidocaine plasma peak level may actually
24 h. The patient is instructed to return to the office on occur after the patient has left the office, it is impera-
the first postoperative day where the medical team tive that the patient also be aware of the signs of
assists them with removing the garments for the first lidocaine toxicity: difficulty speaking, ringing in the
time. This is best done with the patient supine, and ears, tremors or tingling around the mouth, and confu-
they should be closely monitored for hypotension as sion. I prefer to have the patient in the company of
the pressure garment is removed. another person for 12–24 h after surgery so they are
Incision sites are not sutured postoperatively, and not left unattended. Epinephrine toxicity is initially
therefore tend to drain copious amounts of fluid. Super manifest by patient anxiety, agitation, or palpitations.
With increased levels, hypertension, tachycardia, or skill and artistry that ultimately determines outcomes,
arrhythmias may occur. A study of twenty patients and the surgeon can create beautiful contours by man-
undergoing liposuction, monitored at 3-, 12- and 23-h aging the interplay of skin healing dynamics, cannula
after tumescent fluid infiltration, demonstrated the motion and position, thoroughness of fat removal, and
peak serum epinephrine levels to occur at 3-h. The body shape.
majority had returned to normal at 12 h. The only
reported side-effect was anxiety.7
The patients are asked to not drink alcohol for 3 days Appendix A: Medications Which Inhibit
after surgery, refrain from smoking for as long as possi- Cytochrome P450
ble, and to avoid strenuous activity for 1 week. They are
encouraged to drink fluids and have a soft diet for the first
Drug Generic name (Trade name)
24 h, after which they may resume their regular diet.
Generic name (Trade name) Miconazole (Micatin)
Edema, ecchymosis, dysesthesia, fatigue, and sore- Acebutolol (Sectral) Midazolam (Versed)
ness are common complaints that improve with time. Acetazolamide Nadolol (Corzide)
Wearing the compression garments will also improve Alprazolam (Xanax) Naringenin (grapefruit
these symptoms. For this reason, some patients will Amiodarone (Cordarone) juice)
choose to wear their garments for many weeks after Anastrazole (Arimidex) Nefazodone (Serzone)
Atenolol (Tenoretic) Nelfinavir (Viracept)
the procedure. Areas that become firm to the touch can
Cannabinoids Nevirapine (Viramune)
be gently massaged, twice a day for 10–15 min until Nicardipine (Cardene)
Carbamazepine (Tegretol)
they resolve. This usually occurs between weeks 2–4. Cimetidine (Tagamet) Nifedipine (Procardia)
Dysesthesia of the overlying skin tends to resolve over Chloramphenicol Omeprazole (Prilosec)
1–3 months, and some patients may complain of an Clarithromycin (Biaxin) Paroxetine (Paxil)
“itchy” sensation. It is important to inform the patient Cyclosporin (Neoral) Pentoxifylline (Trental)
that this is a normal phenomenon. Some degree of Danazol (Danocrine) Pindolol
Dexamethasone (Decadron) Propranolol (Inderal)
entry site scars should be expected by the patient, and
Diltiazem (Cardiazam) Propofol (Diprivan)
followed clinically for improvements over a year. After
Diazepam (Valium) Quinidine (Quinaglute)
the initial dressing change on postoperative day 1, Erythromycin Remacemide
patients are seen again 1 week postoperatively to assess Esmolol (Brevibloc) Ritonavir (Norvir)
healing and effectiveness of garments. Modifications Fluconazole (Diflucan) Saquinavir (Invirase)
can be made to the postoperative plan as indicated, and Fluoxetine (Prozac) Sertinadole
patients are routinely seen 1 month postoperatively Fluvoxamine (Luvox) Sertraline (Zoloft)
and then again at 3–6 months. Norfluoxetine Stiripentol
Flurazepam Tetracycline (Achromycin,
Indinivir (Crixivan) Sumycin)
Isoniazid (Rifamate) Terfenadine (Seldane) (not
Itraconazole (Sporanox) available)
Conclusion Ketoconazole (Nizoral) Thyroxine
Labetolol (Normodyne, Timolol (Blocadren,
Trandate) Cosopt, Timolide)
Liposuction is a challenging surgical procedure that Triazolam (Halcion)
Methadone
can produce superb aesthetic results when performed Troglitazon (Rezulin)
Methylprednisolone
properly. Careful suctioning, use of the smart hand, (Solu-Medrol, Troleandomycin (Tao)
triangulation, and fluid management are all important Depo-Medrol) Valproic Acid (Depakote)
parts of the liposuction procedure. Final outcomes Metroprolol (Toprol-XL) Verapamil (Calan)
depend on both the skill of the surgeon and the heal- Metronidazole (Flagyl) Zafirlukast (Accolate)
Mibefradil (Posicor) Zileuton (Zyflo)
ing response of the patient. However, it is the respon-
sibility of the surgeon to have thorough knowledge Modified from Shiffman M. Medication potentially causing
lidocaine toxicity. Am J Cosmet Surg. 1998:227-229. McEvoy
and training in the procedure to minimize the possibil-
GK, ed. AHFS drug information. Bethesda, MD: 2000. Gelman
ity that surgical technique is the contributing factor to CR, Rumack BH, Hess AJ, eds. Drugdex R. System. Englewood,
less than optimal results. It is the blend of physician CO: Micromedex Inc; 2000.
192 C.I. Jacob
Appendix B: Medications that May Dristan Decongestant Tablets/ Verin

Affect Bleeding Capsules
Duragesic Viromed Tablets
Patient to avoid use of these agents 2 weeks prior to Vitamin E
liposuction
Accutane-Alert MD Ecotrin
Advil Empirin References
Alka-Seltzer Tablets Emperin with Codeine
Alka-Seltzer Plus Cold Emprazil-C Tablets 1. Coldiron B, Coleman WP III, Cox SE, et al. ASDS Guidelines
Medicine of care for tumesent liposuction. Dermatol Surg. 2006;32:
Anacin Capsules and Tablets Equagesic 709-716.
Anacin Maximum Strength Excedrin 2. Klein JA. Tumescent technique for liposuction surgery. Am J
Capsules/Tabs Cosmetic Surg. 1987;4:263.
APC Tablets Fiorinal with Codeine 3. Lillis PJ. Liposuction surgery under local anesthsia: limited
APC with Codeine, Tabloyd Four (4)-Way Cold blood loss and minimal lidocaine absorption. J Dermatol
Brand Tablets Surg Ondol. 1988;14:1145.
Arthritis Formula by the makers of Gemnisyn 4. Narins RS, Coleman WP. Minimizing pain for liposuction
Anacin Tablets Goody’s Headache anesthesia. Dermaol Surg. 1997;23(12):1137-1140.
Powders 5. Hanke CW, Bernstein G, Bullock S. Safety of tumescent lipo-
suction in 15, 336 patients. Dermatolo Surg. 1995;21:459-462.
Ascodeen-30 Ibuprofen
6. Klein JA, Kassarjdian N. Lidocaine toxicity with tumescent
Ascriptin Indocin
liposuction: a case report of probable drug interactions.
Aspirin Measurin Dermatol Surg. 1997;23:1169-1174.
Aspergum Midol 7. Hanke W, Cox SE, Kuznets N, Coleman WP III. Tumescent
Aspirin Suppositories Momentum Muscular liposuction report performance measurement initiative:
Backpain Formula national survey results. Dermatol Surg. 2004;30(7):967-977.
Anarox Monacet with Codeine 8. Coldiron B, Fisher AH, Adelman E, et al. Adverse event
Bayer Aspirin Motrin reporting: lessons learned from 4 years of Florida office
Bayer Children’s Chewable Naprosyn data. Dermatol Surg. 2005;31(9 Pt 1):1079-1092.
Aspirin 9. Coleman WP III. Liposuction and anesthesia. J Dermatol
Bayer Children’s Norgesic/Norgesic Forte Surg Oncol. 1987;13:1295.
Cold Tablets 10. Klein JA. Tumescent technique for regional anesthesia per-
Bayer Timed-Released Norwich Aspirin mits lidocaine doses of 35 mg/kg for liposuction. J Dermatol
Aspirin Surg Oncol. 1990;16:248-263.
11. Ostad A, Kageyama N, Moy R. Tumescent anesthesia with a
BC Powders Pabirin Buffered Tablets
lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol
Buff-a Comp Tablets Panalgesic/Percodan/
Surg. 1996;22:921-927.
Percodan Demi tabs
12. deJong RH. Local Anesthetics. St. Louis, MO: Mosby-Year
Buffadyne Persistin Book Inc., 1994.
Bufferin Quiet World Analgesic/ 13. Covino BG. Clinical pharmacology of local anesthetic agents.
Sleeping Aid In: Cousins MJ, Bridenbough PO, eds. Neural Blockade.
Bufferin Feldene Robaxisal Tablets Philadelphia: Lippincott; 1988.
Butalbital Salsalate 14. Tucker GT, Boas RA. Pharmacolkinetic aspects of intrave-
Cama Inlay Tablets SK-65 Compound nous regional anesthesia. Anesthesiology. 1971;34:538-542.
Cetased, Improved St. Joseph’s Aspirin for 15. Grazer FM. Complications of the tumescent formula for
Children liposuction. Plast Reconstr Surg. 1997;11(7):1893-1896.
Cheracol Capsules Sine-Aid 16. Burk RW, Guzman-Stein G, Vasconez LO. Lidocaine and
Clinoril Sine-Off Sinus Medicine/ epinephrine levels in tumescent technique liposuction. Plast
Aspirin Formula Reconstr Surg. 1996;97(7):1379-1384.
17. Sifton DW, ed. Epipen. Physician’s Desk Reference, 54th
Congespirin Stendin
edn., Napa CA: Dey; 2000:958.
Cope Stero-Darvon with
18. Bouloux P, Perett D, Besser GM. Methodological consider-
Aspirin
ations in the determination of plasma catecholamines by
Coricidin D Decongestant Tablets Sulindac high-performance liquid chromatography with electrochem-
Coricidin Medilets Tablets for Supac ical detection. Ann Clin Biochem. 1985;22:194.
Children
Darvon Synalgos Capsules
Darvon with Aspirin Tolectin
Darvon-N with Aspirin Triamcinilin
Chapter 26
Skin Tightening Off the Face with Radiofrequency
and Broadband Light
Douglas Fife and Anthony Petelin
Introduction and understands that the results are unpredictable

and possibly unnoticeable. Few contraindications
to the treatment exist (Table 26.2). During the ini-
Radiofrequency (RF) devices and infrared broadband
tial visit, patients identify their treatment goals and
light (IBBL) are nonablative energy sources designed to
anatomical areas of concern, which are photo-
volumetrically heat the dermis and subcutaneous tissue
graphed and measured. The physician examines
with the goal of skin tightening or girth reduction. They
these areas for firmness, mobility, and thickness,
have been used successfully and safely in all skin types
while anticipating the direction of desired contraction.
on the large areas of the body listed in Table 26.1. IBBL
Circling problem areas and drawing treatment vectors
devices (wavelength 850–1350 nm or 1100–1800 nm)
may assist in visualization during the procedure
penetrate deeply to bulk-heat the dermis without mela-
(Figs. 26.1–26.3). The likely outcome of mild-to-
nin absorption. RF generates heat via the tissue resis-
moderate improvement in laxity, girth, or cellulite2
tance to an electric current passed through the skin,
should be discussed, including the possibility that no
which causes tightening through presumed collagen
appreciable results may be achieved (Fig. 26.4).
remodeling. Unipolar (also called monopolar) RF sys-
Reduction in girth is more commonly seen with unipolar
tems use a ground electrode applied to an area of the
devices compared to bipolar RF or IBBL devices,
body away from the current source and create a high
which do not heat as deeply (Table 26.3).
power area at the electrode tip. Bipolar RF systems rely
on two electrodes located within the handpiece.
Depending on the device, RF and IBBL can be a
one-time treatment or multiple-treatment course that
Method of Device/Treatment
may produce immediate and delayed improvement
without the need for anesthesia.1 Compared to the Application
face, the response to RF and IBBL on the body is
less predictable and often less appreciable, possibly Dose/Setting Selection
due to differences in tissue characteristics (skin thick-
ness, gravity, underlying fat/muscle, pathogenesis of
For both RF and IBBL, the settings vary considerably
laxity) in certain areas of the body. Proper patient
by device (Table 26.3). In general, higher energies can
selection and expectations are of paramount impor-
be tolerated on the body compared to the face. Lower
tance when using these modalities off of the face.
energies are necessary when treating over a bony
prominence such as the knees or elbows or when treat-
ing thin or sensitive skin such as the area around the rib
Clinical Examination/Patient Selection cage, epigastrium, above the pubis, adjacent to the umbi-
licus, inner arms, inner thighs, and sides of the abdo-
The ideal patient is one who is within 15–20 lbs men, due to increased pain. Topical anesthesia is not
of their ideal weight, has mild-to-moderate skin usually helpful as pain is usually perceived in the
laxity or increased girth, has disposable income, deeper tissue, which the anesthesia will not reach.1,3

194 D. Fife and A. Petelin
Table 26.1 Body areas that may be

treated by RF and IBBL
• Inner and outer arms
• Abdomen
• Hips
• Buttocks
• “Love handles”
• Back
• Inner and outer thighs
• Knees
• Dorsal Hands
Table 26.2 Contraindications to treatment with RF and IBBL

Absolute contraindications:
• Implanted electrical device such as a pacemaker, defibrillator,
cochlear implant, or other (this applies to RF only)
• Pregnancy (not well studied)
Fig. 26.1 Vectors when treating skin laxity on the legs. (Illustration
Relative contraindications: by Alice Y. Chen)
• Body mass index (BMI) >30
• Unrealistic expectations expressed by the patient
• Excessive skin laxity, significant diastasis, or striations
(plastic surgery candidates)
Fig. 26.2 Vectors when treating skin laxity on the arms. (Illustration by Alice Y. Chen)
Oral narcotic analgesics and mild anxiolytics may be pinching the skin and treating between the elevated
administered in small doses if needed. area without having to adjust the treatment setting. The
When using RF, treatment energies vary by body generally accepted method of using lower energy set-
site. If using ThermaCool® devices (Thermage, Solta tings with multiple passes is used for RF on the body.4
Medical Inc., Hayward, CA), the 3.0-cm2 ThermaTipTM For the IBBL devices, thicker skin on most areas of
DC is used for volume reduction of larger areas for so- the body compared to the face allows for higher ener-
called “deep contouring.” The conventional tips are gies to be used. With the LuxDeepIRTM (Palomar
used to tighten areas of skin laxity not requiring vol- Medical Technologies Inc., Burlington, MA), for
ume reduction. Similar to RF on the face, energy levels example, a patient may tolerate 70–80 J/cm2 on the
are titrated based on pain feedback, where a 2–2.5 out arms while only being able to tolerate 50–60 J/cm2 on
of 4 pain rating is desirable (Fig. 26.5). When treating the face or 45 J/cm2 on the neck. The patients should
sensitive areas, heat sensation may be reduced by feel warmth but minimal pain.
26 Skin Tightening Off the Face with Radiofrequency and Broadband Light 195
Fig. 26.3 Vectors when treating skin laxity on the abdomen and back. (Illustration by Alice Y. Chen)
Fig. 26.4 Before and 6 months after Thermage treatment of the abdomen. Note the improvement in skin laxity and striae. Treatment
by Richard Asarch, M.D. Photo property of Thermage, Inc
Treatment Technique when using RF with at most a 50% overlap (Fig. 26.6). Then, the current
return pad is placed away from the treatment site on a
No specific pretreatment requirements are necessary. large surface area, and a generous amount of coupling
The patient should remove all metallic jewelry and fluid is applied to the treatment area.
objects. Next, the appropriate treatment grid is applied to While treating on most areas of the body, it is
the skin, which allows pulses to be delivered uniformly advantageous to preposition the skin in the direction of
Table 26.3 Device Comparison Chart

Infrared broadband light sources
Wave Length Device name
nm (Manufacturer) Fluence (J/cm2) Pulse Duration Spot size (mm) Additional features
800–1400 BBL SkinTyteTM up to 55 10 msec–15 sec 15 × 15 Dual-flashlamp, integrated
(Sciton Inc., 15 × 45 thermoelectric cooling
Palo Alto, CA) with sapphire contact
plates, adjustable from 0
to 30°C
850–1350 LuxDeepIR up to154 3–10 sec 12 × 28 Fractionated surface plate
(Palomar protects epidermis with
Medical integrated active contact
Technologies cooling
Inc., Burlington,
MA)
1100–1800 TitanTM (Cutera, 5–65 4–10 sec 10 × 15 (Titan V) Integrated active contact
Brisbane, CA) 10 × 30 (Titan XL) cooling
Traditional IPL Various Variable msec to 1 sec Variable In order to bulk heat
500–1200 without damaging the
epidermis the shorter
wavelengths would have
to be filtered out
Radiofrequency devices
Device Name (Manufacturer) Technical Specifications Additional features:
Aluma Skin Renewal System
TM
Bipolar RF – Vacuum apparatus allows current to flow more
(Lumenis Inc., Santa Clara, CA) deeply through the dermis
– Can be incorporated into the Lumenis One
combination platform
AccentTM XL (Alma Lasers Inc., Bipolar or Unipolar 200 W, – Two separate handpieces that deliver unipolar
Caesarea, Israel) 40.68 MHz or bipolar RF energy
ThermaCoolTM NXT (Solta Medical Unipolar RF 400 W, 6.78 MHz – ThermatipTM capacitive coupling
Inc., Hayward, CA) technology
– Integrated handpiece control with the NXT
system
– Tips of different sizes, including the 3.0 cm2
ThermaTiptm DC for deep contouring
VisageTM (ArthroCare Inc., Sunnyvale, Unipolar RF – Ablative RF technology at cooler temperatures,
CA) “Coblation”
ReFirmeTM, VelaShapeTM (Syneron ELOSTM (Combined infrared light – Chilled sapphire contact tip
Medical Ltd., Yokneam, Israel) and Bipolar RF) – Dermal temperature monitoring system
Fig. 26.5 Pain grading scale

treated with higher energies. Pulses are delivered

adjacent to one another. Compared to treating the face,
treating large areas of the body is more tedious and
time-consuming and may require more concentration
to appropriately cover all areas while at the same time
avoiding overlapping. Initially, it may be helpful to
draw a treatment grid on large areas of the body.
One or two complete passes are made over the entire
treatment area. Similar to RF, vectors or problem areas
can be treated with additional 1–8 passes. The skin
is continually palpated and stretched to monitor for
tightening or swelling/edema, both of which may be
considered endpoints for treatment.
Fig. 26.6 Placement of treatment grid ensures uniform treat-
ment and prevents no more than 50% overlap. Photo property of
Care should be taken when treating thin skin or skin
Solta Medical, Inc. overlying bony prominences where the skin may more
likely burn, possibly due to reflection of light off of the
periosteum and the lack of a tissue “heat sink” below
the treatment area. A good rule of thumb is to either
the desired placement vectors before administering the
decrease the energy by 20% or move the skin off to the
pulse, as this allows the skin to be tightened in the
side of the bony prominence while treating.
direction of desired skin contraction. Keeping the tip
perpendicular to the skin, the first staggered pass is
delivered in a caudal to cephalic, and medial to lateral
direction using the standard “square then circle”
progression until two full staggered passes have been Postoperative Care
completed over the entire grid. Tissue should be warm
to touch, but not hot before retreating the same area. RF and IBBL treatments require little postprocedural
Vector and problem areas are then treated with repeated care. The expected posttreatment reactions include
passes (2–8) in the direction of the vectors (see mild-to-moderate redness, a warm sensation, and
Figs. 26.1–26.3). The total number of pulses depends edema that usually resolve in 1–2 days. A bland emol-
on the tissue response to treatment, the patient’s goals, lient may be applied for comfort. A compression
and the amount of pulses the tip can deliver. It is often garment worn for 1–3 weeks posttreatment during
more difficult to see a visual or palpable endpoint on the daytime may help to improve results. Some
the body compared to the face, so as many pulses are practitioners recommend avoidance of all external
delivered as possible (average 600–900, but may heat for the first 48 h and sunlight for the first 30 days.
require up to 1,200 or more). A record of the patient’s weight and body measure-
When using the AlumaTM bipolar RF device, only ments is essential to evaluate the improvement from
one pass of adjacent pulses is delivered, and either the the treatment. Effective and consistent photographs
pulse time or pulse level can be adjusted to deliver the should be a part of the pre and postevaluation process
desired energy. (Figs. 26.7 and 26.8).
Treatment Technique when using IBBL Number and Frequency of Treatments
The skin is cleansed prior to treatment. For both the Both RF and IBBL treatments cause an immediate
TitanTM and the LuxDeepIRTM, a 2-second precool and a delayed effect. This delayed effect, which may
before each pulse is sufficient for most areas. A 3-sec- gradually improve the skin for up to 6 months, is
ond cool may be required for thicker skin on the body thought to be due to continued “collagen remodeling”
Fig. 26.7 Treatment of the anterior thighs and knees with the LuxDeepIR infrared handpiece (Palomar Medical Technologies, Inc).
Photo Courtesy of Christine Dierickx, M.D.
Fig. 26.8 Treatment of the abdomen with the LuxDeepIR infrared handpiece (Palomar Medical Technologies, Inc). Photo Courtesy
of Christine Dierickx, M.D.
Table 26.4 Alternative treatment strategies for IBBL off of Management of Adverse Events
the face
1. Deliver one treatment now and assess the patient Side effects of RF are similar on the body and the face.
3–4 months later (after a significant amount of “delayed
The most common side effect is burning of the skin,
tightening” has occurred) to determine whether another
session is necessary seen as immediate erythema, crusting, or blistering. If
2. Deliver treatments every 4–6 weeks for a total of 3–4 burning occurs, immediate application of high potency
treatments steroids may minimize the reaction. Standard wound
3. Deliver one treatment now and a second and final care techniques should follow. Skin indentations or
treatment 2 months later
contour irregularities occur rarely, are delayed phe-
nomena, and tend to slowly resolve over time, but
some may be permanent. Both burns and indentations
after the treatment. Thermage RF treatments are a one- can be prevented by using adequate amounts of contact
session treatment. The AlumaTM device uses a multi- gel/coupling fluid, by appropriately staggering pulses
ple-session course of 6–8 treatments, each separated with at most a 50% overlap, and by using multiple
by 1–2 weeks. lower-energy passes while titrating the energy accord-
The optimal number and frequency of IBBL treating to the patient’s pain.
ments on the body is not well studied. Different treatment Side effects of IBBL are rare, especially with newer
course strategies are listed in Table 26.4. devices with superior cooling and mechanisms, which
prevent the delivery of pulses when the delivery plate
is not in full contact with the skin. Burning of the skin • Evaluate each patient and body area on a case-by-case
may occur but is extremely rare when appropriate approach, avoiding the “cookbook” approach.
energies are used and the handpiece is kept in full con-
Specific Pearls for RF treatment on the body:
tact with the skin.
• Avoid overlapping of pulses more than 50%.
• Use multiple pass-low energy technique.
Direction for the Future/Conclusion • Unipolar RF more effective than bipolar at reducing
girth.
Devices combining RF and IBBL into one delivery Specific Pearls for IBBL treatment on the body:
system have recently become available. One example
• When treating over bony prominences lower
is the VelaSmoothTM system (Syneron Medical Ltd.,
fluence by 20% or move skin away to the side before
Yokneam, Israel), which combines bipolar RF with
delivering pulse.
IBBL energy and a pulsatile vacuum suction into one
• Always ensure adequate contact of handpiece to the
hand-held applicator.5,6 While some authors have
skin to avoid burning.
shown this combination of heat effective in the treat-
ment of cellulite,1 further studies are warranted.
Acknowledgments The authors would like to thank Nissan
Traditional intense pulsed light devices (wavelength Pilest, M.D., Robert Weiss, M.D., E. Victor Ross, M.D., Michael
500–1200 nm) were not designed for skin tightening; Kaminer, M.D. and Amy F. Taub, M.D. for sharing their expertise
however, newer devices with longer wavelengths and in the preparation of this chapter.
have higher cut-off filters may have a role. New
ThermaCool® tips, including ThermageTM body tip
16.0 and ThermageTM cellulite tip 3.0 (CL), provide
more options for treatment of the body. References
“Pearls” for using either RF and IBBL on the body 1. Dierickx C. The role of deep heating for noninvasive
skin rejuvination. Lasers Surg Med 2006;38:799-807.
• Select appropriate patients. 2. Goldberg D, Fazeli A, Berlin A. Clinical, Laboratory, and
• Set realistic expectations. Improvement is less notice- MRI analysis of cellulite treatment with a unipolar radiofre-
able on the body compared to the face. quency device. Dermatol Surg 2007;34:1-6.
• Carefully identify and treat vectors and problem 3. Kushikata N, Negishi K, Tezuka Y, Tezuka Y, Takeuchi K,
Wakamatsu S. Is topical anesthesia useful in noninvasive skin
areas. tightening using radiofrequency? Dermatol Surg 2005;31:
• Higher energies are required on most body areas 526-533.
compared to the face. 4. Kist D, Burns AJ, Sanner R, Counters J, Selickson B.
• Areas on the body with thicker skin may be harder Ultrastructural evaluation of multiple pass low energy versus
single pass high energy radio-frequency treatment. Lasers
to lift or tighten. Surg Med 2006;38:150-154.
• Closely monitor patient’s sensation of heat and 5. Sadick N, Sorhaindo L. The radiofrequency fronteir: a review
discomfort. Stop the procedure if the patient is of radiofrequency and combined radiofrequency pulsed-light
experiencing too much pain. technology in aesthetic medicine. Facial Plastic Surgery
2005;21:131-138.
• Be aware of areas of thin of sensitive skin (abdomen, 6. Sadick N, Magro C. A study evaluating the safety and effi-
inner thighs, inner arms) where patients may expe- cacy of the velasmooth system in the treatment of cellulite. J
rience more pain. Cosmet Laser Ther. 2007;9:15-20.
Chapter 27
Female Genital Surgery
Francesca De Lorenzi, Elena Mascolo, Francesca Albani, and Mario Sideri
Introduction In this chapter, we will describe the technique of

labia minora reduction, Mons Pubis and labia majora
enlargement, and vaginal rejuvenation.
Our society attributes great importance to appearance
and body image. In the recent past, cosmetic vulvar
plastic surgery has been widely introduced in the
western world. Modification of the cultural environ- Functional and Aesthetic Labia Minora
ment and increasing vulvar “visibility” have generated Reduction
the erroneous identification of an ideally “normal”
appearing vulva. The links between partner’s relation-
ship, sexuality, and body image have become more strict, Introduction and Definition
and vulval morphology has become an important
player in this complex scenario, especially at certain Enlarged or hypertrophic labia minora are characterized
periods of the women’s life, for example after delivery by different degrees of exposure between and beyond
or during menopause, because of the changes and labia majora, whereas during childhood and in many
adaptations that the organs and the female genital adult virgins these cutaneous refolds are not out-
system undergo normally. Cosmetic vulval surgery is wardly visible. It can be functionally or psychologically
therefore a natural evolution of our cultural environment. bothersome. In the literature review, labia minora length
However, there are few papers addressing in detail this exceeding 4 cm is considered for surgical reduction.
issue, indications, contraindications, and side effects.
Clinicians who receive requests for cosmetic vulvar
surgery should discuss with the patients the reasons for
that request and perform an evaluation for any clinical Clinical Examination and Patient History
signs or symptoms that may indicate the need for a
surgical intervention. A patient’s concern regarding the Psycological concerns are the most important reason for
appearance of her genitalia may be alleviated by a women to have the size of their labia minora reduced.
frank discussion on the wide range of normal geni- Protuberance of this genital structure is considered to be
talia and reassurance that the appearance of external aesthetically and socially inconvenient, not only when
genitalia varies significantly from woman to woman the woman is naked but also when wearing tight-fitting
and rarely is associated with functionality. On the clothes or swimsuit. Mechanical inconveniences may
contrary, any surgical intervention on the vulva can also be present in the personal history of these patients,
be the cause of worsening sexual function because of with problems concerning difficulty in vaginal penetra-
the scarring process, which is unpredictable in this area. tion, local irritation, problems of personal hygiene
Concerns regarding sexual gratification may be addressed during menses, or after bowel movements, and pain or
by careful evaluation for any sexual dysfunction and discomfort during cycling or sitting.
an exploration of nonsurgical interventions, including During medical consultation, possible reasons for
counselling. hypertrophic labia minora are investigated although in

202 F. De Lorenzi et al.
the majority of cases congenital factors are responsible.

Between them, mechanical irritation through excessive
manipulation and intercourse, chronic irritation and
inflammation as a consequence of local infections
and dermatitis, exogenous androgen hormones, and
stretching with weights.
During clinical examination, the redundancy of
skin and mucosa of labia minora is assessed as well as
skin laxity to determine the amount of tissue to be
resected. All patients with labia minora length exceed-
ing 4 cm are potential candidates for their reduction.
Even after the patient has been assured that labia
minora enlargement has no clinical significance and
that variation in size is normal, many women remain
dissatisfied and suffer psychological distress and there- Fig. 27.2 Labia reduction. Straight amputation of the protuber-
ant section of the labia minora and oversewing of the raw edge
fore they ask for surgery.
Treatment Application
1. Local anesthesia.
Labium minus reduction is performed with the patient in
the dorsal lithotomy position and under local anesthesia
(1% lidocaine with 1:200,000 epinephrine).
2. Treatment technique and alternative methods
The simple and straight amputation of the protuberant
segment and over-sewing the edge is usually performed
(Figs. 27.1–27.3), but with this technique the labial edge
is replaced by a stiff breakable suture line, potentially Fig. 27.3 Labia reduction. Straight amputation of the protuberant
section of the labia minora and oversewing of the raw edge
associated to discomfort while walking and local

irritation. Moreover, linear scar contraction can let to
advancement of the posterior fourchette, resulting in
the partial obliteration of the vaginal introitus and risk
of painful intercourse. Alternative methods to overcome
these undesirable outcomes include the running
W-shaped resection with interdigitated suturing of the
protuberant labia (zigzag technique, Fig. 27.4a; or
wedge resections, Fig. 27.4b). In every case, the borders
of the resection are directly approximated with inter-
rupted absorbable sutures. Urinary catheterization is
not necessary. Patients receive treatment with intrave-
Fig. 27.1 Labia reduction. Straight amputation of the protuberant nous antibiotics and oral administration of antibiotics
section of the labia minora and oversewing of the raw edge is continued until the third or fifth postoperative day.
27 Female Genital Surgery 203
Fig. 27.4 Running W-shaped resection with interdigitated suturing of the protuberant labia. (Illustration by Alice Y. Chen)
They are discharged on the day of surgery or until the the most common complication, it can be the only
first postoperative day. unfavorable event or can be caused by marginal
necrosis of the surgical edges or hematomas. When the
3. Postoperative care
patient complies with postoperative recommendations,
Patient instructions include personal hygiene of the minimal dehiscence usually heals spontaneously and
external genitalia after urinating, maintaining the vulva mucosa completely re-epithelializes within 2 weeks,
and the surgical wounds dry, topical application of iodine resulting in unrestricted function and satisfactory
on the wounds, and placement of a dry sterile gauze to appearance. Hematomas can drain spontaneously or
protect the suture line for approximately 10 days. mechanically. Infected wounds are treated with oral
A medical examination of the vulvar region is required antibiotics with satisfactory outcomes.
about 1 week after surgery to evaluate the healing Late complications such as sexual dysfunction,
process and exclude wound complications. local pain, or skin retraction are rare, which can be
avoided through an accurate selection of candi-
4. Management of adverse events
dates, performing the zigzag technique or the wedge
Adverse events are mainly correlated to wound healing resections, and monitoring early wound healing
problems and occur in the immediate postoperative problems which can impair the functional and aesthetic
period. Wound dehiscence of the surgical borders is outcome.
204 F. De Lorenzi et al.
Vulvar Reshaping and Vaginal appropriate material is at the surgeons’ discretion. In

Rejuvenation the following, we shall suggest what is best for the
female genital mucosal tissues, which are extremely
delicate and sensitive.
Introduction and Definition On the basis of the areas to be treated, we ought to
take into consideration that the aims could either be
Under this section, we address two types of cosmetic the increase in volume (mons veneris) or major tissue
and functional interventions: Mons veneris (mons trophism or both. Therefore, the following substances
pubis) and labia majora reshaping, and labia minora will be chosen:
and vaginal rejuvenation. • Mixture of amino acids and Vitamin C, able to
The aim of Mons veneris (mons pubis) and labia deeply restructure the tissues by means of fibroblast
majora reshaping is to preserve or increase turgidity, re-activation.
prominence, and elasticity. In contrast, the aim of labia • Mixture of vitamins and hyaluronic acid, able to
minora and vaginal rejuvenation is to preserve or re-structure and moisture tissues through their water
restore vaginal walls elasticity and hydration. absorption action.
• Mere fillers, able to provide the desired volumes so
that the treated areas become trophic again. They
Clinical Examination and Patient History also have a water absorption action.
Women might express a wish for rejuvenation on the Volume Augmentation of the Mons Veneris
basis of functional problems often mainly during and Labia Majora
menopause and in the postpartum period. With time
Mons pubis and labia majora tend to atrophy. Vaginal Re-absorbable hyaluronic acid is an invaluable material.
walls tend to lose elasticity and hydration leading to a It is prepared in 0.5/0.8/1 ml preloaded sterile syringes,
lower sensitivity and lubrication during coitus with a with 30.5-G and 27.5-G fine needles according to the
consequent dyspareunia and loss of sexual desire. These density of the material chosen. (As an alternative, the
problems can influence the psychological sphere of surgeon can perform liposuction of adipose tissues
women as well as that of their partner. Conversely, other removed from the abdomen or from the patient’s fattier
patients wish their own ideal image to correspond with areas. The fatty tissue is then regrafted in the subcuta-
reality. neous area to be hypertrophied. This is an outpatient
Following a thorough medical history evaluation surgical technique.)
as well as accurate clinical examinations the possible Hyaluronic acid injections have to be performed
treatments are assessed, taking into consideration that in the medium or deep dermis – according to the
these surgical techniques are invasive and may be the parallel-arranged linear inoculation technique – in
cause of side effects. Rejuvenation of the female genital order to fill up the desired area, taking care to avoid
mucosa means re-structuring, re-hydrating, and giving injecting the vasal tissue (possible drawing). Small
new turgescence not only for aesthetical purposes but amounts of Hyaluronic acid should be injected in
also improving the functionality of the areas of interest. order to avoid vascular compression and necrosis in
The procedures can affect sensitivity and lubrication this highly vascularized area. It is advisable to use
during coitus and influence the psychological sphere 0.5 ml pre-loaded syringes. The treated area needs
of women as well as that of their partner. to be massaged after administering the injection so
that the substance is homogeneously and thoroughly
distributed.
With this type of treatment, as with the fillers used
Treatment Application in facial rejuvenation treatment, following an initial
hyaluronic acid injection which the patient finds
As in facial rejuvenation treatments, 1 ml syringes and satisfactory, the surgeon will need to reassess and if
30.5-G needles are employed. The choice of the most necessary re-inoculated additional hyaluronic acid
27 Female Genital Surgery 205
every 4–6 months, at least for the first 18 months. to be treated. Yet, the essential difference lies in the
Subsequent hyaluronic acid re-inoculations could be fact that genital organs are more delicate and that also
performed every 6–12 months, according to the patient’s special psychological care should be taken when treating
local tissue metabolism. these areas. Moreover, in some cases, local anesthetics
Contraindications: There are surely more contrain- (lidocaine) are mixed with active principles or injected
dications with respect to the re-structuring technique with subcutaneously in variable dosages (though lower than
the above-mentioned substances. Hyaluronic acids are 1 ml) according to the patient’s sensitivity.
mere fillers, surgeons need to take the same precautions We suggest positioning an ice pack before treating
as for facial rejuvenation treatments. These substances the areas as cooling reduces tissue sensitivity to pain.
should not be used in patients who tend to develop Each area requires a treatment time which varies
hypertrophic scars, in patients with streptococcal infec- from approximately 15–30 min, patient cooperation
tions, who have previously suffered from autoimmune permitting. Treatment frequency is based on the reaction
diseases, or who have a known hypersensitivity to and on the desired results. As regards restructuring,
hyaluronic acid during pregnancy or breast-feeding. weekly treatments are generally necessary for the first
In case of valvular prolapse or prostheses, patients need 3–4 weeks, subsequently treatments can be performed
to be prescribed an antibiotic prophylaxis (penicillin- every month or two.
type antibiotics are highly recommended, as is the Contraindications: There are no particular contrain-
case in surgical operations). Moreover, in the 2 weeks dications except for hypersensitivity to Vitamin C in
following treatment, patients are strongly recommended some subjects. Therefore, Omega-3 and acetyl-salicylic
not to expose themselves either to temperatures below acid assumption is highly recommended during treatment
0° or to saunas or Turkish baths. Also, the surgeon is because of the lower platelet aggregation.
required to inform patients (and to have them sign the Also, the prescription of preparations based on
informed consent) regarding possible early or late side Arnica Montana is recommended, to be administered a
effects, which may arise such as: couple of days before and after inoculations in order to
diminish the traumatic effect caused by needle pene-
• Inflammatory reactions (rash, edema, erythema),
tration. Nevertheless, small ecchymoses might appear;
itching, pain when exerting pressure on the treated
these will spontaneously resolve within 2–3 days.
areas (for a maximum duration of 1 week).
• Hardening or nodules where the injections were
administered.
• Pigmentation of the treated area.
• Low treatment efficacy or low filling effect.
References
As regards facial inoculations, contraindications/side 1. Lloyd J, Crouch NS, Minto CL, et al. Female genital appearance:
effects such as necroses, abscesses, or granulomas are “normality” unfolds. BJOG. 2005;112(5):643-646.
referred to in the literature, which the surgeon should 2. ACOG Committee Opinion No 378:. Vaginal Rejuvenation and
Aesthetic Vaginal Procedures. Obstet & Gynecol. 2007;110:
take into consideration. 737-738.
3. Maas SM, Hage JJ. Functional and aesthetic labia minora
reduction. Plast Reconstr Surg. 2000;105(4):1453-1456.
Re-structuring, Hydration, and Turgescence 4. Giraldo F, Gonzalez C, de Haro F. Central wedge nymphec-
tomy with a 90-degree Z-plasty for aesthetic reduction
of Vulvo-vaginal Mucosae of the labia minora. Plast Reconstr Surg. 2004;113(6):
1820-1825.
A commercial mix (vitamins, hyaluronic acid) used for 5. Munhoz AM, Filassi JR, Ricci MD, et al. Aesthetic labia
facial rejuvenation, amino acids with a small diaphragm minora reduction with inferior wedge resection and superior
pedicle flap reconstruction. Plast Reconstr Surg. 2006;118(5):
made of ascorbic acid and lidocaine, hyaluronic acid 1237-1247.
and vitamins, hyaluronic acid having a heavier molecular 6. Likes WM, Sideri M, Haefner H, et al. Aesthetic practice
weight in order to more deeply re-hydrate the tissues. of labial reduction. J Lower Fem Gen Tract. 2008;12(3):
Doses will be proportional to the extent of the tissues 210-216.
Chapter 28
Reduction of Excess Abdominal Skin via Liposuction
and Surgical Excision
Emil Bisaccia, Liliana Saap, and Dwight Scarborough
Introduction history of thrombophlebitis, are morbidly obese, or have

moderate to severe upper abdominal laxity and lower
abdomen flaccidity are not good candidates for these
Since the inception of liposuction by Ilouz in 1977,1
procedures as they are at increased risk for compli-
many modifications have been done to liposuction to
cations and less than satisfactory results. Among the
increase its margin of safety and improve upon the
principal factors that need to be assessed are the degree
cosmetic results, including the Klein technique of
of centripetal adiposity, the amount of skin laxity over
tumescent anesthesia.2 For many patients who have
the abdomen, and the degree of flaccidity of the
good skin tone, abdominal liposuction alone can give
abdominal wall musculofascial system. This is best
good to excellent results.3 However, there is a subset of
done by examining the patient in the supine, upright,
patients who have small amounts of skin laxity of the
and bent forward position into the diver’s position.4 As
lower abdomen that can benefit from a skin tightening
the patient is in the upright position, the pinch test
procedure.4 These patients have excess lower abdominal
(between thumb and index finger) is done to measure
skin while still maintaining good abdominal muscle
the subcutaneous fat. If there is good skin tone, no
tone underneath making them excellent candidates for
overhanging redundant skin, and a pinch test of more
a “miniabdominoplasty” using a combination of tumes-
than 1 in., liposuction alone is all that is needed. When
cent liposuction and limited skin resection.4 The good
the patient bends in the diver’s position, the weakened
underlying muscle tone and minimal diastasis of
abdominal muscles will bulge. The patient is then
the musculoaponeurotic wall obviate the need for a more
asked to contract the abdominal muscles, providing
extensive abdominoplasty.4–13 For example, a young
further testing of muscle tone and indication of any
multiparous woman who has lower abdominal skin
hernias. The patient then lies supine and raises the
laxity and striae but still maintains minimal or mild
head and shoulders to tighten the muscles. This allows
lower abdominal musculofascial looseness is an excellent
the surgeon to again check the musculoaponeurotic
candidate for this procedure.
system for weakness, hernias, and diastasis of the
rectus muscles.
The ideal patient for the miniabdominoplasty has
Clinical Examination and Patient History poor lower abdominal skin tone with mild to moderate
laxity, yet only minimal lower abdominal musculofas-
Proper selection is paramount to a successful procedure. cial looseness. If the patient has good skin tone and mild
First, one must assess what is the underlying physical or no abdominal musculofascial looseness, then he/
deficiency, and what specific procedures can provide she may benefit from liposuction alone, while if muscu-
satisfactory results, as well as what are the patients’ lofascial looseness is marked then he/she may benefit
expectations and preferences concerning the degree of from a more extensive abdominoplasty (Table 28.1).11–13
skin tightening, scarring, and morbidity. Finally, it is important to review with the patient the extent
A general assessment of health and risk factors of improvement as well as limitations of the procedure
needs to be reviewed. Patients who smoke , have a as well as scarring.

208 E. Bisaccia et al.
Table 28.1 Decision making guide for abdominal recontouring

Physical findings Treatment options
Lower abdominal adiposity Liposuction alone is treatment
only of choice
Abdominal adiposity Combination liposuction
combined with discrete with limited
skin laxity only miniabdominoplasty
Abdominal adiposity Combination of liposuction
combined with significant with rectus muscle
skin laxity and abdominal plication and miniabdomi-
muscle flaccidity noplasty or standard
abdominoplasty
Mild to moderate pannus Two-stage liposuction
formation procedure (Liposuction
surgery followed by
mini-abdominoplasty 3–6 Fig. 28.1 Two standard incisions made above the mons pubis so
months later) that liposuction debulking can be done
Adapted from Bisaccia and Scarborough11
Method of Device and Treatment

Application
First and foremost, the surgeon has to have requisite
knowledge of the relevant anatomy. The abdominal
wall is multilayered and has its principle blood supply
originating superiorly and inferiorly. The blood supply
to the skin of the abdomen is supplied by the direct
cutaneous vessels and musculocutaneous perforating
vessels.4,10,15 These blood vessels are spared in liposuc-
tion by the use of tumescence and blunt tunneling. If
these are disrupted sloughing of the skin and necrosis Fig. 28.2 Transverse incision is then made with a 15-blade that
can occur. The innervation of the abdominal wall is connects the two liposuction incisions
routinely supplied from the lateral oblique direction
and is derived from the roots of the nerves T7 to L4. incisions (Fig. 28.2). The tunnels are horizontally
The skin of the lower abdomen is more movable because connected using Metzenbaum scissors to a level midway
it is less firmly attached, covering the soft areolar to one-third below the umbilicus, depending on the
subcutaneous tissue. In the upper abdomen, the skin is extent of the skin resection desired (Fig. 28.3).
usually less mobile and more firmly attached by the The excess skin is pulled inferiorly with an appro-
many retinacula to the deep fascia. This is the reason priate degree of tension and bifurcations are made to
liposuction more easily removes the lower abdominal approximate the amount of redundant skin to be excised
fat. More in depth anatomy review of the abdominal wall (Fig. 28.4). If additional skin needs to be removed, the
is beyond the scope of this chapter and can be obtained incisions may be extended latero-superiorly in accord
in other anatomy text books and articles.14,15 with the French-line method. The field is dried using
Tumescent liposuction is performed first, employing unipolar electrocautery. In select cases, limited plication
a standard tumescent technique,3 via two small of the rectus muscle is then accomplished using non-
incisions just above the mons pubis (Fig. 28.1). This absorbable monofilament suture. Multiple absorbable
provides for debulking, while the dermatoadipose flap tacking sutures may be placed from the subcutaneous
development is assisted by this pretunneling of the tissue to the musculofascial layer to help advance the
lower abdomen staying superficial to the abdominal flap downward, taking tension of the final closure
musculoaponeurotic system. A transverse incision is then line (Fig. 28.5). These sutures form attachments that
made with a 15-blade that connects the two liposuction change a large “dead space” into smaller compartments,
28 Reduction of Excess Abdominal Skin via Liposuction and Surgical Excision 209
Fig. 28.3 (a and b) The tunnels are horizontally connected using Metzenbaum scissors to a level midway to one-third below the
umbilicus
Fig. 28.4 (a and b) The excess skin is pulled inferiorly with an appropriate degree of tension and bifurcations are made to approximate
the amount of redundant skin to be excised
which helps prevent seromas or hematomas. We routinely

use no drains. Final closure includes subcutaneous closure
with absorbable sutures and a subcuticular pullout suture
on the skin, although in certain cases, small skin staples
are used (Fig. 28.6). After completing the closure, sterile
surgical tape strips cover the wound and an elastic
binder provides support (Figs. 28.7–28.10).
Postoperative care
Fig. 28.5 Multiple absorbable tacking sutures are placed

Patients are instructed to avoid aspirin or any non-
from the subcutaneous tissue to the musculofascial layer to
help advance the flap downward, taking tension of the final steroidal anti-inflammatory drugs, such as ibuprofen and
closure line naproxen, for 2 weeks prior to the surgery and 2 weeks
Fig. 28.6 Final closure includes subcutaneous closure with Fig. 28.7 Final closure with skin staples
absorbable sutures and a subcuticular pull-out suture on the skin,
although in this case, small skin staples were used
Fig. 28.8 Pre (a,c) and post-op (b,d) miniabdominoplasty and liposuction
postoperatively. Patients are also instructed to stop patients are instructed to begin a light exercise regimen
smoking, 2 weeks prior and 4 weeks after the proce- of brisk walking for at least 1 h, 3–4 times a week
dure, and stop consuming alcoholic beverages for 24 h starting at least 2 weeks before the procedure.
prior or 3 days after surgery. To minimize risk of infec- Postoperatively, gentle normal activity is recom-
tion, an appropriate antibiotic is given starting 24 h mended for days 1–10, followed by increasing activity
prior to surgery. Pain medications are prescribed prior to walking at a gentle pace for 10–20 min a day from
to surgery, so patient can have them ready before day 10 to 3 weeks. Between weeks 3 and 6 weeks mod-
leaving recovery. To optimize results of the procedure, erate walking is recommended, with one mile per day
28 Reduction of Excess Abdominal Skin via Liposuction and Surgical Excision 211
Fig. 28.9 Pre (a) and 7 weeks post-op (b) miniabdominoplasty without liposuction
Fig. 28.10 Pre (a,c) and 8-week post-op (b,d) miniabdominoplasty and liposuction
and increasing to 30–40 min or 3 miles as day. After Possible Complications

6 weeks, full exercise and/or brisk daily walks are
recommended in the amount of 40 min for a minimum
In a study of all types of abdominoplasties, seromas
of 6 months.
(5%) were the most common complication followed
The garment that is applied immediately postopera-
by hematomas (3%), infection (3%), skin or fat necrosis
tively should be worn for 72 h. After 72 h, it can be
(2.5%), and delayed healing (2%).16 Late complications
removed for a brief shower, and then put back on after
in this study included ‘dog ears’ (12%), localized fatty
wound care. Wound care consists of cleansing the
excess (10%), and unsatisfactory scars (8%). Pulmonary
wound with water in a cotton-tip applicator, applying
emboli and pancreatitis accounted for only 1 out of 278
an antibiotic ointment on a telfa pad, and applying tape
patients each (0.3%).16 Unfortunately, this study did
to secure the telfa pad twice a day. At night, the tape
not divide complications according to type of abdomi-
can be omitted to minimize skin irritation. The binder
noplasty performed, though only 65 of the 278 patients
is to be worn for 3–6 weeks, 24 h a day for the first 21 days,
underwent a miniabdominoplasty and 206 underwent
and then 12 h a day for the next 21 days. As the body
primary standard abdominoplasty.
shrinks, the binder may become loose, and if so patients
The occurrence of seromas may be limited by using
are asked to purchase a second commercial girdle to
sequential tension sutures as described earlier17 and
account for a smaller size. Follow-up visits are scheduled
limiting liposuction to the lower abdomen, as lipo-
at 3 days, 2–3 weeks, and 3 months after surgery. Sutures
suction to both the upper and lower abdomen have
or surgical clips are removed at 14–21 days.
increased risk of seroma formation. If seromas do patients. The use of minimally invasive techniques
form, these can be treated by aspirating and evacuating with liposuction alone, liposuction combined with the
them with an 18-gauge needle. Hematomas are rare in skin excisions and fascial plication can provide a com-
our experience and can be prevented by appropriate parable aesthetic result with less morbidity than tradi-
use of tumescent anesthesia with blunt tunneling and tional abdominoplasty in select patients.
suction, as well as adequate hemostasis before closing
the flap. If they occur, the flap may need to be partly
opened to allow for drainage, and appropriate antibiotics References
given to prevent infection. Meticulous attention to
sterile perioperative technique as well as pre- and post-
1. Illouz YG. A new technique for localized fat deposit. Paris:
operative infection prophylaxis is the best approach to Les Nouvelles Esthetiques; 1978.
avoid infection. In the event of an infection, early rec- 2. Klein JA. The tumescent technique for liposuction surgery.
ognition and treatment is paramount. Skin sloughs are Am J Cosmet Surg. 1987;4:263.
very rare after modified abdominoplasty and seem to 3. Bisaccia E, Scarborough DA. Syringe-assisted liposuction: a
cosmetic surgeon’s office technique. J Dermatol Surg Oncol.
be more common in more extensive abdominoplasties. 1988;14(9):982-989.
The recommended approach is to limit undermining 4. Scarborough DA, Bisaccia E. Miniabdominoplasty using
only under the skin that is planned to be excised so as combination liposuction and limited skin resection. Cosmetic
not to disturb the musculocutaneous perforators.10 Dermatol. 1997;10(7):10-12.
5. Matarasso A. Minimal-access variations in abdominoplasty.
Dehiscence is possible with too much tension on the Ann Plast Surg. 1995;34(3):255-263.
closure, a severe coughing spell, overexertion, or 6. Eaves FF 3rd, Nahai F, Bostwick J 3rd. Endoscopic abdomi-
straining from constipation. Sequential tension sutures, noplasty and endoscopically assisted miniabdominoplasty.
as well as a regimen of fiber medication to decrease Clin Plast Surg. 1996;23(4):599-616; discussion 617.
7. Matarasso A. Liposuction as an adjunct to a full abdomino-
constipation that can be caused by pain medications plasty. Plast Reconstr Surg. 1995;95(5):829-836.
are important. Just as with liposuction, other possible 8. Ribeiro L, Accorsi AJ, Buss A. Midiabdominoplasty: indi-
complications include transient hypesthesia, hyper or cations and technique Aesth Plast Surg. 1998;22:313-317.
hypopigmentation, asymmetry or contour irregularities, 9. Brauman D. Liposuction abdominoplasty: an evolving
concept. Plast Reconstr Surg. 2003;112(1):288-298; discus-
and hypertrophic scarring in incision sites. sion 299-301.
Pulmonary emboli are rare but the risk is increased 10. Avelar JM. Abdominoplasty combined with lipoplasty
in patients with a family history of PE, a history of without panniculus undermining: abdominolipoplasty – a
deep venous thrombosis, malignancy, systemic lupus, safe technique. Clin Plast Surg. 2006;33(1):79-90, vii.
11. Bisaccia E, Scarborough DA. Body analysis. In: The
protein C and S deficiency, nephrotic syndrome, and Columbia manual of dermatologic cosmetic surgery.
being on oral contraceptives. To minimize risk of pul- New York: McGraw-Hill; 2002:85-94.
monary embolism, proper patient selection is para- 12. Matarasso A, Belsley K. Abdominal contour procedures:
mount, as well as minimizing the duration of surgery evaluating the options. Dermatol Clin. 2005;23(3):475-493,
vi-vii. Review.
and encouraging mild activity as outlined above. Fat 13. Sozer SO, Agullo FJ, Santillan AA, Wolf C. Decision making
emboli are a very rare but a possible complication. in abdominoplasty. Aesthetic Plast Surg. 2007;31(2):117-127.
This risk is minimized using tumescent anesthesia. 14. Grevious MA, Cohen M, Shah SA, Rodriguez P. Structural
and functional anatomy of the abdominal wall. Clin Pastic
Surg. 2006;33:169-179.
15. Netter F. Abdomen: body wall. In: The Atlas of Human Anatomy.
Conclusion New Jersey: Ciba-Geigy Corporation; 1989:231-250.
16. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM,
Waterhouse N. Complications of 278 consecutive abdomi-
Recent developments in abdominal contouring proce- noplasties. J Plast Reconstr Aesthet Surg. 2006;59(11):
1152-1155.
dures have included the extensive use of liposuction 17. Khan UD. Risk of seroma with simultaneous liposuction and
and the use of modified or limited scars, producing a abdominoplasty and the role of progressive tension sutures.
“downsizing” of the operative procedures for many Aesthetic Plast Surg. 2008;32(1):93-99.
Part VII
Advanced and General Topics
Chapter 29
Ablative Laser Resurfacing Off the Face
Richard Fitzpatrick and William Groff
Introduction Patient Selection
Though ablative laser resurfacing is generally considered The conditions amenable to ablative treatment include
to be the gold standard for the rejuvenation of facial the following:
photodamage and scarring, its use has declined dramat-
• Neck and chest: photodamage and scarring of
ically because of its associated risk factors: postoperative
various etiologies as well as epidermal growths
infection, hypopigmentation, and scarring. To avoid
• Hands and arms: photodamage, scarring, and epi-
these problems, it requires significant expertise and
dermal growths
experience. When ablative laser procedures have been
• Torso – hips: striae alba, scars, and epidermal
attempted off the face, the margin for error is much
growths
smaller, and the possibility of complications increases
• Legs and feet: photodamage, scars, and epider-
dramatically. In order to control these risks, the depth of
mal growths
resurfacing generally has to be limited to the epidermis,
and the surface area must be significantly limited. Photodamage includes dyschromia (permanent irregular
Achieving dermal effects of tissue tightening, scar hyperpigmentation, telangiectasia, lentigines, and
correction, rejuvenation of atrophic or wrinkled skin ephelides), altered texture (atrophic skin with irregular
may not be realistic and must be approached with crepey texture), skin laxity, and wrinkles. Epidermal
extreme caution. Any treatment on the legs becomes growths are usually coexistent or a component of
even more problematic because of the slow healing photodamage and include seborrheic keratoses, skin
related to that area. tags, actinic keratoses, and disseminated superficial
Ablative resurfacing of the chest and the lower 1/3 actinic porokeratosis (DSAP). Scars are visible because
of the neck is particularly risky if depths extending of discoloration (red, brown, or white), shadowing
deeper than the epidermis are attempted. When attempt- secondary to their atrophic nature (with either smooth
ing to treat epidermal lesions that may extend into the or sharp borders) or because of the elevation above the
dermis via rete ridges, such as seborrheic keratoses surface (hypertrophic).
or actinic keratoses, particular care must be taken.
Compound nevi are challenging as well because of
the dermal component of the lesion. Failure to remove Method of Device and Treatment
deep epidermal extensions of seborrheic keratoses,
actinic keratoses, and compound nevi results in the
Application
regeneration of the lesions. On the other hand, abla-
tion to depths of complete removal can result in The advent of new technologies has revived interest in
significant dermal injury and often results in a hypop- the use of ablative procedures off the face and has
igmented scar. given physicians the tools to achieve excellent results

216 R. Fitzpatrick and W. Groff
without significant risk. The new technologies to be many patients. Pulse energies as high as 3.0 J may be
discussed are Portrait® Plasma Skin Regeneration, used safely on the upper 1/3 of the neck, but the energy
fractional CO2 resurfacing (Reliant Fraxel Re:pair will should be dropped to 2.0–2.5 J for the lower 2/3 of the
be discussed), and the adjunctive use of spot therapy neck. Repeat passes are necessary to assure complete
with the conventional CO2, erbium or alexandrite lasers and even coverage. For the hands and arms, pulse
with epidermal enzymes. energies of 2.5–3.0 J may be used safely.
When using the Portrait® Plasma Skin Rejuvenation Lentigines and ephelides are pretreated with the
(Rhytec Inc., Waltham, MA) procedure on the neck, Q-switched alexandrite laser using a 4 mm spot and
chest, hands, or arms, it is important to decrease the 4.0–5.5 J/cm2. Thick seborrheic keratoses located off
pulse energy according to the anatomic location. the face are treated with a focused spot of CO2 laser,
Achieving even, thorough epidermal coverage is pulse-stacking to create an epidermal–dermal blister to
important as well. Supplementing the procedure with lift off the lesion precisely at the epidermal/dermal
alexandrite laser pretreatment of lentigines and sebor- juncture (Fig. 29.1).
rheic keratoses will result in a more significant clinical
benefit. The Portrait® will achieve improvement in the
epidermal components generally 50–90%, and may
give mild improvement in some of the dermal features Fractional Resurfacing
of photodamage and scarring, but more than one
treatment session may be necessary. Dermal heating of The Fraxel Re:pair however allows much more
collagen occurs down to approximately 300 µm at aggressive and deeper treatment of these conditions
these parameters, so there is definitely stimulation of off the face. Depths of treatment as great as 1600 µm
new collagen and this will result in some degree of can be used safely, but there must be close attention to
smoothing of the skin’s texture and skin tightening in density, or percent coverage. The primary area of
Fig. 29.1 (a)Before and (b) 3 months after Fraxel Re:pair of the face and neck and with spot treatment using a traditional CO2 laser
for seborrheic keratoses
29 Ablative Laser Resurfacing Off the Face 217
concern off the face, as far as potential poor healing or the anticipated four treatments in order to decrease the
scarring, is the lower neck. Densities greater than 20% downtime of the patient. For the Fraxel Re:pair, we use
should not be used in this area or on the chest. Although densities of 10–30% and pulse energies of 20–50 mJ
a single treatment with 25–30% coverage leaves when treating photodamage. Isolated areas of traumatic
70–75% of the tissue untreated, we have seen infection or surgical scarring are usually treated with 70 mJ pulse.
occur at these settings that has resulted in scarring As with other procedures discussed, the alexandrite
(Fig. 29.2). The ability of the lower neck to respond to laser is used first to treat the most visible lentigines
any adverse event posttreatment appears to be severely and seborrheic keratoses (Fig. 29.4). One lesion seen
compromised at these densities. When treating mod- commonly on the forearms is hypopigmented flat
erate to severe photodamage or scarring of the upper seborrheic keratoses. These lesions are treated lightly
neck, we commonly use densities of 35% and pulse with an erbium or CO2 laser to help improve response,
energies of 40–70 mJ. When treating mild to moderate because of the lower densities generally being used
photodamage or scarring, we generally drop the upper with the Fraxel Re:pair.
neck density to 20–35% and the pulse energy to When the Fraxel Re:store is used as a follow-up
20–30 mJ. The lower neck and chest are treated at treatment, we will use pulse energies of 70 mJ and
densities of 10–20% and pulse energies of 20–50 mJ. 32% coverage.
Repeat treatment sessions are likely to improve the With this approach, we invariably see significant
overall response and these may be done at 1–6 months improvement in texture, lines, tissue laxity as well as
intervals. more uniform color, with elimination of lentigines,
As with the Portrait® procedure, we commonly use seborrheic keratoses, and actinic keratoses. Lesions of
the Q-switched alexandrite laser as an adjunctive treat- DSAP do diminish somewhat, but in order to eliminate
ment when there are large numbers or large lesions of these persistent lesions, a more targeted approach is
lentigines or seborrheic keratoses. necessary, which will be discussed in the section on
In a single treatment, we expect to see mild tightening treatment of the legs.
(10–30%) (Fig. 29.3), mild improvement in lines and Striae alba are very common findings on the lower
texture (15–40%), and significant improvement in abdomen after pregnancy and on the hips and upper
dyschromia, including poikiloderma (usually >75%). lateral thighs secondary to adolescent growth spurts.
Treatment of the hands and arms is generally There has never been a treatment that we have felt
approached as a series of treatment, often combining capable of giving significant improvement in the
the less-aggressive Fraxel Re:store for one or more of cosmetic appearance of these lesions. Not only are
they visible because of the hypopigmentation and loss
of natural skin texture lines, but many are also atro-
Fig. 29.2 Three months after treatment with Fraxel Re:pair.

Patient had been treated at 30 mJ and 35% coverage on upper
neck and 25% density on lower neck. Linear vertical scar
corresponding to the medial edge of the platysma is present.
More subtle scarring noted in horizontal plane secondary to Fig. 29.3 Before and 1 month after treatment with the Fraxel
wound infection during first week of postoperative recovery Re:pair. Treatment setting were 20 mJ and 10% density
218 R. Fitzpatrick and W. Groff
Fig. 29.4 Before and 5 months after treatment of lentigines and seborrheic keratoses with a Q-switched alexandrite laser
Treatment of Lesions on the Leg

Treatment of the legs has been confined at this time to
targeting individual lesions of seborrheic keratoses,
actinic keratoses, lentigines, and DSAP. The challenge
with all of these lesions is to achieve complete epi-
dermal/dermal separation throughout the lesion so that
recurrence is limited and scarring or hypopigmentation
is avoided.
Our approach is to use the erbium laser (Sciton, Inc.
25 µm ablation/25 µm coagulation and 3 mm spot size,
2–5 Hz) to ablate the stratum corneum and upper 50%
of the epidermis (Fig. 29.4). Once this is accom-
plished, trypsin and papain are applied sequentially.
Fig. 29.5 Before and 1 week after treatment of seborrheic These enzymes will not penetrate through the stratum
keratoses with erbium YAG laser in conjunction with enzymes corneum, so this layer must be fully ablated. Trypsin
disrupts the protein bonds between the cells of the
epidermis and papain disrupts the protein bonds between
phic. We have found in a small number of patients the basal cell layer and the dermis. Once the enzymes
treated that each has had some degree of improvement, are applied, Saran Wrap is placed over the area to
enough so that continued treatment is warranted. enhance penetration. When pinpoint bleeding is seen
The treatment density used with Fraxel Re:pair has throughout the lesion, the treatment session is com-
been 20–25% density and the pulse energy has varied plete. If this is not seen (usually because of the
from 20 to 40 mJ. With Fraxel Re:store, the recom- thickness of the lesion), a second or third application
mended setting is 17–32% density at 40–70 mJ. When of the enzymes is performed to reach the appropri-
comparing between Fraxel Re:store and Fraxel ate endpoint. Using this technique, we can achieve
Re:pair, the later has a higher likelihood of improve- >75% improvement in elimination of these epidermal
ment at the expense of an extended recovery period up lesions without causing hyperpigmentation or scarring
to 3 weeks. (Figs. 29.5 and 29.6).
29 Ablative Laser Resurfacing Off the Face 219
Fig. 29.6 DSAP present for 35 years and recalcitrant to numerous previous treatments, shows excellent improvement following
treatment with erbium laser stratum corneum ablation followed by application of trypsin and papain
Chapter 30
Prepackaged Injectable Soft-Tissue Rejuvenation
of the Hand and Other Nonfacial Areas
William Philip Werschler and Mariano Busso
Introduction of the aging hand.6,7 Experienced clinicians know that

treatment of the hand poses challenges both in terms of
efficacy and pain management. Autologous fat grafting,
The presence of soft tissue fillers in aesthetic surgery has
for example, requires multiple visits and ongoing man-
grown exponentially since the introduction of botulinum
agement of pain in the innervated areas of the hand.6
toxin A into the aesthetic environment in the early 1990s.
Combining CaHA with lidocaine mitigates much of
Representative soft tissue fillers currently seen in
the pain associated with injection into the hand, with
clinician offices include collagens (Cosmoplast®,
results that are both immediate and long-lasting.
Zyderm®, Zyplast®), hyaluronic acid compounds
Other off-label areas of the body in which CaHA
(Captique®, HylaForm®, HylaForm Plus®, Juvederm®,
and other soft tissue fillers hold promise include the
Restylane®, Perlane®), poly-L-lactic acid (PLLA;
chest, the feet, the nipples, and other areas where soft
Sculptra®), polymethylmethacrylate (PMMA; Artefill®),
tissue augmentation is desired, for example, following
and calcium hydroxylapatite (CaHA; Radiesse®).
surgery or trauma. In this chapter, the authors provide
The last filler mentioned here is a soft tissue filler
instructions on how to combine the CaHA with anesthetic
increasingly referenced in the clinical literature and
agents, how to approach treatment of the hand with
the one described in detail herein for the soft tissue
CaHA, and suggest other nonfacial areas of treatment
augmentation of nonfacial areas.
that might be pertinent in the future.
Radiesse is a biphasic mixture of 30% CaHA
microspheres (25–45 mm in diameter) and 70% car-
boxymethylcellulose carrier gel. The gel dissipates
in vivo typically within 8–12 weeks, leaving the micro-
spheres intact. In the soft tissue, they induce collagen-
esis so that a matrix forms around each of the
microspheres. The duration of effect in soft tissue has Prior to injection of any soft tissue filler, the patient
been estimated from nearly a year up to 18 months.1–3 should be counseled about the product itself, expected
Approved in late 2006 for treatment of moderate to duration of effect, posttreatment self-care procedures,
severe wrinkles, such as nasolabial folds, and also for possible adverse events, pain management, and sched-
treatment of HIV-associated facial lipoatrophy, CaHA ule for follow-up. Counseling may include a rationale
has also been used in several other off-label areas of the for selection of one product over another, based on the
face. These include cheek augmentation, marionette needs of the patient at the time. Informed consent
lines, prejowl sulcus, and nasal defects.1,4,5 should be obtained in the same counseling session.
In addition to its use in facial areas, the use of CaHA Pretreatment photos, with standardized placement of
in other parts of the body has begun to be explored by the camera, can help the patient remember the appear-
clinicians. For example, two articles published in early ance of the treated area in the moments, days, and
2008 describe the application of CaHA for the treatment weeks post injection.

222 W.P. Werschler and M. Busso
Administration of CaHA in the Hand
The treatment tray should be set up in advance of the

first session so that the clinician has the necessary
equipment for combining the soft tissue filler with
lidocaine. Table 30.1 is a checklist for the procedure
(courtesy of Dr. Busso).
Combining CaHA and lidocaine. To combine the Fig. 30.1 Mixing CaHA with lidocaine, using a Luer-Lok
CaHA and the lidocaine requires a 1.3 mL syringe of connection. (All figures courtesy of Journal of Dermatologic
Therapy; used with permission.)
Radiesse (CaHA and gel), a “Luer-Lok” connector,
and a second syringe also having a Luer-Lok connec-
tor and containing 0.15 mL of plain 2% lidocaine. The
wrist crease, and distally by the metacarpophalangeal
Radiesse syringe contents should be introduced to the
joints. Approximately 1.3 mL of Radiesse fills this
anesthetic first, with the Luer-Lok connection. Push
subcutaneous space of the dorsum of the one hand.
the Radiesse into the syringe containing 0.15 mL of
2% lidocaine. Then press the pusher of the lidocaine- Isolating the area of treatment. Skin tenting is used to
containing syringe back into the Radiesse syringe. Ten separate skin from vascular and tendinous structures
“passes” of the Radiesse-lidocaine are sufficient for by using the thumb and forefinger of the noninjecting
homogeneity.7 Mixing the CaHA and the lidocaine hand to lift skin over the dorsal aspect of the hand
lowers the viscosity and the extrusion force found in being treated, as shown in Fig. 30.2a.
the original Radiesse formulation but does not com-
Injecting the mixture into the hand. Filler mixture is
promise the properties of the CaHA. The particles
introduced as a bolus (0.5–1.4 mL) in the areolar plane
remain suspended in the gel carrier so that the com-
between the subcutaneous layer and superficial fascia
pound can be injected normally into the targeted area
as shown in Fig. 30.2b.
(Fig.30.1).6
Immediately after injection, the injection site should
(Author’s note: Portions of this section previously
be gently massaged (Fig. 30.2c) until the filler has been
appeared in the Journal of Dermatologic Therapy.
evenly spread. The patient should make a fist of the
Used by permission of the publisher.)
newly injected hand while the physician manipulates
Identifying the area of treatment. The space that is the injected area to allow for more even distribution.
injected is bound laterally by the fifth metacarpal, medi-
Posttreatment. Immediately post injection, photo-
ally by the second metacarpal, proximally by the dorsal
graphs of the treated area may be taken after any direc-
tional markings have been removed. Patients are
counseled NOT to massage the treated area on their
own. Follow-up visits may be scheduled from 4 to
Table 30.1 Procedure checklist for administration of soft
tissue filler 8 weeks post initial injection to document any adverse
 Informed consent obtained, patients screened for risk factors
events and provide touch-up injection as necessary.
 Pretreatment photograph obtained Topical Arnica Montana may help reduce bruising and
 Areas to be treated marked for injection with washable marker swelling. Vitamin K may be provided to the patient as
 Injection of CaHA and lidocaine mixture well, for topical administration. Anecdotal reports
 Postprocedure massage for several minutes have suggested that bromelain may have an obviating
 Posttreatment photograph obtained usually after removal effect on bruising and swelling.
of markings
 Posttreatment instructions given (written and oral) Adverse Events. Adverse events reported from injection
 Follow up appointment scheduled of CaHA have typically been of short duration and low
 Treatment notes written into patient chart severity. They include, but are not limited to, edema,
30 Prepackaged Injectable Soft-Tissue Rejuvenation of the Hand and Other Nonfacial Areas 223
Fig. 30.2 Injection technique. This figure shows the tenting technique (Fig. 30.2a) when injecting a bolus of filler into the dorsal
aspect of the hand (Fig. 30.2b). A massage of the treated area should follow injection of the bolus (Fig. 30.2c)
ecchymosis, temporary pain, and tissue soreness in the fer has been the treatment of choice for most nonfacial
first days following injection. Patients taking blood augmentation procedures.
thinners may experience more swelling and bruising than Moving beyond hands, certainly feet are an area of
patients who are not taking these agents. cosmetic concern for many aesthetically minded
In addition, anecdotal reports to the authors have patients. With the increasing attention to grooming of
been noted concerning swelling of the hand post the skin and nails of the feet associated with footwear
augmentation in a few patients. The swelling began fashion that exposes the tops of the feet, many patients
immediately, post procedure in one case and as late as would conceivably be candidates for dorsal subdermal
3 weeks after injection in another. Risk factors in these injections of filling agents to address many of the same
few cases may have included the patient being greater appearance factors that affect the backs of hands.
than 60 years of age and injection with more than one The age associated thinning of the dermis combined
CaHA syringe into each hand. Treatment consisted of with photo damage serves to expose the architectural
watchful waiting, hand elevation, and perhaps oral anatomy of the dorsal foot. As can be seen with the before
steroids. In each of these anecdotal cases, the swelling and after photos of the feet of a 42-year-old woman
resolved without sequelae. treated with CaHA (Fig. 30.3a, b), the aesthetically
enhanced appearance rivals that of hand rejuvenation
with CaHA (Fig. 30.4a, b).
The technique guidelines, administration, and
CaHA in Other Nonfacial Areas mixing of CAHA with lidocaine are unchanged from
hand augmentation. Additionally, foot augmentation
While nonfacial areas have traditionally not been patients are requested to refrain from wearing any
treated with injectable filling agents, there are anec- tight-fitting footwear (especially over the instep portion
dotal reports of collagens being used for traumatic and of foot) for 2 weeks post injection. Those patients who
postsurgical defects off of the face. Additionally, these have compromised circulation, diabetes, active infection,
agents have been used for cosmetic augmentation of or any other type of medical condition that could impair
the nipples, labia, clitoris, and penis. While these uses healing and/or predispose to infection, ulceration or
have been acknowledged, they are not typically widely skin compromise are currently not recommended for
performed. With the exception of postsurgical (mas- this procedure.
tectomy) or inverted/asymmetric nipple reconstruction Because no overcorrection is needed, the treatment
and augmentation,8,9 and the more recently described provides real-time results as soon as the treatment is
hand rejuvenation (Fig. 30.2c), other body areas gener- completed. The addition of anesthetic into the soft tis-
ally have not been treated with fillers. Rather, fat trans- sue compound allows deposition in areas traditionally
224 W.P. Werschler and M. Busso
considered painful to treat, for example, the hands and

feet. Within several weeks, the gel will dissipate, leav-
ing the microspheres to form a cellular matrix in the
tissue. Before and after results of the injection of the
combined mixture of anesthetic and Radiesse are
shown in Fig. 30.4.
Conclusion
Soft tissue fillers have been the mainstay of facial aes-

thetic correction for some time now. Some of these
fillers have a versatility that lends them to new appli-
cations to other areas of the face. Both CaHA and
PLA, for example, have approvals for facial correc-
tion; some clinicians may prefer the immediate cor-
rection property of CaHA over the accrued correction
of PLA. We have found that both are good candidates
for nonfacial applications too. In particular, CaHA has
broad potential for treatment of both the aging hand
and foot. As the elderly population inevitably expands,
the call for viable treatment of the hand, with attenua-
tion of attendant pain, will likely increase along with
it. CaHA carries a favorable profile in terms of safety
and efficacy in treatment of the face. We see no obvi-
Fig. 30.3 Before and after photos of the feet of a 42-year-old
female. Patient received 1.3 mL of CaHA in the left foot and ous reason why its use in nonfacial areas should be
1.3mL of CaHA in the right foot viewed with skepticism.
Fig. 30.4 Patient before and after hand augmentation. This figure shows a 38-year-old patient before (a) and immediately after
injection of 1.3 mL of CaHA for augmentation of the hands (b)
30 Prepackaged Injectable Soft-Tissue Rejuvenation of the Hand and Other Nonfacial Areas 225
Acknowledgements The authors express appreciation to BioForm sensus recommendations. Plast Recon Surg. 2007;120(Suppl):
Medical researcher staff members Robert Voigts, Dale DeVore, 55S-66S.
PhD, Michelle Johnson, and Xanthi Merlo for their studies on 2. Tzikas TL. Evaluation of Radiance™ FN soft tissue filler for
the properties of CaHA. The authors also thank the editors of the facial soft tissue augmentation. Arch Facial Plast Surg. 2004;6:
Journal of Dermatologic Therapy for permission to use images 234-239.
and some text that appeared earlier in their journal. Finally, the 3. Felderman LI. CaHA for facial rejuvenation. Cosmetic Dermatol.
authors value the editorial assistance provided by David J. 2005;18(22):823-826.
Howell, PhD, San Francisco, CA. 4. Becker H. Nasal augmentation with calcium hydroyxylaptite in a
Disclosures. Dr. Werschler is an advisory board member, carrier-based gel. Plast Recon Surg. 2008;121(6):2142-2147.
clinical investigator, consultant, investor, and/or speaker for 5. Werschler WP. Treating the aging face: a multidisciplinary
Allergan, Inc, Artes, BioForm Medical, Inc, DermAvance approach with calcium hydroxylapatite and other fillers, part 2.
Pharmaceuticals, Inc, Johnson & Johnson, MyoScience Inc, Cosmetic Dermatol. 2007;20(12):791-796.
Medicis Pharmaceutical Corporation, Revance Therapeutics, 6. Busso M, Applebaum D. Hand augmentation with Radiesse®
and Sanofi-Aventis. (calcium hydroxylapatite). J Dermatol Ther. 2007;20(6):
Dr. Busso has been an investigator for Radiesse and ArteFill 315-317.
clinical trials; he is a member of the BioForm Medical Education 7. Busso M, Voigts R. An investigation of changes in physical
Faculty. He is also on advisory boards for Dermik and Allergan. properties of injectable calcium hydroxylapatite in a carrier gel
(Radiesse®) when mixed with lidocaine and with lidocaine-
epinephrine. Dermatol Surg. 2008;34(Suppl 1):S16-23.
8. Jacovella P. Calcium Hydroxylapatite Facial Filler (Radiesse™):
indications, technique, and results. Clin Plast Surg. 2006;33(4):
References 511-523.
9. Evans KK, Rasko Y, Lenert J, et al. The use of calcium
hydroxylapatite for nipple projection after failed nipple-
1. Graivier MH, Bass LS, Busso M, et al. Calcium hydroxylapatite areolar reconstruction: early results. Ann Plast Surg. 2005;55:
(Radiesse®) for correction of the mid- and lower face: con- 25-29. [discussion 29].
Chapter 31
Cosmeceuticals Off the Face
Zoe Diana Draelos
Introduction desquamating corneocytes, but aggressively on the

body for the reduction of calluses. Photoprotection
remains important both on the face and the body, but
Cosmeceuticals are a category of topical agents designed
clothing provides the bulk of the daily sun protection
to improve the appearance of the skin. Traditionally,
on the body while sunscreens play an important role
the cosmeceutical market has focused on products
during recreation. Finally, skin lightening and antiaging
designed for facial application, yet the use of these
therapies are increasing in popularity on the body;
topicals for body appearance improvement is rapidly
however, efficacy is reduced due to the increased skin
increasing. Cosmeceuticals are substances found in
thickness off the face.
both the over-the-counter (OTC) and prescription arena
This discussion has focused on the differences
that can be effectively used by dermatologists to
between the well-established facial cosmeceutical
maintain or improve the results obtained with other
market and the emerging body cosmeceutical market.
rejuvenative procedures. Cosmeceuticals must be distin-
Our next topic of discussion is the implementation of
guished from colored cosmetics, designed only to adorn
cosmeceuticals as a complement to minimally invasive
the body using pigments. The intent is that cosmeceuticals
cosmetic treatments.
will produce an improvement in skin functioning by
modifying texture, roughness, pigmentation, erythema,
and desquamation. This chapter discusses how to use
cosmeceuticals off the face.
Cosmeceuticals represent a broad category of
products including cleansers, exfoliants, moisturizers,
sunscreens, skin lightening agents, and antiaging All patients undergoing minimally invasive cosmetic
therapies. Each of these areas will be evaluated for treatments require the use of some cosmeceuticals
their utility off the face (Table 31.1). Facial application for basic hygiene and the posttherapy maintenance
has been the main target area for the use of these phase. These products include cleansers and moisturizers
products for many years. This is because the thinner with the addition of sunscreens. Other patients will
facial skin is more amenable to visible change and require the use of cosmeceuticals for augmentation of
possesses unique anatomic characteristics. The abundant the results obtained postprocedure. These cosmeceuticals
sebaceous glands create the need for frequent facial include exfoliants, skin lightening agents, and antiaging
washing, yet aggressive over removal of sebum induces moisturizers. Table 31.2 presents the ingredients and
flaky dry skin and increased wrinkles of dehydration. mechanism of action for these cosmeceutical categories.
Wrinkles of dehydration do not occur on the body, but The art of cosmeceutical use is selecting the proper
problems with dry skin are common requiring careful agents for the unique need of a specific patient. The
cleanser selection. Moisturizers are used more for rest of the discussion focuses on those cosmeceuticals
improving skin feel than for wrinkle reduction. available for treatment plan customization as outlined
Exfoliants are used gently on the face for removal of in Table 31.3.

228 Z.D. Draelos
Table 31.1 Function and attributes of body cosmeceutical categories

Product
category Function Body use unique attributes
Cleansers Removes environmental dirt, sebum, bacteria, Must remove surface sebum without damaging intercellular
and fungus to maintain skin hygiene lipids, must provide odor control in axilla and on genitalia
Exfoliants Prevents and minimizes the build up of Callus formation in areas of body trauma (elbows, knees,
corneocytes heels, etc.) can be treated and controlled
Moisturizers Creates an environment for optimal for barrier Itch reduction, especially on sebum poor areas such as the
repair while creating tactile skin smoothness hands, feet, lower arms, lower legs, and upper back,
and pruritus reduction assumes importance
Sunscreens Provides a thin covering over the skin surface Large body surface area application with copious sweating
to absorb and reflect UV radiation and frequent rubbing necessitates frequent application and
reduces efficacy
Skin lightening Decreases the production of melanin Thick body skin creates challenges for pigment reduction and
agents reduces efficacy
Antiaging Modifies skin functioning to create the Body skin is less amenable to topical antiaging therapies, but
therapies appearance of younger skin photoaging is proportionately less on the body
Table 31.2 Composition of body cosmeceuticals

Product category Main functional ingredients Mechanism of action
Cleansers Surfactants consisting of soaps and synthetic Oily sebum and oil soluble environmental dirt is emulsified
detergents (sodium lauryl sulfate, sodium by surfactant and water soluble environmental dirt are
laureth sulfate) rinsed from body
Exfoliants Physical exfoliants (polyethylene beads, Desquamating skin cells are physically removed by abrasive
ground nut pits, dissolving granules) particles and/or chemically removed by low pH
possibly alone or combined with chemical substances intended to dissolve intercellular bridges
exfoliants (salicylic acid, glycolic acid)
Moisturizers Oily occlusive substances (petrolatum, mineral Occlusive substances create a water impermeable barrier
oil, dimethicone) are combined with over the skin surface and humectants attract water from
humectants (glycerin, propylene glycol, the dermis to the epidermis and stratum corneum
sorbitol) to increase skin hydration
Sunscreens Organic (octyl methoxycinnamate, homosalate, Organic substances absorb UV radiation converting it to
octocrylene, oxybenzone, avobenzone, heat while inorganic substances reflect UV radiation
ecamsule) and inorganic (zinc oxide, from skin surface
titanium dioxide)
Skin lightening Hydroquinone, kojic acid, deoxyarbutin, Modulation of tyrosinase leads to decreased melanin
agents azelaic acid production coupled with reduced exposure to UVA
Antiaging Retinoids (tretinoin, retinol, retinaldehyde, Retinoids modulate keratinocytes differentiation, most
therapies retinyl esters), botanicals extracts botanicals function as antioxidants
Table 31.3 Problem oriented approach to cosmeceutical selection

Skin attribute Cosmeceutical category Mechanism of action for cutaneous improvement
Texture Occlusive moisturizer, retinoid moisturizer, Increase skin hydration with petrolatum and dimethicone,
film-forming moisturizer normalize keratinocyte differentiation with tretinoin or retinol,
create thin protein film over skin surface
Smoothness Moisturizing body wash, emollient Minimize skin dryness with petrolatum depositing body wash, use
moisturizer emollient moisturizer with dimethicone to fill intercellular
keratinocytes spaces
Desquamation Exfoliant cleanser and moisturizer Speed removal of desquamating corneocytes with polyethylene
beads, Continue corneocyte removal process with urea and
lactic acid moisturizer
Erythema Antioxidant botanical moisturizer Decrease erythema with anti-inflammatory botanical moisturizer
(feverfew, bisabolol, licorice extract, etc)
Pigmentation Sunscreen, skin lightening agent Select inorganic sunscreen with zinc oxide to decrease pigment
production, Inhibit pigmentation with hydroquinone
31 Cosmeceuticals Off the Face 229
Body Cosmeceutical Treatment of removal of intercellular lipids, in which case a

Application moisturizer should be used to improve skin texture and
feel. However, in mature individuals, an increase in
skin scaling may result from a desquamatory failure.
Cleansers This can be visualized as coarse skin scale on the ante-
rior shins, thickened skin over the elbows or knees,
Cleansers for the body must be selected to maintain and calluses of the feet. Moisturizers will temporarily
hygiene while preserving the intercellular lipids, which smooth the skin scale, but the “dryness” will soon
form the skin barrier. The three major chemical categories return requiring the use of an exfoliant. Exfoliants can
of cleansers are soaps, syndets, and combars, which can physically or chemically dislodge the scale from the
be placed on a variety of cleansing implements from skin surface (Table 31.2). Physical exfoliants, such as
the hands to a washcloth to a disposable face cloth polyethylene beads or ground fruit pits, can be placed
(Table 31.4). True soap is a specific type of cleanser with in cleansers to scrub away the skin scale while chemi-
an alkaline pH of 9–10 created by chemically reacting cal exfoliant moisturizers, containing urea or lactic
a fat and an alkali to create a fatty acid salt with detergent acid, can dissolve the intercellular bridges allowing
properties. Soap efficiently removes both sebum and the skin scale to slough revealing healthy skin.
intercellular lipids making it an excellent general skin Exfoliants can be used to rejuvenate the appearance of
cleanser for wounded skin requiring debridement, but dry, aged body skin.
a poor choice for dry, sensitive body skin. Milder cleans-
ing for normal to dry body skin is found in the syndet
cleansers, which contain sodium cocoyl isethionate Moisturizers
formulated at a neutral pH of 5.5–7. This more neutral
pH removes fewer intercellular lipids preventing further Moisturizers form the largest category of cosmeceuticals
barrier damage during body cleansing. Where infection and are applied to the body following cleansing to
or odor control is an issue, combar body cleansers at a pH minimize transepidermal water loss (TEWL) thus
of 7–9, containing soap and syndet combinations, along creating an environment optimal for healing following
with the antibacterial triclosan should be selected. If the a minimally invasive cosmetic procedure. Body mois-
patient has extremely dry body skin or tendencies toward turizers are also used to improve skin aesthetics and
eczematous skin conditions, a moisturizing body wash reduce itching. Moisturizers may also be a delivery
that leaves behind a thin layer of petrolatum, dimethicone, vehicle for other cosmeceutical ingredients, discussed
or vegetable oils should be selected. later in this chapter. There are three categories of sub-
stances that can be combined to enhance the water
content of the skin include occlusives, humectants,
Exfoliants and hydrocolloids (Table 31.5). Occlusives are oily
substances that retard TEWL by placing an oil slick
Body skin cleansing may increase the amount of desqua- over the skin surface, while humectants are substances
mating corneocytes. This may be due to excessive that attract water to the skin, not from the environment,
Table 31.4 Body cosmeceutical cleansers

Body cleanser category Formulation Appropriate patient selection
Soap Fatty acid salt, pH 9–10 Normal to oily skin, postprocedure wound
(Ivory, P&G; Pure and Natural, Jergens) debridment
Syndet Synthetic detergent (sodium Normal to dry skin, general body cleansing
(Dove, Unilever; Olay Bar, P&G) cocoyl isethionate), pH 5.5–7
Combar Soap and syndet combined, Triclosan antibacterial useful in patient with
(Dial, Dial Corporation; Irish Spring, pH 7–9 wound infection, bacterial colonization, or
Coast, Colgate-Palmolive) body odor
Moisturizing body wash (Olay Ribbons, Synthetic detergent combined Extremely dry skin, similar to conditioning
P&G; Dove Nutrium, Unilever) with petrolatum, dimethicone, shampoo, leaves behind a thin film of
and/or vegetable oils occlusive moisturizers to minimize skin
scaling and roughness
230 Z.D. Draelos
Table 31.5 Body cosmeceutical moisturizers

Moisturizer category Ingredients Skin effect
Occlusive Petrolatum, mineral oil, cetyl alcohol, dimethicone, Prevent water evaporation from skin, smooth
cyclomethicone, soybean oil, lanolin, shea desquamating corneocytes, place protective film
butter, cocoa butter, sesame oil, borage oil, all over nerve endings to alleviate itch, add skin shine
vegetable oils
Humectant Glycerin, hyaluronic acid, sodium PCA, sorbitol, Act as a sponge to hold water within the skin enabling
propylene glycol, vitamins, gelatin hydration
Hydrocolloid Proteins, hyaluronic acid, colloidal oatmeal Create a physical barrier to water evaporation from
the skin
unless the ambient humidity is 70%, but rather from Table 31.6 Cosmeceutical sunscreens
the inner layers of the skin. Humectants draw water Sunscreen Spectrum of
from the viable dermis into the viable epidermis categories protection Ingredients
and then from the nonviable epidermis into the Organic UVB 290–320 nm Octyl methoxy cinnamate,
filters ocytocrylene, octyl
stratum corneum. Lastly, hydrocolloids are physi- salicylate
cally large substances, which cover the skin thus Organic UVA 320–360 nm Ecamsule, avobenzone,
retarding TEWL. Body moisturizers are typically filters oxybenzone, menthyl
more occlusive than those designed for the face, since anthranilate
Inorganic Total reflection Zinc oxide, titanium dioxide
the sebaceous glands are reduced on the body, yet
UVB/UVA of all
they are formulated for better spreadability over large filters radiation
surface areas.
probably most important following minimally invasive

Sunscreens resurfacing on the hands, neck, and décolleté where it
is difficult to achieve photoprotection with clothing.
Sunscreens are an important body cosmeceutical to
prevent postprocedure pigmentation and to provide
photoprotection. Sunscreens contain a careful combi- Skin Lightening Agents
nation of organic and inorganic ingredients designed
to provide full UV spectrum protection (Table 31.6). Skin lightening agents function to decrease the activity
Organic sunscreens contain filters, such as octyl methoxy of tyrosinase, the key enzyme in melanin synthesis
cinnamate, octocrylene, and octyl salicylate, which undergo (Table 31.7), when used in combination with the previ-
a chemical transformation, known as resonance ously discussed sunscreens. Hydroquinone, available in
delocalization, absorbing UV and radiating the energy prescription strengths of 4% or higher and nonprescrip-
from the body as heat. This reaction occurs within the tion strengths of 2% or less, represents the gold standard
phenol ring, which contains an electron-releasing group for skin lightening agents. Hydroquinone inhibits tyro-
in the ortho- and/or para- position. This chemical reaction sinase likely by interfering with copper binding, thereby
is irreversible rendering the filter inactive once it has reducing the conversion of dihydroxyphenylalanine
absorbed the UV radiation. This has led to the recognition (DOPA) to melanin, but it is also cytotoxic to melano-
that photostable sunscreens are important to prevent cytes. Recent debate over possible carcinogenicity by
the need for frequent reapplication. Photostability can damaging DNA in rodent models and cell cultures has
be achieved by combining sunscreens, such as oxyben- caused the FDA to question its safety. This has led to the
zone and octocrylene and avobenzone, or by selecting search for other cosmeceutical botanically derived
inorganic filters. Inorganic filters are ground particu- pigment lightening agents, such as azelaic acid, kojic
lates that reflect or scatter UV radiation, absorbing acid, arbutin, licorice extract, and vitamin C.
relatively little of the energy. They do not undergo a Azelaic acid is a 9-carbon dicarboxylic acid obtained
chemical reaction and are thus inherently photostable. from cultures of Pityrosporum ovale that may be a treat-
Zinc oxide is an example of an inorganic filter that ment alternative for individuals allergic to hydroquinone.
does not whiten skin, yet provides excellent protection Although its lightening effects are mild, several large
from postprocedure body pigmentation. Sunscreens are studies done with a diverse ethnic background population
31 Cosmeceuticals Off the Face 231
Table 31.7 Body lightening ingredients

Skin lightening ingredient Effect on melanogenesis Relative efficacy
Hydroquinone Inhibits tyrosinase by interfering with copper binding reducing conversion of Highest
dihydroxyphenylalanine (DOPA) to melanin
Azelaic acid Inhibits tyrosinase by interfering with copper binding reducing conversion of Moderate
Kojic acid Inhibits tyrosinase by interfering with copper binding reducing conversion of Moderate
Arbutin Decreases tyrosinase activity without affecting messenger RNA expression Moderate
Liquiritin Increases melanin granule dispersion Low
Vitamin C Interacts with copper ions to reduce dopaquinone and blocks dihydrochinindol- Low
2-carboxyl acid oxidation
have compared its efficacy to that of hydroquinone. which encompasses all of the naturally occurring
It too interferes with tyrosinase activity, but may also retinol derivatives.
interfere with DNA synthesis. Another skin lightening The currently most popular topical flavonoid for
chemical that is fungally derived from Aspergillus body application is genistein, obtained from fermented
and Penicillium species is kojic acid, chemically known soy, which functions as phytoestrogens when orally
as 5-hydroxymethyl-4H-pyrane-4-one). It functions by consumed. Some of the cutaneous effects of soy have
binding to copper thereby inhibiting tyrosinase. linked to its estrogenic effect in postmenopausal
Two plant derivatives that are found in cosmeceuticals women. Topical estrogens have been shown to increase
to lighten skin are arbutin, obtained from the leaves of the skin thickness and promote collagen synthesis. It is
Vaccinicum vitis-idaca and licorice extracts. Arbutin is interesting to note that genistein increases collagen
a naturally occurring gluconopyranoside that causes gene expression in cell culture, however there are no
decreased tyrosinase activity without affecting messenger published reports of this collagen-stimulating effect in
RNA expression. It is felt to be effective than liquiritin topical human trials thus its benefit, as a body moisturizer
and isoliquertin, which are licorice glycosides. Liquiritin additive, cannot be confirmed.
induces skin lightening by dispersing melanin. Some Curcumin is an example of a polyphenol antioxidant
plants also rich in ascorbic acid are used in hyperpigmen- derived from the turmeric root, which is a popular spice
tation formulations, since vitamin C interrupts the produc- and natural yellow food coloring. Tetrahydrocurcumin,
tion of melanogenesis by interacting with copper ions a hydrogenated form of curcumin, is off-white in color
to reduce dopaquinone and blocking dihydrochinindol- and can be added to skin care product not only to func-
2-carboxyl acid oxidation. These plant derivatives are tion as a skin antioxidant, but also to prevent the lipids
distinctly ineffective on the body, since the thicker skin in the moisturizer from becoming rancid. Resveratrol,
precludes penetration. a related chemical to curcumin, is found in red wine
accounting for the antioxidant effect of this beverage.
Again, data is lacking on the topical body benefits of
Antiaging Therapies polyphenols.
Carotenoids, in the form of retinoids, are the best
The discussion now turns to antiaging therapies for the studied body antiaging cosmeceuticals. Tretinoin, a
body, however there are too many substances and prescription retinoid, has been proven to produce the
techniques in the cosmeceutical realm to present in antiaging effects listed in Table 31.5. There is some
this brief discussion, yet it is worthwhile examining evidence that naturally occurring cosmeceutical forms
the major categories of botanical antioxidants and of vitamin A, such as retinyl palmitate and retinol, can
retinoids. Most botanical antioxidants can be classified function as topical antioxidants, enhancing function-
into one of three categories as flavonoids, polyphenols, ing of benign photodamaged skin. Retinyl palmitate
and carotenoids. Flavonoids possess a polyphenolic can become biologically active following cutaneous
structure that accounts for their antioxidant, UV enzymatic cleavage of the ester bond and subsequent
protectant, and metal chelation abilities. Polyphenols conversion of retinol to retinoic acid. It is this cutaneous
compose the largest category of botanical antioxidants. conversion of retinol to retinoic acid that is responsible
Lastly, carotenoids are chemically related to vitamin A, for the biologic activity of some of the new stabilized
232 Z.D. Draelos
Table 31.8 Cutaneous effects of vitamin A Moisturizers

Gross dermatologic effects:
Improvement in fine and coarse facial wrinkling
3. Draelos ZD. Therapeutic moisturizers. Dermatol Clin.
Decreased tactile roughness 2000;18:597-607.
Reduction of actinic keratoses 4. Flynn TC, Petros J, Clark RE, et al. Dry skin and moisturizers.
Lightening of solar lentigenes Clin Dermatol. 2001;19:387-392.
Histologic dermatologic effects 5. Rawlings AV, Harding CR, Watkinson A, Scott IR. Dry and
Reduction in stratum corneum cohesion xerotic skin conditions. In: Leyden JJ, Rawlings AV, eds.
Decreased epidermal hyperplasia Skin Moisturization. New York:Marcel Dekker; 2002:
Increased production of collagen, elastin, and fibronectin 119-144.
Reduction in tonofilaments, desmosomes, melanosomes 6. Draelos ZD. Moisturizers. In: Draelos ZD, ed. Cosmetics In
Dermatology, 2nd edn. New York:Churchill-Livingstone;
More numerous Langerhans cells
1995:83-95.
Angiogenesis
Decreased glycosaminoglycans
Reduced activity of collagenase and gelatinase
Normalization of keratinization of the pilosebaceous unit
Sunscreens
OTC vitamin A body moisturizers designed to improve
the appearance of photodamaged skin (Table 31.8). 7. Nash JF. Human safety and efficacy of ultraviolet filters and
sunscreen products. Dermatol Clin. 2006;24:35-51.
Unfortunately, only small amounts of retinyl palmitate 8. Gasparro FP, Mitchnick M, Nash JF. A review of sun-
and retinol can be converted by the skin, accounting screen safety and efficacy. Photochem Photobiol. 1998;68:
for the increased efficacy seen with prescription prepa- 243-256.
rations containing retinoic acid. 9. Moloney FJ, Collins S, Murphy GM. Sunscreens: safety,
efficacy and appropriate use. Am J Clin Dermatol. 2002;3:
185-191.
Conclusion
Skin Lightening
Cosmeceuticals for body rejuvenation are an impor-
tant part of the dermatologic armamentarium. Evidence
10. Balina LM, Graupe K. The treatment of melasma. 20% azelaic
exists for the efficacy of cleansers and moisturizers in
acid versus 4% hydroquinone cream. Int J Dermatol. 1991;
skin hygiene and barrier maintenance. New filters with 30(12):893-895.
enhanced photostability are increasing the value and 11. Lim JT. Treatment of melasma using kojic acid in a gel
longevity of sunscreens to prevent photodamage. Yet, containing hydroquinone and glycolic acid. Derm Surg.
1999;25:282-284.
areas such as skin lightening and antiaging therapies,
12. Hori I, Nihei K, Kubo I. Structural criteria for depigmenting
outside of hydroquinone and prescription retinoids, are mechanism of arbutin. Phytother Res. 2004;18:475-469.
lacking in evidence. The future requires documenta- 13. Amer M, Metwalli M. Topical Liquiritin improves melasma.
tion of the dose and expected effects of cosmeceuticals Int J Dermatol. 2000;39(4):299-301.
that are used as antioxidants for skin rejuvenation.
Antiaging
References
14. Glazier MG, Bowman MA. A review of the evidence for
Cleansers the use of phytoestrogens as a replacement for traditional
estrogen replacement therapy. Arch Intern Med. 201;161:
1161-1172.
1. Willcox MJ, Crichton WP. The soap market. Cosmet Toilet. 15. Duell EA, Derguini F, Kang S, Elder JT, Voorhees JJ.
1989;104:61-63. Extraction of human epidermis treated with retinol yields
2. Wortzman MS. Evaluation of mild skin cleansers. Derm retro-retinoids in addition to free retinol and retinyl esters.
Clinics. 1991;9:35-44. J Invest Dermatol. 1996;107:178-182.
Chapter 32
Special Considerations in Asian Patients
Sherry Shieh and Henry H.L. Chan
Introduction nonsurgical cosmetic procedure performed in Asians.

While the forehead, glabella, and periorbital rhytides
are the most commonly treated areas, treatment of
The approach to rejuvenation of the Asian neck and
nonfacial areas, such as the neck and gastrocnemius,
body requires a thorough understanding of key anatomic
are sometimes requested. Horizontal neck rhytids rather
and physiologic traits and familiarity with the intrinsic
than platysmal bands are more problematic in Asian
and extrinsic aging process. As a group, Asians have
patients, and selection of patients can be improved
a smaller frame and body weight, shorter stature, and
with 30–40 units. Caution must be taken when injecting
short, muscular legs. Cutaneous racial differences
the neck with Botox® as muscle weakness and dysphagia
include: decreased terminal body hair, reduced sweat-
are potential side effects. Masseter hypertrophy can
ing, fewer leg veins, increased incidence of keloid
be treated with Botox injection (50–65 units per jaw).
formation, and higher epidermal melanin content that
As alluded to earlier, Asians have muscular calves,
predisposes to postinflammatory hyperpigmentation
and this is often considered undesirable. Botox® is an
(PIH). Histologically, the dermis of Asian skin is thicker,
acceptable nonsurgical alternative that can be used to
and wrinkling is delayed by approximately 10 years
reduce enlarged medial gastrocnemius muscles and
as compared to age matched Caucasian counterparts.1
create a more slender shape. Lee et al. have shown that
Photoaging in Asians is frequently characterized by
doses of 72 units can be used with no functional impair-
pigmentary disorders such as solar lentigines and
ment and a durability of 6 months.3,4 The author has
seborrheic keratoses on the head and neck.2 The neck
used doses of up to 100 units per leg safely with results
also ages differently in Asians compared to Caucasians.
lasting 9–12 months (Fig. 32.1). Appropriate consultation
Poikiloderma of Civatte is uncommon, and platysmal
prior to injection is essential as the clinical outcome
neck bands in Asians are less problematic. Finally,
depends not only on the doses of injection but also the
differences in cultural aesthetic goals also exist. In
amount of exercise the patients perform. For example,
Asians, there is a greater focus on toning and tightening
the outcome would be suboptimal among regular
of the body rather than performing procedures such as
runners. The technique involves six injections into
breast augmentation, liposuction, and abdominoplasty.
the medial and lateral gastrocnemius muscle using a
Below, we will review various minimally-invasive reju-
27 G 1¼ in. needle.
venation methods and highlight special considerations
when treating the Asian patient.
Laser and Radiofrequency Skin

Treatment Applications Rejuvenation
Botulinum Toxin A (Botox®) Laser Considerations in Asian Skin
According to the 2006 Survey of American Society Skin types vary greatly amongst Asiatic races, and it is
of Plastic Surgeons, Botox® is the most common important to note that the Fitzpatrick skin typing system

234 S. Shieh and H.H.L. Chan
Fig. 32.1 (a) Enlarged gastrocnemius. (b) After 100 units of Botox per calf
is not directly applicable to the Asian population. levels can also reduce the risk of PIH in Asians.6,7. The
Careful attention should be given to ethnic background typical parameters used for the neck are 40–50 mJ,
and skin type when selecting laser parameters given treatment level 4–6, and 8 passes. Radiofrequency tis-
the higher risk of PIH in this group. Means to reduce the sue tightening with Thermage Thermacool TC (Solta
PIH include: selecting longer wavelengths, ensuring Medical Inc., Hayward, CA, USA) causes dermal and
adequate cooling, and increasing pulse duration. Strict subdermal tissue heating through the conduction of
sun avoidance and application of skin preparations electric current with subsequent collagen remodeling
containing sunblock, medium potency steroids, hydro- and skin tightening. Patient satisfaction is high, espe-
quinone 4–6% and azelaic acid 20%, tretinoin, glycolic cially when the upper neck is treated. With the use of
acid or kojic acid for 2 weeks before and after treatment effective cooling, lower fluences, and multiple passes,
are strongly advocated. PIH is uncommon in Asians.
Neck Rejuvenation Body Contouring
The primary goal of laser neck rejuvenation in Asians is Cellulite, central adiposity, abdominal laxity, and striae
to address skin laxity and improve textural changes. after childbirth are frequent complaints in Asian patients.
Radiofrequency devices and fractional resurfacing can Nonsurgical techniques are preferred and several radio
both be used safely on the neck in Asians with minimal frequency and infrared devices show promise for treat-
downtime. Fraxel (Fraxel re:store, Solta Medical Inc., ment in Asian patients since their effect is independent
Hayward, CA) utilizes a 1,540 nm laser to create zones of skin type. Velasmooth (Syneron Medical Ltd), is
of microscopic thermal injury that are surrounded by FDA approved for the treatment of cellulite and com-
normal tissue, which allows rapid re-epithelialization of bines bipolar radiofrequency, infrared, and mechanical
the epidermis.5 In Asian patients, cooling is critical to massage to improve cellulite. Sadick et al. showed an
reduce bulk tissue heating and diminish the risk of PIH. average decrease in 0.53 cm of the upper thigh and
Recently, it has been observed that decreasing density 0.44 cm of the lower thigh after 6 weeks of bi-weekly
32 Special Considerations in Asian Patients 235
treatments.8 Thermage with a deep contouring (DC™) a mean circumference reduction of 2 cm of treated
tip can also be used for cellulite treatment (Fig. 32.2). areas was noted in the second week and sustained for
Ultrashape (UltraShape Ltd, Tel Aviv, Israel) is a new 12 weeks. However, for Asians with a smaller body
focused ultrasound device that causes selective lipoly- size, the results were much less impressive. A smaller
sis (Fig. 32.3). In a multicenter study of 137 patients9, transducer is necessary to improve outcomes.10 For the
Fig. 32.2 (a) Cellulite of the buttock and thigh. (b) Cellulite reduction after Thermage deep tip
Fig. 32.3 (a) Abdominal pannus. (b) Ultrashape abdomen

236 S. Shieh and H.H.L. Chan
treatment of abdominal striae, Thermage combined followed by 595 nm PDL at subpurpuric doses (0.45 ms,
with the 585 nm pulsed dye laser (PDL) was reported 10 mm spot size, and 4–5 J/cm2). Fraxel is also an
to be successful in 37 Asian patients. After 1 session of effective treatment for hypertrophic scars on the body
Thermage and two PDL treatments 1 month apart, (Fig. 32.4). High energies and densities are necessary
89% of patients showed clinical improvement with to improve hypertrophic scars (70 mJ, treatment level
histologic increase in elastin and collagen.11 Thermage 8–11, 8–10 passes).
and other infrared devices, such as the Titan (Cutera,
Brisbane, CA), and infrared handpiece (Starlux,
Palomar, Burlington, MA), can also be used to tighten Hair Removal
the abdomen. Further studies are needed to determine
the optimal treatment parameters and long-term Several lasers can be used safely for hair removal in
efficacy of these relatively new devices. Asians, including the long pulsed Alexandrite, Diode,
and Nd:YAG.15,16 A retrospective analysis of 805
patient comparing these systems revealed a slightly
Hypertrophic and Keloid Scars greater efficacy with the long-pulsed Alexandrite and
long-pulsed diode laser compared to the long pulsed
Hypertrophic and keloid scars resulting from acne or Nd:YAG.17 Due to the increased epidermal melanin
traumatic injury are commonly seen in the Asian popu- content in Asians which competes with the pigment in
lation and may cause functional impairment, pruritus, the hair follicle, lasers with longer wavelengths, longer
and pain. The 585 nm PDL has been used at doses of pulse widths, and adequate cooling are necessary to
3.5–5.5 J/cm2 with a 10 mm spot size to improve the avoid adverse effects. Intense Pulsed Light with a filter
appearance and symptoms of hypertrophic scars by of 645–950 nm is also effective and safe in Asians.18
selective destruction of blood vessels and decrease in
collagenesis.12,13 Manuskiatti showed that there was no
significant difference between fluences of 3, 5, and,
7 J/cm2 with a 5 mm spot size, but noted a trend towards Conclusion
improvement with lower fluences.14 Lower subpur-
puric doses avoid thermal injury and further scar Noninvasive rejuvenation procedures amongst Asians
induction. In Asians, a lower fluence should be used are increasingly common. Knowledge of inherent
since melanin acts as a competing chromophore to differences in Asian skin types, variable treatment
hemoglobin and epidermal injury may occur. Our parameters, and an appreciation for cultural aesthetic
current approach is to perform a series of monthly goals allows safe and effective treatment of this growing
intralesional injections of triamcinolone +/- 5-FU population.
Fig. 32.4 (a) Burn scar. (b) After five full fraxel treatments
32 Special Considerations in Asian Patients 237
References 10. Shek SY, Yu CS, Yeung CK, et al. Non-invasive body con-
touring with focused ultrasound technology. Lasers Surg
Med. 2007;S20:60.
1. Yu S, Grekin R. Aesthetic analysis of Asian skin. Facial 11. Suh DH, Chang KY, Son HC, et al. Radiofrequency and 585-
Plast Surg Clin North Am. 2007;15(3):361-365. nm pulsed dye laser treatment of striae distensae: a report of
2. Chung JH. Photoaging in Asians. Photodermatol Photoimmunol 37 Asian patients. Dermatol Surg. 2007;33(1):29-34.
Photomed. 2003;19:109-121. 12. Alster TS. Improvement of erythematous and hypertrophic
3. Han KH, Joo YH, Moon SE, et al. Botulinum toxin A treatment scars by the 585nm flashlamp-pumped pulsed dye laser. Ann
for contouring of the lower leg. J Dermatol Treat. 2006; Plast Surg. 1994;32:186-189.
17(4):250-254. 13. Nouri K, Jimenez GP, Harrison-Balestra C. 585nm pulsed
4. Lee JH, Huh CH, Yoon HJ, et al. Photoepilation results of dye laser in the treatment of surgical scars on the suture
axillary hair in dark-skinned patients by IPL: a comparison removal day. Dermatol Surg. 2003;29:65-73.
between different wavelength and pulse width. Derm Surg 14. Manuskiatti W, Fitzpatrick RE, Goldman MP. Energy
2006;32(2):234-240. density and number of treatments affect respone of keloidal
5. Manstein D, Herron GS, Sink RK. Fractional photothermoly- and hypertrophic sternotomy scars to the 585nm flashlamp-
sis: a new concept for cutaneous remodeling using microscopic pumped pulsed-dye laser. J Am Acad Dermatol. 2001;45:
patterns of thermal injury. Lasers Surg Med. 2004;34:426-438. 557-565.
6. Chan HH, Manstein D, Yu CS, et al. The prevalence and 15. Chan HH, Ying Y, Ho WS, et al. An in vivo study comparing
risk factors of post-inflammatory hyperpigmentation after the efficacy and complications of diode laser and long-
fractional resurfacing in Asians. Lasers Surg Med. 2007;39(5): pulsed Nd:YAG laser in hair removal in Chinese patients.
381-385. Dermatol Surg. 2001;27(11):950-954.
7. Kono T, Chan HH, Groff WF, et al. Prospective direct 16. Hussain M, Polnikorn N, Goldberg DJ. Laser assisted hair
comparison study of fractional resurfacing using different removal in Asian skin: efficacy, complication, and the effect of
fluences and densities for skin rejuvenation in Asians. Lasers single versus multiple treatments. Dermatol Surg. 2003;29(3):
Surg Med. 2007;39(4):311-314. 249-254.
8. Sadick N, Magro C. A study evaluating the safety and effi- 17. Bouzari N, Tabatabai H, Abbasi Z, et al. Laser hair removal:
cacy of the VelaSmooth system in the treatment of cellulite. comparison of long-pulsed Nd:YAG, long-pulsed alexan-
J Cosmet Laser Ther. 2007;9(1):15-20. drite, and long-pulsed diode lasers. Dermatol Surg. 2004;30(4
9. Teitelbaum SA, Burns JL, Kubota J, et al. Noninvasive body Pt 1):498-502.
contouring by focused ultrasound: safety and efficacy of the 18. Lee HJ, Lee DW, Park YH, et al. Botulinum toxin A for
Contour I device in a multicenter, controlled, clinical study. aesthetic contouring of enlarged edial gastrocnemius muscle.
Plast Reconstr Surg. 2007;120(3):779-89. [discussion 790]. Dermatol Surg. 2004;30(6):867-871.
Chapter 33
Treatment and Prevention of Dyspigmentation in Patients
with Ethnic Skin
Smita S. Joshi and Roopal V. Kundu
Introduction about the patient’s ethnicity as patients with lighter

phenotypes may exhibit skin characteristics of type
IV–VI individuals.1 Important screening questions
Ethnic skin, also referred to as skin of color, is primarily
for darkly pigmented patients are summarized in
composed of Fitzpatrick skin types IV–VI and encom-
Table 33.1.
passes many racial and ethnic groups, including African–
An important goal in the treatment of patients with
Americans, Asians, and Hispanics. Body rejuvenation
darker skin is the prevention of PIH. Prior to initiating
can be successfully completed for these patients, but it
any body rejuvenation procedure on sun-exposed
requires knowledge of adverse reactions in darker
sites, counseling on sun avoidance is mandatory. It is
skin. The increased melanin in richly pigmented skin
essential to educate persons of skin of color about the
can lead to greater susceptibility to postinflammatory
association of sun and dyschromia. Most people of
hyperpigmentation (PIH), particularly from an underly-
color do not feel it is necessary for them to wear sun
ing inflammatory cutaneous disorder or secondary to an
protection because of their innate pigment and lower
irritation from therapeutic interventions (Fig. 33.1).
risk of skin cancer; however, daily sun protection with
Prevention of inciting inflammation, sun avoidance, and
a minimum of SPF 15 should be strongly encouraged
topical depigmenting agents are the mainstay of therapy
to help limit and prevent uneven skin color and PIH.
for dyspigmentation in ethnic skin.
Patients should avoid sun exposure for 4 weeks prior
to body rejuvenation. A body rejuvenation procedure
should be delayed on an actively sunburned or tanned
area of skin.
Clinical Examination and Patient History Outside of sun avoidance techniques, pretreatment
with depigmenting agents has been used adjunctively
The physician must elicit a careful history prior to to prevent PIH. Hydroquinone is the mainstay of ther-
performing any body rejuvenation procedure in a patient apy. Hydroquinone 4% twice daily can be added 2
with ethnic skin. Inquiry into a history of PIH or hypop- weeks prior to and 2 weeks post any intervention that
igmentation, dermatologic reactions to previous has potential to lead to PIH. Other adjunctive thera-
procedures or skin trauma, delayed wound healing, and pies include azelaic acid cream used twice daily in
hypertrophic scar or keloid formation should be either the 15% gel or 20% cream formulation.
initiated (Fig. 33.2).1 Sunscreen use, tanning, and recent It is advisable to stop use of topical retinoids or
sun exposure should also be reviewed. A medication cosmeceuticals containing any retinoid derivatives at
history should be obtained with particular attention to least 1 week prior to a procedure. These can be resumed
photosensitizing agents such as tetracyclines, retinoids, after their postprocedure visit, typically 1–2 weeks
nonsteroidal anti-inflammatory drugs, and oral contra- after intervention. Photosensitizing medications may
ceptives.1 The patient’s Fitzpatrick skin type must be be discontinued for the preprocedural period after
determined, however, the practitioner must also ask consulting with the patient’s primary physician.1

240 S.S. Joshi and R.V. Kundu
Table 33.1 Important screening questions for darkly pigmented

patients
How often do you…
Apply sunscreen? What strength of sunscreen do you use?
Tan?
Do you have…
A recent tan? How much sun exposure have you had over
the last month?
Any upcoming trips or outings planned that will involve
significant sun exposure?
A history of abnormal darkening or lightening of the skin,
abnormal scarring, or skin reactions?
A history of wound healing problems?
A history of hypertrophic scars or keloid scars?
Do you wear long-sleeved shirts, pants, wide-brim hats, or any
other garments to protect your skin from the sun?
What is your ethnic/racial background?
Does anyone in your family have a history of abnormal
scarring or skin reactions?
Fig. 33.1 Postinflammatory hyperpigmentation (PIH). PIH What medications do you take? (Specifically note any
secondary to pseudofolliculitis barbae and years of daily plucking photosensitizing agents)
to treat ingrown hairs
of Dyspigmentation in Ethnic Skin
Topical hydroquinone is the gold standard for treating

PIH. Other treatment modalities include cosmetic cover-
up, topical retinoids, azelaic acid, and chemical peels.1,2
There are also several cosmetic skin brightening agents
(non-FDA approved) commercially available in the
United States including arbutin, kojic acid, and licorice
extract.2 Table 33.2 summarizes the most commonly
used topical treatments for PIH in dark skin. Prior to
using any topical agent, a small test spot should be
applied to an inconspicuous part of the body (i.e., upper
Fig. 33.2 Keloid Scar. Keloid formation subsequent to ingrown
hairs and attempts at physical epilation along lower abdomen inner portion of arm) and any irritation or allergic
and suprapubic region response should be noted.
Postinflammatory hypopigmentation is less common
but more difficult to treat, typically requiring passage
of time to allow for any potential melanocytes to resume
Discontinuation of isotretinoin for at least 6 months producing melanin. Repigmentation, if to occur, can
prior to a procedure is also recommended. be expected 1–3 months postprocedure. Along with
For patients with active dyschromia, guidance sun protective measures, avoidance of topical bleaching
on cosmetic camouflage options to use prior to and agents or any treatment regimens which may further
posttreatment, such as CoverFX© and Dermablend®, irritate the skin is essential.
which have a large palate of colors to help closely Pigmentary, or melanin, incontinence is a unique form
match skin tone, may also be offered. of PIH that is not amenable to topical depigmenting agents.
33 Treatment and Prevention of Dyspigmentation in Patients with Ethnic Skin 241
Table 33.2 Topical treatments for post-inflammatory hyperpig area of PIH. Hydroquinone should be applied twice
mentation in dark skin daily (morning and night) and may be used for months,
Treatment Dose resulting in gradual depigmentation. Patients should
Hydroquinone <2% formula over the counter, 3–4% be advised to use broad spectrum sunscreens during
prescription formulations, 5–10%
compounded formulations and after treatment. Hydroquinone will bleach both
Azelaic acid 15% gel, 20% cream lentigines and freckles, but will spare café-au-lait spots
a-Hydroxy acid Start at 20–30% solution, gradually and pigmented nevi.
(glycolic acid) increase
b-Hydroxy acid 20% solution, 30% solution
(salicylic acid)
Alternative Treatment Methods
Kojic acid 1–4% formula
Arbutin 3% formula
Licorice extract Various concentrations Antioxidants, such as vitamin C, retinoids, and alpha-
Topical retinoids Multiple formulations ranging from hydroxy acids, may be used as additives to increase
0.02 to 0.1% creams and gels penetration and enhance efficacy in the treatment
of PIH. 2 Hydroquinone has also been combined
with both topical retinoids and glucocorticoids to
Histologically, it is seen as an accumulation of melanin enhance efficacy.
and melanophages in the upper dermis and treatment
modalities such as Q-switched laser therapy have been
used with limited success.3 Management of Adverse Effects
Adverse reactions include nail discoloration and

irritant or allergic contact dermatitis; however, the
Hydroquinone latter may be avoided by performing a test spot of the
agent prior to regular use. Paradoxically, PIH may
Hydroquinone is a hydroxyphenolic compound that occur from the contact dermatitis. Reversible hypopig-
inhibits the tyrosinase enzyme, reducing melanin mentation in the form of a halo around the treated area
production. of hyperpigmentation is often seen in skin of color
patients.2 Individuals must be carefully counseled to
use hydroquinone products only twice daily and to
Dose Selection limit treatment only to affected areas to prevent this
adverse effect. Fortunately, these side effects usually
Hydroquinone is available in over the counter con- resolve spontaneously with the discontinuation of
centrations (<2%) and prescription formulations (3 and hydroquinone.
4%). There are no evidence based recommendations The most serious side effect of hydroquinone is
for treating the body as opposed to the face; however development of ochronosis with prolonged use of
4% hydroquinone is often suitable for mild to moderate high concentrations over large body surface areas. It
PIH. Higher concentrations (5–10%) may be necessary is more common in South African women and is
to treat severe PIH but may be unstable and irritating.2 infrequently reported in the United States.2 However,
products with high concentrations of hydroquinone
can be obtained illegally and may result in an increase
Treatment Technique in the incidence of hydroquinone-induced ochronosis
in the United States. Ochronosis is often considered
Hydroquinone 4% may be used prophylactically 2 permanent. Treatment is difficult, but may respond to
weeks prior to and 2 weeks post any body rejuvena- use of topical retinoids and topical corticosteroids
tion procedure that has the potential to lead to PIH. and/or combined with a series of superficial salicylic
Hydroquinone 4% may also be used to treat any existing acid chemical peels.4
242 S.S. Joshi and R.V. Kundu
Azelaic Acid Management of Adverse Effects
Local irritation is common, but can be minimized if

Azelaic acid is a naturally occurring nonphenolic
the keratolytic agent is introduced at lower concentra-
dicarboxylic acid isolated from cultures of Pityros-
tions. Paradoxically, PIH may occur if keratolytic
porum Ovale.
agents are started at too high concentrations. Sunscreen
must be used judiciously before and after treatment to
minimize the risk of PIH. Salicylic acid chemical peels
Dose Selection and Treatment Techniques
have been found to be safe in darker-skinned patients
and most effective when combined with 4% hydro-
Azelaic acid is available as a 15% gel (Finacea™) and a
quinone.5 Salicylism has been reported with widespread
20% cream (Azelex®) formulation. It should be applied
and prolonged use of salicylic acid, however it is
twice daily (morning and night) to hyperpigmented
extremely rare.
macules. Azelaic acid has no depigmenting effect on
normally pigmented skin, freckles, lentigines, or nevi
due to its selective effects on abnormal melanocytes.2
Topical Glucocorticoids
Management of Adverse Effects If there is a brisk inflammatory reaction after a procedure,

a low-potency topical glucocorticosteroid (i.e., classes
Azelaic acid is generally very well tolerated but may V–VII) can be added to the postprocedure regimen
cause local irritation such as tingling and stinging to not only reduce erythema and dermatitis, but also
sensations. possibly elicit the well-recognized side effect of hypop-
igmentation from topical corticosteroid use. High and
super-potent topical steroids are not advisable because
Keratolytic Agents (a-Hydroxy Acids of their known depigmenting effects, however repig-
mentation of affected skin usually occurs if the topical
and b-Hydroxy Acid)
steroid is removed promptly.
Hydroxy acids agents reduce the thickness of hyper

keratotic stratum corneum by reducing corneocyte
adhesion. Examples of Class V–VII Glucocorticoids
0.05% Desonide
Dose Selection and Treatment Technique 0.025% Triamcinolone acetonide
0.1% Hydrocortisone butyrate
a-Hydroxy acids (lactic acid, glycolic acid, citric 0.01–0.025% Fluocinolone acetonide
acid, glucuronic acid, and pyruvic acid) are found in 0.2% Hydrocortisone valerate
a variety of natural products including cane sugar,
fruits, and yogurt as well as in cleansers, moisturizers,
and chemical peeling agents.1 Therapy should begin at
low concentrations (20–30%) with a gradual increase Laser Therapy
in the concentration and frequency of use to limit
side effects. Salicylic acid, the most commonly Lasers may be used cautiously in darkly complexioned
used b-hydroxy acid, is available commercially as a individuals when utilized for hair removal, tattoo pig-
superficial peeling agent in solution form at concen- ment removal, skin resurfacing, and vascular lesions. The
trations of 20 and 30% (B-Liftx®). Salicylic acid increased epidermal melanin in richly pigmented skin
acts synergistically with 4% hydroquinone to reduce may interfere with the absorption of laser energy aimed
hyperpigmentation.5 at another target. Postinflammatory hyperpigmentation
33 Treatment and Prevention of Dyspigmentation in Patients with Ethnic Skin 243
is a frequently reported side effect of laser therapy and hydroquinone is the gold standard for treating PIH,
sunscreen should be initiated several weeks prior to with rapidly advancing innovation in laser technology
and continued after therapy to reduce this risk. and increased research in ethnic skin, it is likely that
Q-swtiched ruby laser has been used to treat PIH, laser therapy may be a preferred treatment modality of
but with little success.3 No other studies to the authors’ the future.
knowledge have specifically investigated laser treatment
of PIH in darker individuals. However, laser therapy
has been demonstrated to successfully treat other
dyschromias. In Asians, the Q-switched alexandrite References
laser has been found to be effective for freckles and
intense pulsed light for lentigines.3 1. Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol
Ther. 2004;17(2):196-205.
2. Halder RM, Richards GM. Management of dyschromias in
ethnic skin. Dermatol Ther. 2004;17(2):151-157.
Conclusion 3. Bhatt N, Alster TS. Laser surgery in dark skin. Dermatol
Surg. 2008;34(2):184-194. discussion 94–95.
4. Levin CY, Maibach H. Exogenous ochronosis. An update on
With the consideration of prevention of potential PIH clinical features, causative agents and treatment options. Am J
and working knowledge of available treatment modalities Clin Dermatol. 2001;2(4):213-217.
5. Grimes PE. The safety and efficacy of salicylic acid chemical
of dyspigmentation, body rejuvenation can be safely peels in darker racial-ethnic groups. Dermatol Surg. 1999;25(1):
performed in persons of richly pigmented skin. While 18-22.
Index
A B
Abdominal skin reduction Body Cosmeceutical treatment application
clinical examination, 207–208 antiaging therapies, 231–232
method of device, liposuction and surgical excision, cleansers, 229
208–209 exfoliants, 229
possible complications, 211–212 moisturizers, 229–230
post-operative care, 209–211 skin lightening agents, 230–231
Ablative laser resurfacing sunscreens, 230
device and treatment application methods Botulinum toxin, 3–7
fractional resurfacing, 216–218 Botulinum Toxin A (Botox®), 233
lesions treatment, 218–219 clinical examination, 77
Portrait® Plasma Skin Rejuvenation, 216 patient selection, 77
patient selection, 215 treatment application, 77–78
Acne scarring treatment technique
ablative lasers, 58 clinical trial, 79–81
hypertrophic and keloidal, 56–57 mechanism, 79
pulsed dye laser, 57–58 special considerations, 80–81
semi-ablative lasers, 58 Breast reduction
Ambulatory phlebectomy (AP) adverse events management, 75–76
clinical examination, 135–136 clinical examination and patient history, 73
contraindications, 135 device and treatment application method, 73–75
indications, 135 results and post-operative care, 75
treatment application tumescent liposuction, 73
complications, 141
postoperative instructions, 141
procedural protocol, 136–141 C
sclerotherapy, 141 Calcium hydroxylapatite (CaHA) administration
Antiaging therapies, 231–232 hand
AP. See Ambulatory phlebectomy (AP) adverse events, 222–223
Arm fat reduction lidocaine, 222
liposuction posttreatment, 222
clinical examination and patient history, 111 non-facial areas, 223–224
complications, 115 Cellulite reduction, subcision
indications, 111 adverse events management, 170–171
postoperative instructions, 113–115 classification, 168
procedural protocol, 111–113 clinical examination and patient selection,
surgical excision 167–168
clinical examination and patient history, 117–118 method of device and treatment application
outcomes and complications, 120 postoperative recommendations, 169
treatment application, 118–120 preoperative recommendations, 168
Asian patients technique, 168–169
cutaneous racial, 233 Chemical peeling, keratoses and lentigines
treatment applications clinical examination, 85
Botulinum Toxin A (Botox®), 233 conventional approaches, 85
laser and radiofrequency skin rejuvenation, device methods and treatment applications
233–236 postoperative care, 87
245
246 Index
Chemical peeling, keratoses and lentigines (Continued) contraindications, 147–148

side effects, 87 postoperative instructions, 151
superficial peeling, 87 principle, 145
patient history, 85 treatment application
pigment alterations, 87 procedural protocol, 148
postoperative care, 87 technique, 148–151
side effects, 87
Chemical peels, poikiloderma
Cook body peel F
glycolic acid, 42 Face skin tightening methods
Jessner’s solution, 42 clinical examination, 193
salicylic acid, 43–44 contraindications, RF and IBBL, 194
superficial peeling agents and concentrations, 41–42 device comparison, 196
tretinoin, 43 method of device
trichloroacetic acid (TCA), 42 adverse events management, 198–199
Cook body peel, 39, 44 dose/setting selection, 193–194
Cosmeceuticals infrared broadband light (IBBL) technique, 197
clinical examination post-operative care, 197
antiaging therapies, 231–232 radiofrequency (RF) technique, 195–197
cleansers, 229 treatments number and frequency, 197–198
exfoliants, 229 Facial acne scars, 55
moisturizers, 229–230 Fat grafting, 105
skin lightening agents, 230–231 Female genital surgery
sunscreens, 230 labia minora reduction
facial application, 227 clinical examination, 201–202
definition, 201
treatment application, 202–203
D vulvar reshaping and vaginal rejuvenation
Device and treatment application methods clinical examination, 204
fractional resurfacing definition, 204
Fraxel restore and repair, 216–217 treatment application, 204–205
Portrait® procedure, 217 Foam sclerotherapy
lesions treatment, 218–219 consensus statements, 99
Portrait® Plasma Skin Rejuvenation, 216 solution preparation, 99
Dynamic cooling device (DCD), 39 Fractional photothermolysis, 69
Dyspigmentation treatment and prevention Fraxel restore and repair, 216–217
clinical examination and patient history, 239–240
treatment application
azelaic acid, 242 G
hydroquinone, 241 Geometric Broken Line Closure (GBLC), 70
keratolytic agents, 242
laser therapy, 242–243
post-inflammatory hyperpigmentation (PIH), 240 H
topical glucocorticoids, 242 Hair follicle composition, 62
Hand atrophy, fat transplantation
clinical examination, 105
E treatment application
Endovenous laser treatment, leg veins anesthesia considerations, 105–106
alternative treatment methods, 151 fat harvesting, 106–107
clinical examination and patient history, 148–152 fat injections, 107–108
complications, 151–152 fat processing, 107
contraindications, 147–148 postoperative management, 108
postoperative instructions, 151 Hydroquinone, 241
principle and recanalization, 145
treatment application
procedural protocol, 148 I
technique, 148–151 Infrared broadband light (IBBL) technique
Endovenous radiofrequency treatment, leg veins adverse events management, 198–199
alternative treatment methods, 151 clinical examination, 193
clinical examination and patient history, 148–152 contraindications, 194
complications, 151–152 dose/setting selection, 193–194
Index 247
post-operative care, 197 pre-operative antibiotics, 190

vs. RF device, 196 super absorbent pads application, 190
Injection lipolysis treatment method
adverse effects anesthesia, 178–179
local effects, 27–28 arms, 180
persistent nodularity and paresthesias, 28 buttock, 183
skin necrosis and hyperpigmentation, 28 cannulas, 175
systemic effects, 28 end-point for infusion, 178
clinical examination, 23–24 epinephrine dose, 176
treatment application method, 25–27 equipments, 175
Intense pulsed light (IPL) systems, 39 infusion devices, 175
legs, 183–188
lidocaine concentration, 176
J love handles and abdomen, men, 188–190
Jessner’s solution, 42–43 non-dominant smart hand, 179
preoperative mark, 174, 179
pre-operative photographs, 174
K sedatives and analgesics, 178
Keratolytic agents, 242 triangulation, 179
Keratoses and lentigines trunk, 180–183
off-face laser treatment
device method and treatment application, 89–98 N
patient history, 89 Neck laxity treatment
peels and PDT clinical examination, 9
clinical examination, 85 infrared wavelengths
conventional approaches, 85 infrared light, 13–14
device methods and treatment applications, 86 1,310 nm laser, 14
patient history, 85 quantitative grading and classification system, 10
radiofrequency
adverse events management, 12–13
L dose/settings, 9–12
Labia minora reduction post-operative care, 12
clinical examination, 201–202 treatment protocols, 11
definition, 201 ultrasound technique
treatment application, 202–203 adverse events management, 20
Lanugo hair, 61 alternative treatment methods, 20
Laser and radiofrequency skin rejuvenation dose/setting selection, 19
body contouring, 234–236 high intensity focused ultrasound (HIFU), 18
hair removal, 236 patient history and clinical examination,
hypertrophic and keloid scars, 236 17–19
laser considerations, 233–234 post-operative care, 20
neck rejuvenation, 234 treatment technique, 19
Laser-mediated photodynamic therapy with pulsed dye laser 1550 nm erbium-doped fractional photothermolysis
(PDL), 96–98 (Fraxel™), 92–96
Laser therapy, 242–243 Noninvasive body rejuvenation
Lesions treatment, 218–219 device methods/treatment application
Liposuction Accent RF, 163
arm fat reduction adverse event management, 163
clinical examination and patient history, 111 dosages and settings, 161
complications, 115 postoperative care, 163
indications, 111 ReFirme, 163
postoperative instructions, 113–115 Smoothshapes, 161
procedural protocol, 111–113 Thermage, 161–162
clinical examination and patient history Titan, 162–163
skin examination, 173–174 Ultrashape, 163
snap test, 173 Velashape, 161
postoperative clinical considerations patient history and clinical examination
compression garments, 190, 191 abdomen, 155–156
lidocaine toxicity signs, 190 arms, 156–161
pain control, 190 thighs and buttocks, 156
248 Index
O Q
Off-face laser treatment, keratoses and lentigines Q-switched (QS) (532nm) Nd:YAG and 694 nm QS ruby
clinical examination, 89 lasers, 89–92
device method and treatment application
fractional photothermolysis, 92
pulsed-dye laser-mediated PDT, 97–98 R
QS ruby and 532 nm QS Nd:YAG lasers, 89 Radiesse, 221
patient history Radiofrequency (RF) technique, face skin tightening
adverse events management, 198–199
P contraindications, 194
PDL. See Pulsed dye lasers (PDL) dose/setting selection, 193–194
Photodynamic therapy (PDT), keratoses and lentigines post-operative care, 197
clinical examination, 85 vs. IBBL device, 196
conventional approaches, 85 Relaxed skin tension lines (RSTL), 67, 69, 70
device methods and treatment applications, 86 Revision technique alogrithm, 67
patient history, 85
photodamage and actinic keratoses (AK), 86–87
Platysmal bands treatment S
clinical examination, 3 Sclerotherapy, hand veins
treatment indications clinical examination, 100
alternative treatment methods, 6–7 device methods and treatment application,
Botulinum toxins, 7 100–103
setting selection, 3–4 vs. endovenous laser hand vein ablation
treatment technique, 4–6 (EVLH), 100
Poikiloderma of civatte (POC) Sclerotherapy, leg veins
bleaching treatments, 51 clinical examination, 127–128
clinical examination and patient history definition, 127
patient evaluation, 40–41 treatment application
preoperative evaluation, 40 adverse events management, 133
dynamic cooling device (DCD), 39 compression, 132
fractional photothermolysis, 39 foam sclerotherapy, 131–132
intense pulsed light (IPL) systems, 39, 49–51 large and small vessels, 128–131
laser treatment post-operative care, 132
argon laser, 48 sclerosants, 128
potassium-titanyl-phosphate (KTP), 48 Skin lightening agents, 230–231
pulsed dye laser (PDL), 48–49 Skin tightening, arms and legs
postoperative care, 44 clinical examination, 123
treatment application intense pulsed light (IPL), 121–122
chemical peels, 41–44 radiofrequency (RF)
preoperative patient preparation, 41 electrode configurations, 121
Poikiloderma treatment properties, 121
clinical examination and patient history, 31–32 treatment application
definition, 31 adverse events, 124
method of device, fractional resurfacing anesthetics, 123
alternative treatment methods, 34 grid marking pattern, 123
dose/setting selection, 32–34 non-facial skin, 123
management, adverse events, 35 patient feedback, 123
post-operative care, 34–35 post-procedural care, 124
treatment techniques, 33–34 Subcision technique
Portrait® Plasma Skin Rejuvenation, 216 adverse events management, 170–171
Post-inflammatory hyperpigmentation (PIH), 240 classification, cellulite, 168
Prepackaged injectable soft-tissue rejuvenation clinical examination and patient selection, 167–168
clinical examination, 221 method of device and treatment application
Radiesse, 221 postoperative recommendations, 169
treatment application, CaHA administration preoperative recommendations, 168
hand, 222–223 technique, 168–169
non-facial areas, 223–224 Surgical scars
Pulsed dye lasers (PDL) clinical examination and patient history, 65–67
acne scarring, 57–58 treatment methods
surgical scars, 69 cryosurgery, 68
Index 249
intralesional injections, 68 Truncal hair removal

laser treatments, 68–69 clinical examination, 61
surgical treatments, 69–70 treatment application
topical treatments, 67–68 hirsutism, 61
hypertrichosis, 61–63
Tumescent liposuction, 73
T
Telogen hair, 61
Terminal hair follicle, 61–62 V
Topical glucocorticoids, 242 Vaginal rejuvenation. See Vulvar reshaping
Trichloroacetic acid (TCA), 42 Vellus hair, 61
Truncal acne scarring Vulvar reshaping
patient history and clinical examination, 55 clinical examination, 204
therapeutic considerations and applications definition, 204
ablative lasers, 58 treatment application
fillers, 59 mons veneris and labia majora, 204–205
intralesional corticosteroids, 59 vulvo-vaginal mucosae, 205
non-ablative lasers, 58
pulsed dye laser, 57–58
semi-ablative lasers, 58 W
surgical excision, 55–57 W-plasty, 70

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What are some of the techniques discussed for treating neck laxity?

What are some of the techniques discussed for treating neck laxity?

What are some laser treatment options discussed for treating poikiloderma?

What are some laser treatment options discussed for treating poikiloderma?

Murad Alam

ISBN 978-1-4419-1092-9 e-ISBN 978-1-4419-1093-6

Library of Congress Control Number: 2009942274

© Springer Science+Business Media, LLC 2010

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Part I Neck and Upper Chest

1 Treatment of Platysmal Bands with Botulinum Toxin........................... 3

2 Treatment of Neck Laxity with Radiofrequency

3 Treatment of Neck Laxity with Therapeutic Ultrasound....................... 17

4 Treatment of Neck Fat with Injectable Adipolytic Therapy.................. 23

5 Treatment of Poikiloderma with Fractional Resurfacing...................... 31

6 Treatment of Poikiloderma with Chemical Peeling................................ 39

7 Treatment of Poikiloderma by Pigment and Vascular Lasers............... 47

Part II Back and Chest

8 Treatment of Truncal Acne Scarring........................................................ 55

9 Truncal Hair Removal............................................................................... 61

10 Revision of Disfiguring Surgical Scars of the Back................................. 65

Part III Breast

11 Breast Reduction Through Liposuction................................................... 73

12 Botulinum Toxin A for Upper Thoracic Posture

Part IV Hands (and Feet)

13 Treatment of Keratoses and Lentigines with Peels and PDT................. 85

14 Off-Face Laser Treatment of Keratoses and Lentigines......................... 89

15 Treatment of Hand Veins with Sclerotherapy......................................... 99

16 Treatment of Hand Atrophy with Fat Transplantation.......................... 105

Part V Arms (and Legs)

17 Reduction of Arm Fat by Liposuction...................................................... 111

18 Reduction of Excess Arm Skin via Surgical Excision............................. 117

19 Skin Tightening of the Arms and Legs with Radiofrequency

20 Sclerotherapy of Leg Veins........................................................................ 127

21 Ambulatory Phlebectomy.......................................................................... 135

22 Endovenous Laser and Radiofrequency Treatment

Part VI Abdomen, Thighs, Hips, and Buttocks

23 Noninvasive Body Rejuvenation............................................................... 155

24 Reduction of Cellulite with Subcision®.................................................... 167

25 Body Contouring with Tumescent Liposuction....................................... 173

26 Skin Tightening Off the Face with Radiofrequency

27 Female Genital Surgery............................................................................. 201

28 Reduction of Excess Abdominal Skin via Liposuction

Part VII Advanced and General Topics

29 Ablative Laser Resurfacing Off the Face................................................. 215

30 Prepackaged Injectable Soft-Tissue Rejuvenation

31 Cosmeceuticals Off the Face..................................................................... 227

32 Special Considerations in Asian Patients................................................. 233

33 Treatment and Prevention of Dyspigmentation in Patients

Henry H.L. Chan, MD, FRCP

Introduction tend to neutralize the downward pull from this muscle

M. Alam and M. Pongprutthipan (eds.), Body Rejuvenation, 3

Fig. 1.1 Well defined platysma

Fig. 1.2 Injection pattern

Fig. 1.3 Injection pattern for

Introduction contraindicated. In addition, patients with rheumatologic

M. Alam and M. Pongprutthipan (eds.), Body Rejuvenation, 9

Fig. 2.1 Treatment zones of the neck for radiofrequency protocols

quantity of 18 cc of ¼ % lidocaine is used to infil- 4. Management of Adverse Events: Superficial place-

Bleaching treatments using hydroquinone, electro References