An alternative approach to perioral rhytides

Facelift Without Surgery

Facelift without surgery is a true do it yourself anti-aging skin care non-surgical facelift! Look 10 to 15 years younger within 30 days without surgery using acupressure! Facelift Without Surgery is an anti-aging skin care program written for men and women who wish to immediately Look Younger, using acupressure instead of surgical means. The book demonstrates how to perform your own non-surgical facelift Using Your Fingertips. It works fast! The result is that you can look 10 to 15 years younger Within 30 Days. The benefits of the anti-aging facelift program illustrated in this book are: You Will look younger; have less face lines, firmer skin tone, more facial color. Diminish those unsightly eye bags! You Will feel and appear less stressed. You can maintain your facelift for the rest of your life after regaining your looks! You may have some relief to headaches, migraines, and tension headaches. Your digestion might improve. Certain internal organs may function better e.g. Kidneys, lungs, heart, intestines, liver. You Will have conducted your own anti-aging non-surgical facelift! More here...

Facelift Without Surgery Summary


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Combined Facelifting And Laser Resurfacing

Regardless of the surgical technique used for facelifting, some sort of surface modification is needed to improve fine and deep lines etched in the skin. In our practice, CO2 laser resurfacing has entirely replaced deep chemical peeling. When we first began to use the laser, we followed the old accepted principles of only doing regional resurfacing of the perioral region in association with the lift. Full face resurfacing was staged. Based on the experience of two well-known Texas cosmetic surgeons, Bill Miles of Fort Worth and John Pate of El Paso (personal communication), we have come to modify our approach. Both of these surgeons, the former using chemical peel and the latter working with laser, have shown that resurfacing can safely be combined with surgery. About 4 years ago, we began combining laser resurfacing with selected patients undergoing facelift surgery. Our initial approach was to combine the resurfacing with our traditional biplane approach. Because we were concerned...

Introduction to the Opportunistic Biplane Facelift

The biplane facelift described in this chapter is based on principles that increase aesthetics and longevity with limited morbidity. Facial aging is most pronounced from changes occurring in the deeper musculofascial plane that result in ptosis of the malar fat pad, jowl region, nasolabial folds, and neck. Precise elevation and rotation of this plane is accomplished using this biplane facelift technique. We call the operation opportunistic, because there is no set anatomic limit to the deep-plane dissection. Rather, it is based on the concept of elevating tissue to the point where the flap can be easily advanced with the effect of providing adequate lift in the mid- and lower midface regions. Generally, this point is quite obvious. A rather sharp release is effected when sufficient elevation is accomplished, and the surgeon observes a marked lifting effect around the anterior cheek and the corner of the mouth. We have long abandoned postoperative drains or extensive head wraps and...

General Approach to Facelift Surgery

In the senior author's practice, which spans a career in facelifting of 25 years, the biplane facelift has become the workhorse operation and is used for most patients. Newer innovations, including the use of laser dissection and the skin-sparing tech nique described later in this chapter, basically have not altered the approach that has been in use for more than 15 years. In patients who are seeking additional upper facial rejuvenation, the biplane facelift can easily be combined with either a direct or endoscopic coronal lift. However, for patients who are concerned primarily about upper facial rejuvenation, the extended subperiosteal coronal lift is still the operation of choice. In the senior author's opinion, no other operation provides the elegant upper facial rejuvenation that is characteristic of this operation. This is especially true when there is an indication to correct a downward slope of the lateral canthal region. Although the technique of the extended subperiosteal...

Histologic Effects of Photoaging and Skin Resurfacing

Chemical peeling and laser resurfacing techniques reverse the damage created in the skin as a result of photoaging. The obliteration of many of the clinical and histologic changes varies depending on the depth of the wounding agent. Knowledge of histologic changes and the histologic effects of various peeling agents must be understood in order to obtain optimal results and prevent complications.

Skin Resurfacing Laser or Peel

Since the mid 1990s, laser-assisted skin resurfacing has rapidly replaced chemical peels and physical dermabrasion as the most common means of skin exfoliation. Remarkably this has taken place with alarming rapidity and despite the lack of comparative trials. Evidence-based medicine has taught us the value of comparative trials. Without these we must ask ourselves the fundamental questions, how and why has this happened and is it justified The contemporary use of these agents began in the 1960s, and their use has flourished since that time. Well-documented research has shown the beneficial clinical and histologic changes present after the application of various chemical peeling agents. Skin Resurfacing Laser or Peel When the patient is first seen, it is helpful for the surgeon to determine where the patient's concerns and priorities lie. Is the patient most concerned about problems of structure, i.e., sagging of skin around the brows, nasolabial folds, jaw line, and neck, or is the...

Chemical Peels

Chemical peeling involves the application of chemical agents that act to accelerate the normal process of exfoliation. A variety of chemical agents are used to produce varying effects to the skin. Sloughing of the stratum corneum, produced by superficial chemical peeling, improves skin texture by stimulating the growth of a thicker epidermal layer. These peels are also effective for the treatment of superficial skin lesions. Medium-depth peeling agents produce injury to the papillary and upper reticular dermal layers by their chemical cauterant effect. This helps reverse the effects of photoaging, including the treatment of mild to moderate facial rhytids and pigmentary dyschromias. They are also performed for the removal of actinic keratoses. Deeper escharotic peeling agents act by destroying specific layers of skin, creating necrosis and inflammation in the epidermis, papillary dermis, and reticular dermis. The deeper peeling agents are indicated for the treatment of patients with...

Laser Resurfacing

Although laser physics was first described by Albert Einstein in 1917, laser technology did not appear until the 1960s. Only in recent times have the CO2 and erbium lasers found their way into the cosmetic surgeon's armamentarium as skin resurfacing tools. These high-energy lasers have revolutionized the treatment of photoaged skin. In contrast to other forms of skin resurfacing, laser resurfacing has captured the attention of many people worldwide. When referring to laser resurfacing, the media conjure up the image of someone using a magical wand to transform a severely photoaged face into a youthful-appearing one. This fictional belief has led patients who were once fearful of undergoing chemical peeling to flock to the cosmetic surgeon's office for laser skin resurfacing. These patients have been mistakenly told that recovery from laser resurfacing will be markedly reduced and that complications are less likely. As these beliefs are not true, patients must be better informed as to...

Chemical Peels [9

Chemical peels can be performed both in fair and dark skin types, but in the latter case a ten Patients should undergo a superficial peeling every 2 weeks or a medium peeling every month. With a medium chemical peel, the application of the solution must be reduced in time in order to avoid overpeel. It is very difficult to treat melasma. Better results are obtained if between chemical peeling treatments, patients apply topical depigment-ing agents. The synergic action of the two treatments bleaches the skin and reduces melanin formation.


In general, there are few contraindications to salicylic acid chemical peeling. Salicylic acid peels are well tolerated in all skin types (Fitz-patrick's I-VI) and all racial ethnic groups. General contraindications include salicylate hypersensitivity allergy unrealistic patient expectations active inflammation dermatitis or infection at the salicylic acid peeling site acute viral infection pregnancy and isotretinoin therapy within 3-6 months of the peeling procedure. The author has performed more than 1,000 salicylic acid peels without observing any

Chemical Formulations

Recently there have been a variety of suppliers with chemical peel kits claiming ease of use and increased efficacy. These proprietary kits vary from the vehicle used in delivering the TCA to having color indicators to inform the physician of a peel's completion. Caution should be used when using such kits as many times the physician loses the ability to easily assess the degree of frosting and in turn the depth and safety of the chemical peel.

Classification of Peel Depths

Therefore, the medium-depth chemical peel should only be obtained with the combination of 35 TCA and another agent such as Jessner's solution, solid CO2 or glycolic acid. The use of TCA in strengths greater than 35 ,should be discouraged with the exception of deliberate destruction of isolated lesions or where intentional controlled scarring is desired such as the treatment of ice-pick scars (Fig. 7.1). Fig. 7.ia-c. Medium depth chemical peel for widespread lentigines in type II skin. (a) Pre-operative, (b) 10 days status post medium depth chemical peel, (c) One month status post medium depth chemical peel

Facial Versus Nonfacial Skin

Another critical consideration when performing a peel is realizing the difference of peeling facial versus non-facial skin. As a rule non-facial skin takes much longer to heal and is at much greater risk of scarring than when using a similar concentration on the face. This is due to the higher concentration of pilosebaceous units on the face compared with non-facial sites. These units play a critical role in reepithelialization. As a result if a peel is performed on non-facial skin such as the arms, upper chest and lower neck, one should proceed cautiously and not attempt concentrations greater than 25 TCA. Beyond the poor wound healing and higher risk of scarring, another major limitation of chemical peeling off of the face is lack of efficacy in comparison with facial peels. The remainder of this chapter is limited to peeling facial skin.

Advantages Disadvantages of TCA Peels

TCA peels confer several advantages for both the patient and physician. TCA is an inexpensive solution that can be easily prepared, is stable, and has a long shelf life. TCA, as opposed to peels such as Baker's phenol, does not have any systemic toxicity. In addition, as noted previously, it is a versatile agent that can be used for superficial, medium and deep chemical peeling. The frosting reaction can be a utilized as a reliable indicator for the depth of the chemical peel, making this a safe agent in the hands of the experienced dermatologist. However, TCA in concentrations 40 has an unreliable penetration depth and can result in scarring.

Indications and Patient Selection

The main indications for deep chemical peel include dyschromia, wrinkles, premalignant skin tumors, and acne scars. Originally, the ideal patient for deep chemical peel was a blond, blue-eyed woman of fair 8 complexion. Our experience shows that phenol-based peels can be safely performed on olive- and dark-skinned patients with dark eyes Fig. 8.4 a,b. Ideal candidate for deep chemical peeling middle-aged fair-skinned woman with blue eyes and blond hair and photodamage-induced wrinkling before (a) and after (b) deep chemical peel Fig. 8.4 a,b. Ideal candidate for deep chemical peeling middle-aged fair-skinned woman with blue eyes and blond hair and photodamage-induced wrinkling before (a) and after (b) deep chemical peel Fig. 8.4c, d Dark-skinned women are also possible candidates for deep chemical peels. Note the accentuation of intradermal nevus next to the left ala nasi following the peel (d) Fig. 8.4c, d Dark-skinned women are also possible candidates for deep chemical peels. Note...

History and Classification

As far back as 1905, surgical methods have been used to improve skin that has been scarred by facial acne. One hundred years ago two New York dermatologists, George MacKee and Florentine Karp, began using phenol peels for post-acne scarring 8 . Thereafter, methods used to correct acne scars included dermatome dermaplaning 9,10 , dermabrasion 11,12,13 , collagen implantation 14,15,16 , demal over-grafting 17 , punch excision, grafting and elevation 18,19 , dermal grafting 20, 21 , subci-sion 6, 22 , laser resurfacing 23, 24, 25, 26, 27, 28,29 microdermabrasion 30 ,dermasanding 31 and their combinations 32,33,34 . But the mainstay of therapy for skin resurfacing continues to be chemical peels together with abrasion 35,36,37,38,39 . Chemical peels in use to improve facial scarring include alpha hydroxyl acid peels, trichloroacetic acid and deep phenol based methods 38, 39, 40, 41, 42, 43,44 . In this chapter we discuss deep chemical peels for post-acne scar treatment.

Peeling Technique

The full description of the deep chemical peel procedure is found in Chapter 8. Before the peeling, the subcision (subcutaneous incision) technique is used to free the fibrous bands from the base of the scars. For this purpose we use an 18-gauge 1.5-inch NoKor Admix needle (Becton Dickinson and Co). This needle has a triangular tip similar to No. 11 blade (Fig. 9.5). It allows smooth separation of fibrous cords. The needle is inserted through a skin surface, and its sharp edges are maneuvered under the defect to make subcutaneous cuts or incisions. The depression

Patients Informed Consent

My_(site) treated with CHEMICAL PEELING USING A COMBINATION SALICYLIC ACID 20 AND 30 AND TRICHLORO-ACELIC ACID 10 OR 15 . The peeling procedure can improve dark spots (hyperpigmentation), photodamage (sun damage), textural roughness, acne, tone, and the overall appearance of the treated area. This combination peeling agent will cause shedding of the outermost layers of the skin.There may or may not be visible peeling.The procedure involves first having the peel site prepped with alcohol,ace-tone or other pre-peel cleansing agents. The salicylic acid peeling agent is applied first, followed by application of the trichloroacetic ac-id.The area is rinsed and blotted dry.

Morphologic and Physiologic Skin Differences in Dark Skin

Dark skin demonstrates significantly greater intrinsic photoprotection because of the increased content of epidermal melanin. Clinical photodamage, actinic keratoses, rhytides, and skin malignancies are less common problems in deeply pigmented skin. However, darker skin types are frequently plagued with dyschromias because of the labile responses of cutaneous melanocytes 7 . In a survey of 2000 black patients seeking dermatologic care in a private practice in Washington, DC, the third most commonly cited skin disorders following acne and eczema was pigmentary problems other than vitiligo 8 . Of these patients, the majority had a diagnosis of post-inflammatory hyper-pigmentation, followed in frequency by melas-ma. In a survey of 100 women of color assessing issues of cosmetic concerns for darker skin types, the most commonly cited problems were dark spots or blotchy skin, texturally rough skin, and increased sensitivity to topical products 9 . Patients surveyed also complained of oily...

Peeling Preparation

Despite some general predictable outcomes, there is tremendous variability in the reactivity and responses to chemical peels. Even superficial chemical peeling can cause hyperpigmen-tation and scarring in susceptible individuals. Therefore, the author always performs the initial peel with the lowest concentration of the Hematoxylin eosin stains of biopsies of back skin taken 24 h post-chemical peeling. a Glycolic acid peel 70 . Note stratum corneum necrosis

How to Perform the Best Peeling for the Treatment of Rosacea

Erythrosis before (a) and after (b) chemical peel Fig. 17.14a, b. Erythrosis before (a) and after (b) chemical peel Fig. 17.16a, b. Papulo-pustular rosacea before (a) and after (b) chemical peel Fig. 17.16a, b. Papulo-pustular rosacea before (a) and after (b) chemical peel


Used as superficial chemical peeling agents, the pH of these solutions ranges from 0.08 to 2.75. Peeling solutions with a pH below 2 have dem-2 onstrated the potential to induce crusting and necrosis, which has not been seen with the partially neutralized solutions with a pH above 2 4 . The higher concentration acid (70 ) created more tissue damage than the lower concentration (50 ) compared to solutions with free acid. An increase of transmembrane permeability coefficient is observed with a decrease in pH, providing a possible explanation for the effectiveness of glycolic acid in skin treatment.


Glycolic acid has been recognized as an important adjunctive therapy in a variety of conditions including photodamage, acne, rosacea, striae albae pseudofolliculitis barbae, hyper-pigmentation disorders, actinic keratoses, fine wrinkles, lentigines, melasma and seborrheic keratoses 5 . Moreover, it can reduce UV-in-duced skin tumor development and it has been proposed as a therapeutic modality against skin exfoliative conditions such as ichthyosis, xeroderma and psoriasis. In post-menopausal women a cream containing 0.01 estradiol and 15 glycolic acid, applied to one side of the face for 6 months, induces a significant improvement in reversing markers (rete peg pattern, epidermal thickness) of skin aging 6 . Glycolic acid chemical peels are an effective treatment for all types of acne, inducing rapid improvement and restoration of normal-looking skin. In these patients glycolic acid is more widely used than Jessner's solution, considering the equal treatment effect but a reduced...


Complications of glycolic acid peel like hyperpigmentation and infection are rare. Chemical peel with glycolic acid may cause sensible irritation symptoms, characterized by stinging, burning and itching. A substance capable of counteracting sensory irritation is strontium nitrate at 20 concentration, which applied topically with 70 gly-colic acid, potently suppresses the sensation of chemically induced irritation 18 .


Finally, glycolic acid is a member of the alpha-2 hydroxy acid family, which provides an important adjunctive therapy in a variety of skin disorders. It is widely used in chemical peels in a variety of concentrations, ranging from 20 to 70 . People of almost any skin type and color are candidates and almost any area of the body can be peeled.

Skin Preparation

The general goals of preparing the skin for peeling are to maximize peel outcomes while minimizing the potential to develop post-peel complications. A detailed history and cutaneous examination should be performed prior to chemical peeling. Baseline full-face frontal and lateral photos are recommended. Skin preparation for Jessner's peeling includes the use of bleaching agents, topical retinoids, alpha hy

Patient Preparation

Peel preparation varies with the condition being treated. Regimens differ for photodamage, hy-perpigmentation (melasma and postinflammatory hyperpigmentation) and acne vulgaris 10 . In addition there are special issues to be considered when treating darker racial-ethnic groups (see darker skin section). A detailed history and cutaneous examination is performed in all patients prior to chemical peeling. Standardized photographs are taken of the areas to be peeled including full-face frontal and lateral views.

Postpeeling Care

Following the chemical peel, patients are advised to wash their skin gently twice daily with a mild nondetergent cleanser. Acetic acid soaks (0.25 , 1 tablespoon of white vinegar in 1 pint of warm water) are performed up to four times per day, and have antiseptic as well as debriding properties. In addition, a bland emollient such as plain petrolatum is applied to prevent dry-ness of skin and formation of crust. The patient must be advised not to vigorously rub their skin or pick at the desquamating skin, as this can lead to scarring. If patients complain of pruritus and are at risk for scratching, a mild topical steroid such as 1 hydrocortisone can be recommended. Once reepithelialization is complete, patients can use a moisturizing cream instead of the occlusive emollient. Long-term care following TCA peels is essentially the same as pre-peel priming regimen and includes use of broad-spectrum sunscreens, bleaching creams, tretinoin or vitamin C, in combination with an exfoliating...


It is of paramount importance that the dermat-ologic surgeon be familiar with the complications of TCA peels. These include infections (bacterial, viral, fungal), pigmentary changes, prolonged erythema, milia, acne, textural changes, and scarring. Bacterial infections include Pseudomonas, Staphylococcus or Streptococcus. In general, prophylaxis with antibiotics is not indicated and strict adherence to wound care instructions will prevent this untoward complication. In patients with a history of herpes labialis, even if remote, prophylaxis with antiviral agent is necessary. Scarring is a rare, yet feared complication of medium-depth chemical peels. Although the etiology of scarring is unknown, factors which are contributory include poor wound care, infections, uneven peeling depth, mechanical injury and previous history of ablative procedures. Localized areas of prolonged erythema, particularly on the angle of the jaw can be indicative of incipient scarring. Proper attention to risk...

Cardiac Arrhythmias

Oral poisoning after accidental phenol ingestion has caused fulminant central nervous system depression, hepatorenal and cardiopul-monary failure 20 . No hepatorenal or central nervous system toxicities with properly performed chemical peels have been reported in the literature 21 .

Pigmentary Changes

Reactive hyperpigmentation can occur after any depth of chemical peels. Usually lighter complexions have a lower risk for hyperpig-mentation, but genetic factors play an important role, and sometimes light patients with dark genes will hyperpigment unexpectedly. Therefore, we recommend introducing bleaching preparation 2-3 weeks after the peel in all patients and continuing until erythema fades. Demarcation lines can be avoided if the boundaries of the peeling area are hidden under the mandibular line and feathered gradually to the normal skin (Fig. 8.16). Medium-depth neck peel is required in patients with blotchy pigmentation of the neck and in those with no clear mandibular line. Accentuation of the pigment in previously existing intradermal nevi is common and should be recognized when it occurs to avoid any unnecessary alarm of a changing mole .


Scarring is still the most dreadful complication of chemical peels. The contributing factors are 8 not well defined yet. Incidence of scarring with traditional Baker' formula is less than 1 22 , while with less aggressive phenol peels, the incidence is lower. The most common location of the scars is in the lower part of the face, probably due to more aggressive treatment in this area or due to the greater tissue movement, because of eating and speaking, during the healing process. Previous surgical lift elevates the neck skin to the higher position, imitating normal facial skin appearance. Thus, special precautions should be taken while peeling lower lateral portions of the face in post-surgical face-lift patients, even years later. We do not recommend combining deep chemical peels with any other surgical facial procedure, since skin undermining severely compromises the post-peel healing process and increases the risk of scarring. Isotretinoin therapy interferes with normal tissue...

Peeling Preparations

A detailed history and cutaneous examination is performed in all patients prior to chemical peeling. The peeling procedure should be explained in depth to the patient including a discussion of the benefits, as well as the risks of the procedure. In addition, standardized photographs are taken of the areas to be peeled, including full frontal and lateral views. The author has never observed a flare of Herpes following a superficial chemical peel. Hence, pretreatment with antiviral therapy is


Deep chemical peeling include newly formed bands of dermis found directly beneath the epidermis consisting of horizontal compact bundles of collagen and dense network of fine elastic fibers, as well as even and uniform shaped keratinocytes in epidermis. Although peeled skin tends to be hypopigmented, melanocytes are present 13 .These changes are evident even as long as 20 years after the peel 14 .

Peel Selection

Chemical peeling agents are classified as superficial, medium-depth, or deep peels 11 . Superficial peels target the stratum corneum to the papillary dermis (Fig. 13.1). They include glycol-ic acid, salicylic acid, Jessner's solution, tretinoin, and TCA in concentrations of 10-30 . Medium-depth peels penetrate to the upper reticular dermis and include TCA (35-50 ) combination glycolic acid 70 TCA 35 , Jessner's TCA 35 and phenol 88 . Deep chemical peels utilize the Baker-Gordon formula and penetrate to the midreticular dermis. Analysis of morphologic,physiologic, and clinical data (see Introduction) suggests that the benefits of chemical peeling in dark skin can be maximally achieved utilizing superficial peels while simultaneously minimizing risks. Grimes 12 compared the histologic alterations induced by a variety of chemical peels in 17 patients with skin types IV-VI, including glycolic acid 70 , salicylic acid 30 , Jessner's solution, and 25 and 30 trichloroacetic acid (TCA). Peels...

Tretinoin Peeling

Pictures Glycolic Chemical Peel

Tretinoin 1 has also been used as a chemical peeling agent 22,23 . The efficacy of tretinoin peels was compared with glycolic acid peels in the treatment of melasma in dark skinned patients 23 . In a split face study of ten Indian women, 1 tretinoin was applied to one half of the face, while 70 glycolic acid was applied to the opposite side. Peels were performed weekly. Significant improvement occurred on both sides as assessed by photographs and a Modi- tion, and salicylic acid, there is a substantially smaller window of safety when TCA peels are applied to skin types IV-VI. The frequency of post-peel hyperpigmentation is significantly more common in dark skin. Therefore, the author only uses TCA peels in patients recalcitrant to glycolic acid, salicylic acid, or Jessner's peels (Fig. 13.5a, b). TCA peels are cautiously used in darker-skinned patients. Indications include wrinkles, photodamage, stubborn pigmentation, and scarring.

Glycolic Acid

Glycolic acid, an alpha-hydroxy acid (AHA), has become the most widely used organic car-boxylic acid for skin peeling. Glycolic acid formulations include buffered, partially neutralized, and esterified products. Concentrations for peeling range from 20 to 70 . Several published studies have assessed the efficacy of gly-colic acid peels in darker-skinned racial-ethnic groups. A series of ten Asian women with me-lasma and fine wrinkles were treated with 2 hydroquinone and 10 glycolic acid applied to both sides of the face 13 . A series of 20-70 glycolic peels were performed on one side for comparison. Greater improvement with minimal side effects was noted on the side treated with the series of glycolic acid peels. Forty Asian patients with moderate to moderately severe acne were treated with a series of 35-70 glycolic acid peels 14 . The investigators noted significant improvement in skin texture and acne. Side effects were reported in 5.6 of patients. Nineteen black patients with...

Tca Peel Science

Tca Peel Science

Medium depth chemical peel for melasma. (a) Pre-operative, (b) intraoperative - Level III frosting ical peeling and may only require a superficial peeling agent, whereas deeper conditions such as dermal melasma and severe wrinkling may prove difficult if not impossible to treat despite using a deeper peeling agent (Fig. 7.3). As a general rule a higher concentration TCA results in deeper penetration yielding a more thorough and longer-lasting treatment this of course must be balanced with the lengthened downtime associated with a deeper peel. Multiple superficial chemical peels generally do not equal the efficacy of a single medium-depth peel. Still, not all conditions need to be treated with a deeper chemical peel as consideration must be given to what type of condition is being treated and most importantly what the patient's goals and tolerance are for the prescribed peel. Epidermal growths such as actinic keratosis, lentigines or thin seborrheic keratoses can all be...


Hydroquinone is a highly efficacious bleaching agent and is commonly used in the treatment of melasma and post-inflammatory hyperpigmentation, the dyschromia of photoaging, len-tigines and freckles. It remains the gold standard for treating hyperpigmentation. Bleaching agents are often used in conjunction with reti-noids and chemical peeling agents for photodamage (see peeling protocols). Hydroquinone acts by inhibiting tyrosinase and preventing the conversion of tyrosine to dopa 42, 43 . With repeated application, hydroquinone may cause destruction of melanosomes, melanocyte organelles, and melanocyte necrosis 42 . rary complication. The major long-term concern regarding the use of hydroquinone is och-ronosis. This condition is most often observed in African patients who have used products containing high concentrations of hydroqui-none for prolonged periods 45, 46 . In contrast, cases in the United States are rare and are predominantly associated with the use of hy-droquinone 2 ....

Medium Depth Peeling

Samaby et al. 65 performed medium-depth peeling using 70 glycolic acid and 35 TCA in five patients with facial photodamage. Biopsies were performed at baseline, prior to chemical peeling, and at 3 months following the peel. His-tological and ultrastructural assessments showed markedly decreased epidermal intracy-toplasmic vacuoles, decreased elastic fibers, increased activated fibroblasts, and organized arrays of collagen fibrils,suggesting that a combination medium-depth glycolic acid 70 TCA 35 peel improves photodamage. Fig. 15.5a, b. Fine wrinkles and mottled pigmentation before (a) and after (b) two 15 TCA peels Fig. 15.5a, b. Fine wrinkles and mottled pigmentation before (a) and after (b) two 15 TCA peels Pyruvic acid peels have also been used for treatment of photodamage. Pyruvic acid is an a-keto acid which is converted physiologically to lactic acid. It is used in concentrations of 40-70 in water ethanol solutions. Ghersetich et al. 67 treated 20 patients with Glogau's...

Pharmacokinetics and Uses

Pharmacokinetics Also known as carbolic acid, the original surgical antiseptic solution and chemical peel agent rapidly absorbed. Total dose should be limited to less than 50 mg 10 hours. Uses Preservative in injectable meds, chemical peels, injectable neurolytic for cancer pain, diluent for lyophilized glucagon powder and other powdered medications.

Static Procedures For The Recovered Facial Palsy Patient

Patients with partially recovered facial palsy present an interesting problem. Often after a severe but transient facial nerve insult, such as Bell's palsy, recurrent facial paralysis from Melkerson-Rosenthal syndrome, or iatrogenic neuropraxia, patients recover to a House-Brackmann grade II or III level. They have better function than could be expected with grafting procedures but still have complaints relative to facial asymmetry. In these patients, muscle transfer would play no role at all, as they maintain a fair amount of mimetic function. In order to improve resting facial symmetry, a limited, mini facelift technique can provide increased resting support to the affected side, without jeopardizing residual dynamic function. If the affected side has developed a contracture so that the normal side appears flacid in comparison, the unaffected side can be operated on in order to match the contractured side. This is done through standard anterior rhytidectomy incisions. Subdermal...

Comparison of Tuck Rates for Various Techniques

SMAS rhytidectomy vs deep-plane rhytidectomy an objective comparison. Plast Reconstr Surg 1998 102 880. Postoperative healing is slightly different for the two facelift techniques. The deep-plane lift is associated with more swelling in the preauricular area, but there is less swelling and bruising in the cheek as compared to the SMAS lift. Also, after a deep-plane rhytidectomy there are occasionally pleats in the preauricular skin from the deep sutures that can persist for 2 to 3 weeks, but these resolve as edema dissipates. Healing takes longer after the deep-plane surgery because of increased edema. Although most patients return to their normal lifestyle within 2 to 3 weeks, they do not reach their optimal appearance for nearly 3 months.

Indications and Contraindications

The deep-plane technique can be considered for most cases of primary rhytidectomy, except in the unusual situation, when simple skin redundancy is the only concern. It is particularly effective for advanced jowls and heavy nasolabial folds and for patients who smoke or have some other condition that predisposes them to compromised vascularity or infection. Patients with extremely thin skin in whom minor subcutaneous irregularities would be more evident are also better suited for the deep-plane rhytidectomy, as are those who are suceptible to hypertrophic scarring. Revision of a primary rhytidectomy that involved dissection in the sub-SMAS plane could conceivably increase the risk of facial nerve injury due to distortion of surgical landmarks by scar tissue. This will not be determined until more of these patients present for revision. Other contraindications are not specific to the deep plane technique and include patients with Numerous techniques are available to the facelift surgeon...

Management Of The Anterior Platysma

The opportunistic biplane facelift depends primarily on posterior pull of a platysmal flap for neck rehabilitation. Even anterior cervical laxity is well corrected by this procedure. However, if the patient has significant anterior platysmal banding, we do carry out an anterior platysmaplasty. If there is distinct banding, posterior platysmal pull is usually not sufficient, and it is helpful to secure the platysma in the midline. This occurs in approximately 20 of our cases.

Real Examples of Results

Treatment for patients with these deformities involves the use of special training and facial exercises, as well as the judicial use of repeated Botox injections to paralyze unwanted facial muscle function. Most of these patients are unhappy with results of this type, but many physicians dismiss the problem as inconsequential and recommend neither thorough examination nor prompt surgical treatment at a time when surgery could prevent a bad result. It is human nature that patients wish to avoid or delay surgery until they are convinced that it is necessary. They are commonly advised to wait several weeks by a well-meaning relative, friend, or neighbor who made a good spontaneous recovery without treatment 71 will. The problem is that 29 of all patients with untreated acute facial palsy will have not be so fortunate.1 Table 41-1 presents an algorithm for evaluating such cases of acute facial palsy.

Clinical manifestation

Musculoskeletal system arthralgias and morning stiffness sometimes mimicking other systemic autoimmune diseases hand and joint function may decline from skin tightening acroosteolysis (i.e., resorption or dissolution of the distal end of the phalanx) sometimes occurs flexion contractures

Preparing for Surgery

The surgeon will take photographs of you before and after surgery so the two of you can evaluate the results of the procedure. Before surgery the doctor will closely examine the part of your body to be altered and will discuss a number of issues related to the specific type of surgery you wish to have. For example, if you are planning to have a facelift, the doctor will closely evaluate your head

Trichloroacetic Acid Peels

TCA is perhaps the best single agent for skin resurfacing. It exhibits unique properties that afford the cosmetic surgeon tremendous flexibility and versatility in treating a variety of clinical conditions. When properly used, TCA has an overall decreased morbidity as compared with other agents. It allows patients to achieve a predictable result with the benefit of disrupting their lives to a lesser degree. Although TCA is the most popular and most widely used chemical peeling agent, proper usage is imperative to a successful outcome. Ideal candidates for TCA peeling include patients with pigmentation disorders and those who exhibit As with all chemical peeling, the skin should be degreased with an acetone-soaked sponge. The mechanical abrasion helps remove the stratum corneum, helping produce uniform penetration ofthe peeling agent. TCA may be applied as a 10 to 50 concentration, depending on the desired depth of penetration. We strongly discourage the use of TCA in concentrations...


Acne where sweating is an aggravating factor aluminium chloride solution Severe nodulocystic acne unresponsive to other therapies isotretinoin* Acne surgery comedone expression incision and drainage of fluctuant cysts and abscesses chemical peel microdermabra-sion intralesional triamcinolone 2-4 mg ml

Caustic Effects

When applied to the skin in high concentration, AHAs cause necrosis and detachment of keratinocytes leading to epidermolysis (12,23,24). Such injury is a chemical peeling depending primarily upon the disruption of the skin pH. The farther away from the physiological pH, the greater the caustic effect, the greater the risk of side effects, but the more likely the patient is to receive the benefits of the peeling agents. A tolerable sense of burning itch is often experienced by ij



TREATMENT Mild degrees of dermatocholasis may be managed with laser skin resurfacing or chemical peels that tighten the skin and encourage new collagen formation. In most cases, however, surgical excision of skin and muscle will be required to achieve an acceptable cosmetic and functional result. If there is significant loss of connection between the anterior and posterior lamellae, the eyelid crease should be reestablished at the same time to prevent an acquired epiblepharon. When there is concomitant brow ptosis, the brow should be repositioned first since some or even all of the excess skin will be corrected with this procedure. Any excess skin in the lid can then be removed. In the lower eyelid tension must be kept in the horizontal direction to prevent retraction, scleral show, and ectropion. Care must be taken not to put excessive tension on fat pockets especially in the lower lid since cases of blindness have been reported from deep orbital hemorrhage, typically within the...

Douglas D Dedo

Elevation of this 'musculofascial' plane is a key component of the biplane facelift described in this chapter. In my opinion, no other operation provides the elegant upper facial rejuvenation that is characteristic of this operation. This is especially true when there is an indication to correct a downward slope of the lateral canthal region.

Howard A Tobin

SMAS Surgery versus Deep-Plane Rhytidectomy The evolution of the facelift during the twentieth century was dependent on technologic breakthroughs and the understanding of the anatomy responsible for the vagaries of aging. With better lighting and the development of low-reacting suture materials that self-absorbed over weeks and months, surgeons were able to see, manipulate, and secure tissue planes that were previously impossible to work with. During the early 1900s, simple skin excision with minimal if any undermining was the standard.1 With fiberoptic lighting, dissection could be extended farther and farther under the skin with improved results. As late as the 1960s and 1970s, the need to do little more than lift the skin remained controversial. With Mitz and Peyronie's2 landmark anatomic work on the subcutaneous musculoaponeurotic system (SMAS), the innovators were stimulated to plicate, imbricate, excise, and manipulate this layer in a variety of ways. Depending on the approach...


The sub-SMAS (deep-plane) facelift is based on sound surgical principles of tissue mobilization, advancement, and repair. It is important to remember, when repositioning tissue, that the structures influenced by undermining are usually from the point ofincision to the most distal point ofdissection, but not beyond. The surgical incisions for the two operations are identical.

Deepplane Dissection

Once the flap is elevated and hemostasis maintained the flap can be secured. Using a strong permanent suture (3-0 braided silk), the upper part of the flap is attached to the tem-poralis fascia, exerting a strong pull. Next, the platysma muscle is pulled back, attaching it to the mastoid fascia. Immediately, we can see a marked tightening of the face and neck. These are the two primary anchoring sutures. We continue to suture the posterior border of the platysma to the fascia overlying the sternocleidomastoid muscle using interrupted 3-0 silk suture. The pull is actually in a posterior superior direction, such that the platysmal flap actually forms a sling that supports the ear lobe and tends to prevent subsequent inferior migration of the ear, which can result in the deformity commonly called pixie ear. In the facial region, the flap is attached to the parotid fascia in the preauricular area. A firm pull is applied, as this forms the primary support of the facelift.

Postoperative Care

Drains and dressings have not been used at our center for about 8 years. Dressings are more likely to hide problems than to prevent them. Long experience with suction drains indicated that they did not reduce the chance of hematoma. By leaving the surgical site open, small hematomas can promptly be identified in the recovery room where they can often be treated by simply expressing them. When larger hematomas are present, we can identify them much more quickly, allowing for an early definitive correction. A normal blood pressure is maintained in the recovery room, as postoperative hypertension is one of the primary causes of hematoma after facelift. Medication is promptly given if the patient shows signs of nausea or hypertension. Preoperative dimenhydrinate (Dramamine) and postoperative oxygen are used in the recovery room to help allay nausea.

Laser Technique

Although beyond the primary scope of this chapter, it is worthwhile to briefly discuss our laser technique when combined with deep-plane facelifting. We classify our laser technique as moderately aggressive. Because settings vary from instrument to instrument, it is important to realize that wise surgeons will always start at low intensities until they are familiar with the effects of their unit. We use a Luxar CO2 laser. Before surgery, we mark the deepest lines of the patient. After prepping, and before surgery, we etch the deepest lines with several passes using a superpulse setting of 6 to 8 W. The char is wiped off and we then proceed with the facelift. After the facelift is complete, using a computerized scanner, we treat the entire face with a single pass using 9 W of energy with the scanner set at maximum density. We feather into the neck to avoid a demarcated line. We do not wipe the char, but rather apply a layer of Catrix, which the patient is instructed to reapply...

Phenol Peels

Phenol represents the most common deep chemical peeling agent. It leads to dramatic results by producing a controlled chemical burn to the level of the upper reticular dermis. As healing occurs, new stratified collagen is laid down, resulting in younger-appearing skin. Phenol is an extremely effective agent for reversing facial wrinkling and irregular pigmentary changes related to sun exposure and the natural aging process. The most commonly used phenol preparation is the BakerGordon formula, which contains 3 mL USP liquid phenol, 2 mL tap water, 8 drops liquid soap, and 3 drops groton oil. Although this formula remains popular, other buffered phenol solutions exist that are reported to cause less postpeel hypopigmentation. By varying the concentration of phenol, the depth of the peel will change. The lower the phenol concentration, the more deeply it penetrates. In addition, the use of croton oil appears to be especially important in enhancing or limiting phenol penetration. When the...

Facial Surgery

As they age, some men seek to improve the appearance of their face and neck through cosmetic surgery. Facial surgery covers a number of different procedures, including a facelift and forehead lift, eyelid surgery, nose surgery, facial implant surgery, and refinishing treatments for facial skin (such as chemical peels and dermabrasion). Sometimes two or more of these procedures are performed at the same time. Although facial surgery cannot reverse the aging process, it can give the face a younger, rejuvenated look that can increase your self-confidence and sense of well-being. Facelift With age, the muscles and skin of the face and neck begin to sag, and the skin begins to lose elasticity. A facelift can restore a more youthful appearance by removing excess fat, tightening underlying muscles, and repositioning the skin over the face and the neck. Most people who have a facelift are in their 40s, 50s, and 60s, but even older people can benefit from the procedure. Before deciding to have...

Wrinkle Reverse

Wrinkle Reverse

It's true, & deep down we all know it, there is no way to stop the natural aging process, not really. But you can take action to slow this process right down. And when done right you can even start to roll back the years as far as facial appearance goes that is! You know, Anyone can look younger when they know how. Skin rejuvenation is very real & It doesn't have to cost the earth!

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