Part 1 book “Color atlas of cosmetic dermatology” has contents: Topical treatment options, soft tissue augmentation, chemical peels, ablative laser resurfacing, nonablative laser resurfacing, nonablative laser resurfacing, sebaceous hyperplasia, male pattern hair loss,… and other contents.
Trang 2Cosmetic
Dermatology
Trang 4Cosmetic Dermatology Second Edition
Zeina Tannous, M D Chief, Mohs/Dermatologic Surgery, Boston VA Medical Center Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Affiliate Faculty, Wellman Center for Photomedicine
Faculty Director for Dermatopathology, Department of Dermatology, Harvard Medical School
Assistant Professor in Dermatology, Harvard Medical School
Boston, Massachusetts
Mathew M Avram, M D, JD
Director
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Faculty Director for Procedural Dermatology Training, Department of Dermatology, Harvard Medical School
Affiliate Faculty, Wellman Center for Photomedicine
Boston, Massachusetts
Sandy Tsao, M D Director of Procedural Dermatology Harvard Medical School
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Boston, Massachusetts
Marc R Avram, M D
Clinical Professor of Dermatology Weill Cornell Medical School Private Practice-905 Fifth Avenue New York, New York
New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Trang 5Copyright© 2011 by The McGraw-Hill Companies, Inc All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher
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Trang 6I wou ld l i ke t o ded icate this book t o the memory of m y beloved father, who always gave me h is u lti mate love and support
Zeina Tannous, MD
I wou ld l i ke to ded icate this book to my wonderfu l pa rents, Morrell and
Ma ria Avra m You have provided me u ncond itional love a n d end less
support since the day I was born I love you
Mathew M Avram, MD, JD
To my h usba n d , Hensi n You a re my stre ngth a n d inspiration You r love, wisdom a n d encou ragement help me rea l ize a nyth ing is possible You a re a wonderfu l h usba n d , father and best friend I wi l l love y o u a lways To my sons, Se bastian a n d H u nter You r
u nconditional love, enthusiasm and sense o f adventure help me remem ber what is truly
i m porta nt You brighten my days and fi l l my l ife with happiness and love
Sandy Tsao, MD
This book is ded icated to my wife Robin and my two sons Robert and Jacob
I tha n k them for the love and support that they give me every day
Marc R Avram, MD
Trang 8Preface ix
SECTION ONE: PHOTOAGI NG
Chapter 1: Analysis of the Aging Face and
Non-Facial Regions . . 2
Chapter 2: Topical Treatment Options . . 7
Chapter 3: Soft Tissue Augmentation ... 14
Chapter 4: Botulinum Toxin ... . 21
Chapter 5: Chemical Peels . . . . 29
Chapter 6: Nonablative Laser Resurfacing .. . 39
Chapter 7: Ablative Laser Resurfacing .. . 43
Chapter 8: Nonablative Fractional Laser Resurfacing . 52
Chapter 9: Ablative Fractional Laser Resurfacing .. ... 57
Chapter 10: Tissue Tightening ... 62
Chapter 11: Dermatochalasis . 64
Chapter 12: Poikiloderma of Civatte . . 67
SECTION TWO: DISORDERS OF SEBACEOUS GLANDS Chapter 13: Acne Vulgaris . . . . 72
Chapter 14: Rosacea .. . 76
Chapter 15: Sebaceous Hyperplasia 81
SECTION THREE: DISORDERS OF ECCRINE GLANDS Chapter 16: Hyperhidrosis . . . 86
SECTION FOUR: DISORDERS OF HAIR FOLLICLES Chapter 17: Hirsutism . . 92
Chapter 18: Pseudofolliculitis . . 99
Chapter 19: Male Pattern Hair Loss . 103
Chapter 20: Female Pattern Hair Loss .126
Chapter 21: Low Level Light Therapy (LLLT) and Hair Loss .. . . . 133
SECTION FIVE: DISORDERS OF PIGMENTATION Chapter 22: Cafe Au Lait Macule . . 136
Chapter 23: Ephelides .. .139
Chapter 24: Lentigines ..... . .. . 144
Chapter 25: Melasma . . ...... 149
Chapter 26: Nevus of Ota .. . 154
Chapter 27: Postinflammatory hyperpigmentation 158
Chapter 28: Vitiligo . . ... . 163
SECTION SIX: VASCULAR ALTERATIONS Chapter 29: Angiokeratoma .168
Chapter 30: Cherry and Spider Angiomas 170
vi i
Trang 9Chapter 33: Keratosis Pilaris Atrophicans . . 181
Chapter 34: Port-wine Stains . . 183
Chapter 35: Pyogenic Granuloma . 188
Chapter 36: Facial Telangiectasias . 192
Chapter 37: Lower Extremity Telangiectasias, Reticular and Varicose Veins .198
Chapter 38: Venous Lakes . . 203
Chapter 39: Warts . . . . . 206
SECTION SEVEN: BENIGN GROWTHS Chapter 40: Angiofibroma . . . . . 212
Chapter 41: Becker's Nevus . . . 216
Chapter 42: Epidermal Inclusion Cyst .219
Chapter 43: Epidermal Nevus . 222
Chapter 44: Lipoma . 226
Chapter 45: Milium . . . . 229
Chapter 46: Neurofibroma . . 231
Chapter 47: Seborrheic Keratosis . . . 234
Chapter 48: Syringoma . . . . . 238
Chapter 49: Dermatosis Papulosa Nigra . . 241
Chapter 50: Xanthelasma . . . . 243
viii Chapter 52: Basal Cell Carcinoma . 252
Chapter 53: Squamous Cell Carcinoma 256
SECTION NINE: INFLAMMATORY DISORDERS Chapter 54: Lichen Planus . . 262
Chapter 55: Morphea .265
Chapter 56: Psoriasis . 267
SECTION TEN: ADIPOSE TISSUE ALTERATIONS Chapter 57: Gynecomastia .272
Chapter 58: Cellulite . . . . . . . 276
Chapter 59: HIV Lipodystrophy/Facial Lipoatrophy . 280
Chapter 60: Striae Distensae . 285
SECTION ELEVEN: WOUND HEALING ALTERATIONS Chapter 61: Hypertrophic Scars, Keloids, and Acne Scars . 290
SECTION TWELVE EXOGENOUS CUTANEOUS ALTERATIONS Chapter 62: Ear Piercing . 298
Chapter 63: Tattoo Removal . . 300
Chapter 64: Torn Earlobe . . . 308
Index .311
Trang 10There has been a revol ution in the treatment of med ical a n d cos
metic d isord ers of the ski n I n la rge part, this is due to the avail
a b i l ity of procedu res and tech nologies that prod uce clear, cosmet
ic benefit with few side effects and l ittle downti me With the advent
of lasers and l ight sou rces over the past 20 yea rs, cosmetic
i m provement is a matter of q u ick, relatively pa i n less proced u res
N on-laser treatments such as soft tissue fi l lers, botu l i n u m toxin
i njections, sclerothera py, hair tra nsplantation and others have a lso
d ra matica l ly expa nded the scope of this field These procedu res
coincide with the busy l ifestyle of many patients who seek a n
i m provement i n a p pea ra nce that does not interfere with their pro
fessiona l , social or personal obl igations
These proced u res, however, a re not without potentia l side
effects or compl ications Physicians who perform these treatments
in the a bsence of tra i n i ng or ed ucation a re certa i n to encou nter
poor resu lts, compl ications and i rate patie nts Beca use patients
a re p u rsuing elective treatments for cosmetic benefit, a ny worsen
i ng of a p pea rance wi l l understanda bly a nger patients who
under-ix
go these proced u res The decision as to when not to treat a patient
is perha ps the most i m porta nt i n this fie l d With t h i s i n m i n d , Color Atlas o f Cosmetic Dermatology, Second Edition seeks to provide a succinct yet broad overview of cosmetic thera py There a re a plethora i l l ustrations and gra phs to elucidate consu ltation, management, treatment and side effects of n u merous cosmetic proced u res Its practica l format is gea red to the busy practitioner or tra i nee who seeks a q u ick, comprehensive reference for a pproaching the cosmetic patient It a lso emphasizes pitfalls of treatment in order to ed ucate the reader as to potential problems with certa i n treatments It serves as a n i nva l ua ble resource to both the experienced a n d novice
Zeina Ta n nous, M D
M athew M Avra m , M D, J D
Sandy Tsao, M D Marc R Avra m , M D
Trang 12We wou l d l i ke to tha n k two people who provided sign ificant help i n the prod uction of this textbook, Dr Rox Anderson a n d Dr Gary Lask In add ition, we would
l i ke to tha n k the office staff at the Massachusetts Genera l H ospita l Dermatology Laser & Cosmetic Center and the office staff of Dr Marc Avra m for their hard work and
ded ication i n obta i n i ng high-q u a l ity photogra phs
Final ly, we would l i ke to tha n k the professiona l staff at McGraw- H i l l for their great help and d evotion in prod ucing this book Tha n k you for push ing us to
strive for the best possi ble Atlas
Trang 14Photoaging
Trang 15CHAPTER 1 Analysis of the Aging Face a nd No n-Facial R eg i o ns
The face is the focal point of h u m a n bea uty Although
va rious factors i nfluence facial bea uty, the aging process
is the most common as pect prom pting non-s u rgica l
a n d/or surgica l intervention Agi ng is a dyna m i c a n d con
tinual process Different c u ltura l , eth nic, and ge nder
norms (Ta ble 1 1 ) of bea uty exist; however, there a re cer
ta i n featu res which globa l ly tra nscend these d ifferences
to d etermine what is perceptua lly pleasing Hered ity and
environ mental factors (eg, s u n exposu re, w i n d , tra u ma )
a re t h e m a i n determ i n a nts o f aging I n addition , ciga rette
smoking a n d estrogen loss ca n accelerate the aging
process As one ages, cha nges can be observed i n a l l
facial a n d non-facial a natomical com pa rtments, includ
ing the ski n , su bcuta neous fat, m uscle, a n d bony struc
tu re Use of a systematic a p proach i n the a n a lysis of
facial a n d non-facial aging wi l l a l low for the selection of
a p propriate, safe, a n d effective thera pies
TABLE 1.1 • Facial Age-Related Contour Changes
ANATOM IC CONS I D ERAT I O N S
S uccessfu l rej uvenation o f the face a nd non-facial
regions req u i res a thorough u n dersta n d i n g of age-related
conto u r cha nges ( u nderlying soft tissue aging) and tex
tu ra l cha nges (skin aging) (Ta bles 1 1 a n d 1 2 )
TABLE 1 2 • Age-Related Textura l Changes
S u perficia l and deep rhytides
Pigmenta ry d isturbances
Tela ngiectasia formation
Loss of skin elastic ity
Acti n ic keratoses
A youthfu l face can be d ivided i nto th ree facial zones:
u p per, m idd le, and lower zones, as wel l as the u pper neck
The upper face incl udes the forehead , tem ple, and peri
orbital region Agi ng results i n flattening of the brow arch,
eyelid skin red u nda ncy, pseudo fat herniation , and forma
tion of dyna mic rhytides at the latera l canthus Horizonta l
forehead s k i n creases develop secondary t o sustai ned con
traction of the frontal is m uscle in a su bconscious attempt to
elevate the sagging brows A ri m sulcus deformity develops
between the cheek and the eyelid with upper cheek
A
B Figure 1.1 A&B G/ogau type 1 photoaging Minimal signs of aging present
Trang 16th i n n i ng This sulcus is exacerbated by a preexisti ng tea r
trough deform ity Orbicula ris oculi m uscle ptosis can create
a malar fu l l ness, referred to as a malar crescent
The midface incl udes the cheekbones that form a
smooth conti nuous convexity from the eyelid to the l i p
T h e melolabial fold represents a flat, smooth j u n ction
between the lower cheek a n d the u pper lip The aging
face resu lts i n a downward m igration of the malar soft tis
sue, accentuati ng skeletonization of the orbital ri m
Centra l cheek fat ptosis creates a fu l l n ess latera l to the
melola bial fol d , referred to as nasola bial folds
The lower face possesses a wel l-defi ned mand ibular bor
der and a well-defi ned cervicomental a ngle With aging,
platysma! m uscle ptosis a nd cheek fat ptosis a long the
mandi ble prod uce "jowls" overlyi ng the jawl ine Soft tissue
atrophy a nterior to the jowls creates a " prejowl sulcus"
which accentuates the skeletonized a ppeara nce Platysma!
ptosis of the u pper neck blu nts the cervico-mental a ngle,
creati ng platysma! ba nds or a "turkey neck" deformity
Facial textu ra l cha nges i nclude su perficial a nd deep
rhytides, pigmenta ry d istu rba nces, telangiectasia forma
tion, loss of skin elasticity, and acti nic keratoses
PREOPERATIVE EVALUATION
A n individual ized treatment plan designed to minimize sur
gica l risk is essential The goa l is a youthfu l and natural post
operative result A strategy should be formulated for each of
the three facial zones as well as each ind ividual non-facial
region, as each a natomic region req ui res a specific man
agement which influences the rema i n i ng anatomic regions
A systematic eva l uation should include the degree of
textura l changes, rhytid formation, pigmenta ry cha nges,
loss of su bcuta neous fat, cha nges in facia l m usculature,
carti lagi nous a n d bony structu res, a nd elastic ity loss
• G l oga u P h otoag i ng C l ass i f i cat i o n
Wri n k l e Sca l e
The G loga u Photoagi ng Classification has been devised
which b road ly defi nes the cha nges that may be seen at
d ifferent ages with c u m u lative sun exposure
Type 1 -"no wri nkl es" (Fig 1 1 )
Type 2-"wrinkles i n motion" (Fig 1 2)
• Ea rly to moderate photoaging
-Ea rly senile lentigines visi ble
B
Figure 1.2 A&B Glogau type 2 photoaging Fine lines barely visible Minimal pigmentary changes noted
Trang 17-Keratoses pa l pa ble but not visi ble
-Para l lel smile l i nes begi n n i ng to a ppea r
• Patient age : late thirties or forties
• Usually wea rs some fou n dation
Type 3-"wrinkles at rest" (Fig 1 3)
• Adva nced photoaging
-O bvious dysc h romia, tela ngiectasia
-Visi ble keratoses
-Wrin kles even when not movi ng
• Patient age: fifties or older
• Always wea rs heavy fou ndation
Type 4-"only wrinkles" (Fig 1 4)
• Severe photoaging
-Yel l ow-gray [A3l color of skin
-Prior skin mal igna ncies
-Wrin kled throughout, no normal skin
• Patient age : sixties or seventies
• Ca n n ot wea r makeup-" ca kes and cracks"
A vita l aspect of the patient eva l uation is the determina
tion of the patient's skin response to erythema-prod ucing
d oses of u ltraviolet l ight Fitzpatrick's classifi cation of
skin types provides a stro ng i n d i cation of the pote nti a l
f o r post-i nfla m mato ry hyperpigmentation a n d hypopig
mentation and potential fo r d ysc h ro m i a u po n e p i d e r
m a l a n d/or pa p i l l a ry dermal i n j u ry (Ta b le 1 3 )
TAB LE 1 3 • Fitzpatrick's Classification of Skin Types
Skin type Color Reaction to s u n
I Very wh ite or freckled Always burns
A patient's treatment res ponse can be d eterm i n ed
by assess i ng both the d egree of photod a mage present
and the pigmenta ry skin type A proced u ra l risk
benefit ratio wi l l d iffer, d e pend i ng on the patient's i n d i
vid u a l fi n d i ngs ( Figs 1 5 a n d 1 6 ) I n genera l , patients
with Fitzpatrick skin types I-I I I can tolerate more epider
mal a n d dermal i n j u ry with m i n i ma l risk of res i d u a l
dysc h ro m i a Patie nts w i t h Fitz patrick s k i n types IV-V
have a h igh risk of res i d u a l dysc h romia with i n c reased
s k i n i nj u ry that may p rec l u de the use of many treatment
Trang 18• S u b c u ta n e o u s Fat Atro p h y
Agi ng resu lts i n a sign ifica nt d egree of loss or red istri bu
tion of su bcuta neous fat, espec ially of the forehea d , tem
pora l fossae, periora l a rea , chin, a n d premalar a reas
This leads to a skeleton ized a p pea ra nce Restoration of
vol ume loss resu lts i n the reshaping of the face for a
fu l ler, rou nder a p peara nce
• Fac i a l M u sc u l at u re C h a nges
Agi ng also resu lts i n m uscu lar atrophy, contri buti ng to
vol ume loss As wel l , dyna mic rhyti d es, which are m uscu
lar i n origi n , often create a n a ngry, tired, or aged a p pea r
ance Selective chem ical denervation provides marked
relaxation of these l i nes
• C h a nges i n Ca rt i l age , B o n y
Structu res, a n d U n d e r l y i ng
S u p port i ve Structu res
Agi ng resu lts i n sagging and loss of resil iency Red ra pi ng,
repositio n i ng, and jud icious remova l of skin and soft tis
sue assist i n the restoration of a youthfu l a p pea rance
Once a syste m i c approach has been fol l owed , the fou r
Rs of facial rej uvenation-relax, refi l l , red ra pe, and resur- A
face-can be a ppl ied solely or in combi nation to hel p
restore a more youthfu l a p pea ra nce
B I B L I OG RAPHY
C h u ng J H , Eun H C Angiogenesis i n skin aging a n d pho
toaging J Dermatol 2007 ;34(9) : 593-600
Davis R E Facelift and ancillary facial cosmetic surgery pro
ced u res I n : Nouri K, Leai-Nouri S, eds Techniques in
Dermatologic Surgery London: Mosby; 2003, pp 333-344
Fitzpatrick T The valid ity and practica l ity of sun-reactive
ski n types I through V I Arch Dermatol 1 998 ; 1 24:869-87 1
Gloga u R Aesthetic a n d a natomic a na lysis of the aging
ski n Semin Cutan Med Surg 1 996; 1 5(3): 1 34- 138
M ontagna W, Carlisle K, Kirchner S Epidermal and
Dermal Histological Markers of Photodamaged Human
Facial Skin Shelto n , CT: Richardson-Vicks; 1 988
Paes EC, Teepen H J , Koop WA, et a l Periora l wrin kles:
Histologic d ifferences between men and women Aesthet
Surg J 2009; 29(6) :467-472
S haw RB J r, Katzel E B , Koltz PF, et al Agi ng of the
m a n d i ble a n d its aesthetic i m pl ications Plast Reconst
Surg 2010; 125(9 1 ) :332-342
B
Figure 1.4 A&B Glogau type 4 photoaging Extensive wrinkles and prominent dyspigmentation
Trang 19Figure 1.5 Female patient who avoided sun exposure throughout her life Her skin reflects only minimal signs of photoaging
Figure 1.6 Female patient with a history of extensive sun exposure in her life Her skin reflects extensive photodamage with dyspigmentation and extensive wrinkle formation
Trang 20CHAPTER 2 Topica l Treatm e nt Optio ns
M ECHAN I S M OF ACT I O N
• Sunsc reen
-The u ltraviolet ( UV) wavelengths of l ight associated
with c uta neous da mage a re UVB (290-320 n m ) and
UVA (320-400 n m ) l ight
-UVB a bsorption by DNA results i n a p53 tumor s u p
pressor ge ne m utation resu lting i n pyri m i d i ne d i mer
formation , which is m utagenic and l i n ked to cuta
neous carcinogenesis
-Acute UVB expos u re resu lts i n a sun burn ( Fig 2 1 )
-Repeat ac ute UVB exposu res over time have been
associated with the formation of basa l cell carc i noma
a n d melanoma
-Chronic UVB exposure has been linked to the develop
ment of actinic keratoses and squamous cell carcinoma
-UVA is u naffected by wi ndow glass, a ltitude, time of
day, or season and can prod uce a ta n and dyspig
mentation without preced ing erythema
-UVA l ight penetrates deeply into the dermis, prod uc
ing many of the c l i n ical fi n d i ngs associated with
photo da mage ( Fig 2 2 )
-UVA a bsorption b y D N A resu lts i n formation o f oxy
gen free rad icals, thought to contribute to ca rcino
genesis It causes i m m u nosu ppression through the
de pletion of La ngerhans' cells and red uced a ntigen
prese nti ng cell activity
-UVA exposu re has been l i n ked to the development of
melanoma in a n i ma l models
Chem ica l sunscreen (Ta ble 2.1 )-a bsorbs l ight i n the
UV wavelength of l ight ( UVB 290-320 nm) and UVA
TABLE 2.1 • Chemical Sunscreen: Active Ingred ients
Pa ra-a m i nobenzoic acid ( PABA)
Phenyl benzi m idazole su lfonic acid
Sul isobenzone
Trola m i ne sa licylate
Figure 2.1 Patient with an acute sunburn There is marked swelling and redness present The upper back scar is the site of a previous superficial spreading melanoma (Courtesy of Richard Johnson, MD)
Figure 2.2 Patient with marked photodamage due to chronic sun exposure The patient was an avid golfer and reported only occasional sunscreen use
Trang 21320-400 n m ) , transforming this l ight i nto harm less long
wave rad iation and re-em itti ng as heat energy
Physica l screen (Ta b le 2 2 )-scatters or reflects UV
rad iation Can a lso a bsorb UV l ight and release it as
heat
TABLE 2.2 • Physical Sunscreen: Active I ngredients
Tita n i u m d ioxide
Zinc oxide
S u n protective factor-optima l ly a su nscreen wou l d pro
vide protection against the fu l l spectrum of UV rad iation
The sun protective factor (SPF) is the only i nternationa l ly
sta ndard ized measure of a sunscreen's a bi l ity to filter UV
rad iatio n It is the ratio of the UV energy needed to prod uce
a m i n i ma l erythema dose ( M ED) on su nscreen-protected
skin to the UV energy req u i red to prod uce an M ED on
u n protected ski n The American Academy of Dermatology
cu rrently recom mends the daily use of sunscreen with
SPF 30 or greater
• Antioxida nts-theoretica l ly work to red uce and neutral
ize free rad icals that da mage DNA, cytoskeleta l struc
tu res, and cel lular proteins They also possess anti-i
nflammatory effects a n d many play a role in pigment
red uction
-I n order to be biologica l ly effective, these prod ucts
m ust be a ble to penetrate i nto the skin a n d rema i n
biologica lly active l o n g enough t o exert t h e desired
benefits A majority of the cu rrently ava i lable a ntioxi
dant prod ucts a re very unsta ble, with oxidation mak
ing them c hem ically inactive Molecular formation
and packagi ng a re key factors i n the sta b i l ization of
these prod ucts
-Antioxida nts may work synergistica lly to provide thei r
greatest benefit
-Vita m i n C-the only a ntioxidant to date to have
proven benefit for wri nkle i m p rovement due to its
a b i l ity to increase col lagen formation rather than its
a ntioxidative effects
-Vita m i n E-demonstrated to i n h i bit UV-i nd uced ery
thema and edema in a n i mals It has h igh contact
dermatitis risk
-Coenzyme Q l O-natu rally occu rring n utrient added
to many over-the-cou nter prod ucts C u rrently there
a re no stud ies ava i la ble to document its long-term
benefits on skin aging
-l d ebenone-synthetic a nalog of Coenzyme Q l O
• Reti noic acid-reti noids a re natu ra l ly occu rring deriva
tives of I)-carotene and la beled as vita m i n A and its
derivatives I ncl uded a re reti nol, reti nald ehyde, reti nyl
esters, and retinoic acid ( Fig 2.3) Its benefits a re both
preventative a n d repa rative
First Generation (Nonaromatics)
Trang 22-UVB exposu re resu lts in the u p-regu lation of severa l
col lagen-degrading matrix metalloprotei nases, includ
ing col lagenase, gelatinase, and stromelysin, which
cause collagen degradation Reti noids act to i n h i bit the
ind uction of these meta l loproteinases
-UVB exposu re a lso dec reases collagen prod uction
Reti noids work to i n h i bit this loss of pro-col lagen syn
thesis
-Tretinoi n-a fi rst-ge neration reti noid which was the
fi rst ava i l a ble to pica l reti n o i d I t is a nonselective
retinoid , activating a l l reti noic acid pathways It is
not photo-sta ble It is ava i la ble i n a ge neric form, as
wel l as i n bra nd for m u lations such as Renova a n d
Avita Cu rre ntly Renova is F D A a p proved fo r pho
toaging Treti noin is a lso ava i l a ble in com b i nation as
treti n o i n 0 025% with c l i n d a myci n for patients seek
ing benefits fo r both acne and photoaging and as
treti noin 0 2 5 % i n com bi nation with 4% hyd ro
q u i none a n d 0.05% fluocinolone aceto n i d e for
hyperpigmentation
-Reti nol-this prod uct must be converted to reti na lde
hyde a n d then to a l l -tra ns-retinoic acid with i n the ker
atinocyte in order to become active, thus d isplayi ng
less activity than treti noi n I t is thought to be approxi
mately 20% less potent than retinoic acid It is not as
freq uently associated with i rritation or erythema It is
primari ly found i n over-the-cou nter prod ucts at va ri
ous concentrations
-Ada palene-a third -generation reti noid with selective
affi nity for specific retinoic acid rece ptors, which
a l lows for m ore targeted benefit and red uction of
potentia l side effects It is more chemically sta ble
than tretinoin a nd does not brea k down i n the pres
ence of l ight C u rrently ava i lable as Differin in a 0 1 %
a n d a 0.3% concentration It i s cu rrently FDA
a p proved for topica l acne thera py
-Taza rotene-a thi rd-ge neration retinoid with selective
affi n ity for specific retinoic rece ptors for more tar
geted benefit Has been associated with sign ificantly
h igher i rritation than other retinoids I t is ava i l a ble in
0 1 % and 0.05% gels and in 0 1 % and 0.05%
crea ms It is cu rrently FDA a pproved for topica l acne
thera py and plaque psoriasis
• Skin l ighte n i ng agents-these prod ucts act to i n h i bit
one or more ste ps in the mela n i n biosynthesis pathway
The main target is tyrosi nase, wh ich is the rate- l i m iting
step i n mela n i n prod uction (Ta ble 2.3)
-Hyd roq u i none-phenolic compound fou n d natu ra l ly
in m a ny pla nts, coffee, tea , bea r, and wine
I n h i bits conversion of tyrosi nase to mela n i n
Decreases tyrosi nase activity b y 90%
May i n h i bit D N A synthesis
M ay i n h i bit RNA synthesis
TABLE 2.3 • Ski n Lightening Agents
• Tyrosi nase i n h i bitors Hyd roq u i none
Aloes in
Arbuti n
Ascorbic acid Flavonoids Gentisic acid Hyd roxycou marins Koj ic acid Licorice extract
Trang 23Ca n be cytotoxic to mela nocytes prod ucing i rre
versible cel l damage with monobenzyl ether of
hyd roq u i none
Concern rega rd ing carcinogenic potentia l-cu rrently
heavily regulated and/or ba n ned in Europe, Asia,
a n d severa l African cou ntries
Ava ila ble i n over-the-cou nter prod ucts up to 2%
and by prescription i n 3% to 4% concentrations
Ca n be compounded u p to 10% concentration
Cu rrently ava i l a ble in combi nation with topica l
reti noid acid a n d topical steroid a n d with other skin
l ighte n i ng agents
-Reti noic acid
Accelerate epidermal turnover resulting i n incre
ased keratinocyte shed d ing lea d i ng to pigment loss
May i n h i bit tyrosi nase ind uction
May result in keratinocyte pigment d ispersion
May i nterfere with kerati nocyte pigment tra nsfer
-Natu ra l cosmeceuticals
Koj ic acid-d erived from va rious fu nga l species
such as Aspergillus and Penicillium Primari ly used
as a food preservative and to promote the redden
ing of u n r i pe strawberries Genera l ly used i n 1% to
4% concentration N oted to have h igh sensitizi ng
potentia l
Licorice extract-derived from the root of G/ycyrrhiza
g/abra linneva I ts main active i ngred ient is
gla brid i n It i n h i bits tyrosi nase activity with associ
ated cytotoxicity It has been shown to be 1 6 x
more efficacious t h a n hyd roq u i none
Azelaic acid-derived from Pityros poru m ovale Its
mec h a n ism of action i n not fu lly u nderstood It
works best on active melanocytes
Aloesin-derived from aloe vera It acts as a com
petitive i n h i bitor on DOPA oxidation and noncom
petitive i n h i bitor on tyrosine When used in
combi nation with a rbuti n , it has been demon
strated to i n h i bit UV-ind uced melanogenesis
Arbutin-derived from the bea rberry It acts to
i n h i bit mela nosomal tyrosi nase activity Ava i l a ble as
a mono treatment or i n 1% concentration with other
depigmenti ng agents
Paper m u l berry-derived from the roots of an orna
mental tree, Broussonetia papyrifera
Soy-acts to i n h i bit kerati nocyte melanosome
phagocytosis, thus red ucing mela n i n tra nsfer
Cosmeceutica l effect noted only with fresh soy m i l k
N iacinamide-acts t o i n h i bit melanocyte transfer
Also exh i bits anti- i nfla m matory a n d a nti-oxidant
properties
Table 2.4 • Use of the ''teaspoon rule" for sunscreen application can be beneficial in educating patients on the proper of amount of sunscreen that should be appl ied with each appl ication
Use of m ore tha n half a teaspoon each on:
• Head and neck region
• R ight a rm
• Left arm Use of m ore than a teaspoon each on:
Trang 24Ascorbic acid-acts at va rious oxidative steps
in mela n i n synthesis by i nteracting with copper ions
at the tyrosi nase active site a nd red ucing dopa
q u i none
G lycolic acid-has a n epidermal d iscohesive effect,
resulting in increased epidermal turnover for
increased shed d i ng of pigme nted kerati nocytes
Should be used i n lower concentrations to avoid
skin i rritation
I N D I CAT I O N S
• Red uce t h e occu rrence o f acti n i c keratoses a n d
non-melanoma skin cancer
• Red uce the formation of skin aging
• Eva l uation of pre-existing a l lergies t o a n y active i ngred ient
• Past prod uct use a nd res ponse
I DEAL CAN D I DATE
• All patients benefit from the d a i ly a ppl ication of a topi
cal su nscreen , SPF 30 or greater
• Patie nts with rea l istic expectations that topica l medica
tions may provide preventative benefits a n d a re less
l i kely to red uce moderate to d eep rhytides
LESS THAN I DEAL CAN DI DATE
• U n real istic patient expectations
• Patients with ma rked ly d ry or sensitive ski n-topical
treatments may exacerbate cond ition
CONTRA I N D I CAT IONS
• Pre-existing a l lergy t o active i ngred ient
• Use of topical treti n o i n , sa l icylic acid, and skin l ighten
ing agents i n pregnant a n d lactati ng women
APPLI CATION TECH N I QU ES
• A su nscreen shou ld be appl ied a m i n i m u m of 30 m i n
utes prior t o sun exposure
Trang 25• Approximately 35 m l is the average a m o u nt of sunscreen that should be a ppl ied to the average-sized
a d u lt with each appl ication This tra nslates to a teaspoon (approxi mately 6 mU of sunscreen to each leg, back, and chest a n d half a teaspoon ( a pproxi mately
3 m l) a p pl ied to the a rms, face, a nd neck for fu l l coverage (Ta ble 2.4)
• Topical retinoic acid prod ucts should be a ppl ied spa r
i ngly to treatment a reas 30 m i n utes after washing to
m i n i m ize potentia l for i rritation
• B leac h i ng crea ms should be appl ied to hyperpigmented treatment a reas on ly, with efforts made to avoid
u n i nvolved ski n
COM PLICATI ON$
• Contact a l lergic dermatitis
• Contact i rritant dermatitis
sun-• Hyperpigmentation with blea c h i ng crea m use
• Exogenous ochronosis with bleach i ng crea m
• Hypopigm entation with blea c h i ng c rea m
• Potentia l carcinogenic risk of hyd roq u i none use
POSTTREATMENT CAR E
• Strict photo protection should b e followed dai ly, including sun avoidance as m u c h as possi ble, the use of a daily su nscreen S P F 30 or greater, use of a widebri m med hat, a n d s u n protective cloth ing
PEARLS FOR TREATM ENT S U CCESS
• M i n i m ize the n u m ber of prod ucts a ppl ied daily to avoid the potentia l for i rritation
• Check the expi ration dates of a l l prod ucts a ppl ied This
is pa rticular key for sunscreens, as the active i ngred ients may not provide benefit beyond the recommended date of use
• Topical retinoic acid prod ucts shou ld be d isconti n u ed
2 weeks prior to facial proced u res such as waxing or tweezing i n order to avoid skin d esq ua mation
Trang 26• B leac hing agents should be disconti n ued if red ness or
irritation d evelops, as they may worse n existing pig
mentatio n
• It is usefu l t o d isconti n ue t h e use o f a hyd roq u i none
crea m every 3 to 4 months to dec rease the risk of
exogenous och ronosis and to prevent side effects
B I B LIOG RAPHY
B ruce S Cosmeceuticals for the atten uation of extrinsic
and i ntrinsic dermal aging J Drugs Dermatol, 2008;
7(2 S u p p l ) : s 1 7-s22
Colven R M , Pinnell S R To pica l vita m i n C in aging Clin
Dermatol 1 996; 14: 227-234
Dreher F, Maibach H Protective effects of topica l antioxi
da nts i n h u mans Curr Probl Dermatol 2000;29: 1 57-164
Fisher GJ , Ta lwa r HS, Lin J, et al Molecular mechanisms
of photoaging i n human skin i n vivo and their prevention
by a l l -tra ns reti noic acid Photochem Photobiol 1999;69 :
1 54- 1 5 7
Gensler H L, Aickin M , Peng Y M , e t a l I m porta nce o f the
form of topica l vita m i n E for prevention of photoca rcino
genesis Nutr Cancer 1996;26 : 1 83- 1 9 1
Gueva ra I L, Panda AG Melasma treated with hyd ro
q u i none, treti noin and a fluori nated steroid lnt J Dermatol
200 1 ;30: 2 1 2 -2 1 5
Ka ng S, Voorhees J J Photoaging thera py with topica l
treti n o i n : An evidence-based ana lysis J Am Acad
Dermatol 1 998;39:S55-S6 1
Kligman A M The growi ng i m porta nce of topica l reti noids
i n c l i n ical dermatology: A retrospective a nd prospective
ana lysis JAm Acad Dermatol 1998;39:S2-S7
Lin HW, Naylor M, Hon igma n n H , et al America n
Academy of Dermatology Consensus Conference on UVA
protection of su nscreens, s u m m a ry and reco m menda
tions JAm Acad Dermatol 2000;44: 505-508
Naylor M , Boyd A, Smith D, et a l H igh sun protection
factor su nscreens i n the s u ppression of acti nic neoplasia
Arch Dermato/ 1995; 1 3 1 : 1 70- 1 7 5
Ogden S , Sa muel M , G riffiths SE A review o f taza rote ne
i n the treatment of photoda maged skin Clin lnterv Aging
2008;3( 1 ) : 7 1-76
Pica rd M, Ca rrera M N ew and experi menta l treatments
of ch loasma and other hypermela noses Dermatol Clin
2007 ; 25:353-362
Schneider J The teaspoon rule of a pplying sunscree n
Arch Dermatol 2002; 138:838-839
Solano F, B riga nti S, Picardo M, et al Hypopigmenti ng
agents: An u pdated review on biologica l , chemical a n d
c l i n ical aspects Pigment Cell Res 2006; 1 9 : 550-57 1
Trang 27CHAPTER 3 Soft Tissue Aug m e ntatio n
M ECHAN I S M OF ACT I O N
Use of a synthetic or biologica l prod uct or surgical restruc
turing for the replacement of vol ume loss and enha nce
ment of derma l , su bcutaneous, and m uscular deficiencies
that resu lt from trauma, surgical defects, l i poatrophic con
d itions, photoaging, or chronological aging
I DEAL FI LLER (Table 3.1)
• B iocom pati ble
• Provid es reprod uci ble cosmetica l ly beneficial res u lts
• FDA a p p roved if not a utologous
• Demonstrates m u ltipu rpose use
• N o side effects
• Easy to remove in the event of a poor cosmetic outcome
TABLE 3.1 • Commonly Used F i l l ing Agents
Name
Adatosil 5000 ( Dow-Corning, Midland, M l )
Al loderm ( Life Cell Corp., B ra n c h b u rg, N J ;
O baj i Medica l , C h i cago, I L)
Aq uamid (Contu ra I nternationa l , Soebora ,
Den mark)
Artefi l l (Canderm Pharma, I n c , Quebec,
Ca nada; Medical I nternational BV, B reda,
The N etherla nds)
Belotero Soft; Belotero Basic ( M erz
Pha rma , Fra n kfu rt, Germa ny)
Bio-Aica m i d ( B rind is, Italy)
Ca ptique™ ( l named Corp, Sa nta
Monica, CA)
Cosmoderm™, Cosmoplast™ (AIIerga n ,
I rvine, CA)
Cymetra Life Cell Corp , B ra n c h b u rg, N J ;
O baji Medica l , C h icago, I L
Com position FDA approval Skin testing req u i red
cadaveric dermal a l l ograft
Non-a n i ma l-sta bil ized hya l u ronic Yes N o acid ( NASHA) derived from plant
Recom b i na nt h u m a n col lagen Yes N o
Ace l l u l a r processed lyo p h i l ized
h u m a n cadaveric tissue
No
Longevity Permanent
1-2 yr
Permanent Perma nent
4-6 mo Perma nent
4-6 mo
4-6 mo
4-6 mo
(continued)
Trang 28TABLE 3.1 • Commonly Used Filling Agents (Continued)
Name
Fascian ( Fascia B iomaterials, Beverly
H i l ls, CAl
Fat, su bcuta neous
Hylaform® ( B iomatrix I n c , Ridgefield, N J ;
! na med Corp , Santa Monica, CAl
lsolagen ( l solagen I n c , Houston , TXl
J uved erm™ U ltra , U ltra XC, U ltra Pl us,
U ltra Plus XC (AIIerga n , I n c , I rvine, CAl
Prevelle Silk ( Mentor Corporation, Sa nta
Barba ra , CAl
Rad iesse™ ( B ioform Med ical, San
Mateo, CAl
Restylane, Restylane-L, Perlane,
Perlane L™ (Q-Med AB, Sweden;
Medicis, Phoenix, AZl
S i l i kone- 1 000, Adatosil-5000 (Alcon La bs,
I nc, Fort Worth, TXl
Softform ( McGhan Med ical, Santa
Barbara , CAl
Scul ptra ™ ( B iotech I nd ustry, SA,
Luxe m bourg; Derm ik, Berwyn, PAl
Zyderm®, Zyplast® (AIIerga n , I rvine, CAl
PREOPERATIVE EVALUATION
Com position
H u man cadaveric preserved
pa rticu late fascia lata Autologous
Hya l u ronic acid derived from domestic fowl coxcom bs Autologous fibro blasts
N on-a n i m a l-sta b i l ized hya l u ronic acid ( NAS HAl derived from bacteria l fermentation XC formu lations with 0.3% lidoca ine Non-a n i ma l -derived hya l u ronic acid with 0.3% lidocaine Synthetic calci u m hyd roxyla patite
Non-a n i ma l-sta bil ized hya l u ronic acid ( N ASHAl derived from bacterial fermentation
L form ulations with 0.3% lidocaine
Silicone
Gore-Tex
Lyop h i l ized poly- L-Iactic acid
Bovine col lagen
• Identify the a ppropriate patient and treatment region
-Sign ificant past medical h istory, i n c l u d i ng h istory of
bleed i ng or clotting d isorders; keloid formation ; exist
ing d rug a l lergies; i m m u nocom promised state
-Cu rrent med ication use; past or current isotreti noin use
-Past surgica l i nterventions, yea r, and treatment
response
-C l i n ical eva l u ation to determ ine if the d esi red treat
ment a reas a re a menable to correction; outl i ne base
line structu ra l i rregula rities
-Discuss l i ne softe n i ng versus vol u me replacement for
fi l ler selection
-Discuss med ications to avoid 1 0 days preoperatively
when med ica lly safe, i n c l u d ing aspiri n , nonsteroidal
med ications, vita m i n E s u pplements, St J o h n 's Wort,
a n d other herbal medications that have an a nticoagu
Trang 29• Disc uss the risks a n d benefits of the treatment
-Al lergic reaction, loca l ized versus systemic
-Proced u ra l and postoperative d iscomfort
-Postoperative edema
-Postoperative bru ising
-Sca r formation
-I nfection
-Reactivation of herpes sim plex virus
-I ncomplete a ugme ntation
-I rregular contou r/textu re
• Identify contra i n d ications to treatment
-Active i nfection at the treatment site
-Nond istensi ble, rigi d , or icepick sca rs
-Extensive jowl formation, prom i nent folds, and furrows
-Underlying connective tissue d isorder
-U n real istic expectations
• Outl ine the pred icted outcome and l i m itations to the
treatment
-Duration of correction
-Postoperative recovery period
-Tissue sou rce
-Expense
S K I N TESTI NG (WH EN APP L I CAB LE)
• I n itial test d ose-two skin tests recom mended
-I njected in tu berc u l i n manner i nto volar forea rm
-Fou r-week o bservation period for fi rst test
-Repeat skin test placed in opposite forea rm
-Two-week observation period for second test
• Retest d ose-si ngle test recommended
- For new patients who have received treatment by
another physician or patients who have not received
treatment for more than 1 yea r
-Two-week observation period recom mended
• Positive fi ller reaction
-Swe l l i ng, i n d u ration, tenderness , or erythema that
pe rsists or occ u rs 6 hours or longer after test i m plan
Trang 30AN ESTH ES I A
• I njection of soft tissue fil lers may b e pa i nfu l , especia l ly
with treatment of the l i ps Most patients req u i re some
form of anesthesia to m i n i m ize treatment d iscomfort
• "Ta l kesthesia , " hand-hol d i ng, vibratory massager nea r
the treatment site a re usefu l for patient d istraction
( Fig 3 1 )
• Topica l anesthesia ca n b e uti l ized for small treatment
a reas Commonly used agents include Betaca ine
Enhanced Gel (Canderm, Quebec, Canada ) , Betaca ine
P l us (Canderm, Quebec, Canada ) , L-M-X-4 and
5 ( Ferndale La bs, Ferndale, M l ) , E M LA (AstraZeneca,
Boston , MA), and ice ( Fig 3.2)
• Lidoca ine i ntegrated d i rectly i nto the fi ller may e l i m i
nate the need for a lternate forms of a n esthesia
• Regional nerve blocks a re easily a d m i n istered prior to
treatment The patient should avoid extremely hot or
cold beverages and foods for 2 to 3 hours after menta l
and/or i nfraorbita l nerve blocks t o avoid m u cosa l i nj u ry
d ue to i n a b i l ity to detect tem perature acc u rately
• Loca l ized tumescent anesthesia is util ized for fat
extraction with a utologous fat transfer
• I nfi ltrative anesthesia is to be avoided to obviate tissue
d i stortion of the treatment site
PROCEDU RAL M ED I CAT I O N S
• Va ltrex 500 mg B I D x 5 t o 7 days i n itiated 1 day prior
to the proced u re for patients with a h i story of herpes
sim plex virus in or nea r the treatment site
• Keflex 500 mg B I D x 7 days i n itiated 1 day prior to the
proced u re for patients undergoing a utologous fat trans
fer or Gore-Tex i m pla ntation
• Diazepa m 5 to 1 0 mg can be offered to a nxious
patients 30 m i n utes prior to the proced u re
LEVEL OF I NJ ECT ION (Fig 3.3)
• Su perficial dermis: fi ne l i nes; verm i l ion border l i p a
ug-mentation
Zyderm I, I I ; Cosmoderm I, I I ; Restylane Fine Line;
Hylaform Fine Line
• M i d to deep dermis: su perficial to moderate rhytides,
sca rs, and d efects; lip a ugmentation
Ca ptiq ue; Cosmoderm I I , Cosmoplast; Hylaform;
J uved erm U ltra ; Prevelle S i l k ; Restylane; Zyderm I I ,
Zyplast
• Deep dermis, s u bc uta neous fat, and m uscle: deeper,
more su bsta ntia l defects and rhytides ( Fig 3.4)
Autologous fat transfer; Gore-Tex; Hylaform P l us;
J uved erm U ltra Plus; Perla ne; Rad iesse; Scul ptra
Epidermis
Fat
Figure 3.3 Recommended filler injection depths (Adapted from Keyvan
N, Susana L-K, eds Techniques in Dermatologic Surgery United Kingdom: Mosby; 2003.)
A
B Figure 3.4 (A) Prominent nasolabial folds prior to augmentation with hyaluronic acid (B) Softening of folds after 3 c hyaluronic placed into treatment sites
Trang 31• Com bi nation dermal, su bcuta neous, and m uscle:
defects with both a su perficial and a d eep com ponent
uti l ize both a su perficial and deep fixer for opti mal aug
mentation ( Fig 3.5)
I NJ ECT I O N TECH N I QU E (Fig 3.6)
• Seria l pu nctu re : closely spaced punctu res created
a long l i nes, folds ( Fig 3 7 )
• Li nea r threa d i ng: withd rawa l o f fi ller a long t h e length
of the facial defect as a conti n uous th read of material
( Fig 3.8)
• Fa n n i ng: s i m i l a r to l i near threa d i ng N eed le d i rection is
conti n ua l ly cha nged without withd rawing the need le
tip Usefu l for ora l com m issu res, u pper nasola bia l A
folds
• Cross-hatc h i ng: similar to l i near threa d i ng Material is
i njected at right a ngles to the fi rst i njections Used for
shaping facial contours
DEG R E E OF COR R ECT I O N
• Dependent o n the fi ller used I n genera l , overcorrection
is not recommended The most com mon tec h n i q u e
error is under-correctio n
• M u lti ple treatment sessions a re genera l ly req u i red for
vol ume replacement agents, includ i ng sil icone and
poly-L-Iactic acid
DU RAT I O N OF COR R ECTION
Dependent on t h e material i m planted , i m pla ntation tech
n i q ue, a n d a m o u nt i m planted , the type of d efect and
mechan ical stresses at the i m plantation sites
ADVERSE R EACTIONS
• H y perse n s i t i ve
• Prolonged e rythema and edema at i njection sites
• Cyst/a bscess formation-long-lasti ng; can persist for
more than 2 to 3 yea rs
• I nfection-incl udes reactivation of herpes s i m plex virus
and bacterial i nfection
B Figure 3 5 (A) Facial lipoatrophy with "sunken cheek appearance " prior
to Cymetra treatment (B) Improvement of cheek volume after Cymetra treatment, 2 0 cc total volume
Trang 32• Necrosis-d ue to vasc u l a r com promise at the treat
• Tec h n i q u e Com p l i cat i o n s
• I rregular texture-d ue to u neven placement
• Bea d i ng-d ue to too superficia l p lacement ( Fig 3.9)
• I m pla nt rejection-due to too su perficia l placement
• Necrosis-due to vascu l a r i njection or vascular com
pression
PEARLS FOR TREATM ENT S UCCESS
• With fi llers, the affected treatment sites should be fu l ly
a ugmented to ensu re an even, complete a ugmentation
U nder-correction will lead to a n i nadeq uate a ugmenta
tion and patient d issatisfaction With m ost tem pora ry
fi l lers, this is obta i ned at the fi rst treatment Permanent
fi l lers req u i re repeat treatments for correction comple
tio n
• With tem pora ry fi l lers, patients must understa nd that
the treatment response is va riable and can last less
than or greater tha n the average expected time Re peat
treatment will be req u i red over time
• Patient expectations must be tem pered to m i n i m ize
u n rea l istic expectations a bout fi ller benefits Patients
m ust be awa re that the treatment end point is a soften
ing of the affected a reas
• Postoperative bea d i ng is ge nera l ly responsive t o local
ized massage over 5 to 7 days Persiste nt bead ing can
be corrected by i njecting 2 mg/m l of tria mci nolone
acetonide i nto the bead or by 1 1 -blade i ncisional
extraction of the fi l ler material
• A thorough preoperative eva l uation is necessa ry to
ensure that there a re no contra i nd i cations to fi ller use,
especial ly when using perma nent fi l lers
• Conservative a ugmentation of the gla bel lar region is
c ritica l to avoid vasc u l a r necrosis
B I B L I OG RAPHY
Beer K, Solich N Hya l u ron ics for soft tissue a ugmenta
tion : Practical considerations and tec h n ical recommen
dations J Drugs Dermatol 2009;8( 1 2 ) : 1 086- 1 09 1
Clark D P, H a n ke CW, Swa nson N Derma l i m plants:
Safety of prod ucts i njected for soft tissue a ugmentation J
Am Acad Dermatol 1 989;2 1 :992-998
Figure 3.6 Injection techniques A Linear threading technique B Serial puncture technique (Adapted from Keyvan N, Susana L-K, eds
Techniques in Dermatologic Surgery United Kingdom: Mosby; 2003.)
Figure 3.7 Serial puncture method of injection
Trang 33Cohen J L U ndersta n d i ng, avoid i ng and ma naging der
mal fi ller compl ication Dermatol Surg 2008; (34 Su ppl
1 ) :S92-S93
Colem a n S R Facial recontou ring with l i posc u l pture Clin
Plast Surg 1 997;24(2) :347-367
Glaich AS, Cohen J L, Gold berg LH I njection necrosis of
the gla bel la: Protocol for prevention and treatment after
use of dermal fi l lers Dermatol Surg
2006;32(2):276-281
J ones D H Sem i permanent a nd perma nent i njecta ble
fi l lers Dermatol C!in 2009;27(4) :433-444
Matarasso SL I njecta ble collagens: Lost but not forgot
ten-a review of prod ucts, ind ications and injection tech
niq ues Plast Reconstruct Surg 2007; 1 20(6 Suppl ) :
1 7S-26S
Schuller- Petrovic S I m p rovi ng the aesthetic aspect of soft
tissue defects on the face usi ng a utologous fat tra nsplan
tation Facial Plast Surg 1997 ; 13(2) : 1 9-24
Figure 3.8 Linear threading method of injection
Figure 3.9 Filler beading due to too superficial placement
Trang 34CHAPTER 4 B otulinum Toxin
PHARMACOLOGY
Botu l i n u m toxin is a protei n prod uced by the bacteri u m
Clostridium botulinum Seven serotypes exist, designated
as A, B, C 1 , D, E, F, a n d G Eac h one of them is a pro
tease with a l ight chain l i n ked to a heavy chain by a d isul
fide bond
Each is a ntigen ica l ly d istinct H owever, botu l i n u m toxin
A ( BTX-A) , B ( BTX-B ) , a n d F a re the only serotypes c u r
rently ava i lable for c l i n ical use (Ta ble 4 1 )
TABLE 4 1 • Botulinum Toxin Preparations
Type
Botox Cosmetic (AIIerga n I n c , I rvine,
CA)-type A
Relaxin ( Medicis Esthetics, Scottsdale,
AZ), Dysport ( I psen Lim ited , Berkshire,
U K)-type A
Reloxi n/Dysport
Myobloc (Soltice N e u rosciences, San
Francisco, CA)-type B
Xeo m i n ( Merz Pha rmaceutica ls,
Fra n kfu rt, Germa ny)-type A
Neuronox ( M edy-Tox, I n c , Seo u l ,
South Korea )-type A
Prosigne ( La nzhou I nstitute of B iologica l
Prod ucts, La nzhou, China )-type A
M ECHAN I S M OF ACT I O N
U n its toxi n/bottle
1 00 U lyo p h i l ized powder
500 U i n lyo p h i l ized powder
Average 1-2 5 mL i n preservative-free o r preserved sa l i n e
2 , 500, 5,000, and 10,000 U/m L aq ueous solution
1 00 U via l
100 U vial
50 U vial and 100 U vial
I n h i bition of acetylcholine release at the neurom uscu lar
j u n ction resulting i n m uscu la r flaccid pa ra lysis Receptor
site binding is med iated by the heavy chain portion of the
toxi n , is specific for the toxin serotype, and is i rreversible
Once bou nd, the receptor-neurotoxin complex is inter
nal ized i nto the nerve term inal and the toxin l ight chain
acts as a protease to cleave specific synaptic protei n
peptide bonds req u i red for acetylcholine formatio n The
ta rget of BTX-A is the syna ptasome-associated protei n of
25 k Da , SNAP-25 BTX- B and BTX-E cleave the vesicle
associated mem bra n e protein, syna ptobrev i n
Dosing eq u iva lents
Reported 1 U Botox = 1 U Neuronox
N ot wel l esta bl ished
D i l ution
Average 1-4 mL in preservative-free or preserved sa l i n e
M a y b e used as is or d i l ute with sa line
N ot wel l esta bl ished
N ot wel l esta b l is hed
N ot wel l esta blished
Trang 35D I LUTION
BTX-A i s stored i n lyophil ized vials It ca n b e reconsti
tuted in preserved sa line or preservative-free sa l i n e
Dil utions va ry accord ing t o physicia n preference a n d
experience with BTX A d i l ution ra nges from 1 m l
( 1 0 U/0 1 cc) t o 4 m L ( 2 5 U/0 1 cc) Dysport d i l uted to
2 5 ml wi l l atta i n a concentration of 20 U/0 1 cc The
i njected vol u me m ust be sufficiently sma l l to provide
accurate toxin del ivery without a n excessive vol u me
effect or del ivery of toxin to surro u n d i ng m u scles other
tha n the targeted m uscles The vol u me m ust be suffi
ciently large to permit acc u rate i njection i nto the targeted
m uscles
CONTRA I N D I CAT I O N S
• Abso l u te
• U nderlying neurom uscular cond ition such as
myasthe-n ia gravis or a myotrophic latera l sclerosis
• Pregnancy/breast-feed ing-pregna ncy category C
• Active i nfection in treatment a rea
• U n rea l istic patient expectations
• R e l at i ve
• Ca l c i u m channel blockers use-may potentiate effect
• A m i n oglycoside a nti biotic use-may potentiate effect
• Patients who a re dependent on facial expression for
their live l i hood (eg, actors)
• Prominent eyelid ptosis, heavy brow or ectropion
PREOPERATIVE EVALUATION
• Patient expectations must b e defi ned a n d matched
with the expected treatment outcomes
• Patient med ical history
• Past treatment history a n d outcome
• C l i n ical eva l uation
• Determ ine location and extent of i nvolvement of the
treatment site
• Docu ment asymmetries noted ; presence of ptosis/l id
laxity/brow prom i nence
• Lower Eye l i d " S n a p B a c k " Test to
Assess Lower L i d Lax i ty
The middle of the lower l i d is grasped between the index
finger and the th u m b and pul led forwa rd a n d u pwa rd
The lid is then released a n d a l l owed to "sna p" back
Trang 36aga i nst the globe A q u ic k return to its norma l state indi
cates minimal laxity Botu l i n u m toxin to this region can
provide benefit A slow return of skin to its natura l posi
tion ind icates sign ifica nt laxity Botu l i n u m toxin should
not be used i n these patients, as it may accentuate the
l i nes present
PROCEDU R E
• Patient consent o bta i ned
• Preoperative pictures ta ken at rest and with targeted
m usc le grou ps contracted
• Pretreatment with topica l anesthetic or ice for pa i n
red uction
• Patient placed u p right
• Treatment a reas wi ped with a lcohol
• I njections a d m i n istered Use of 1 ml syri nges with a 30
to 32 ga uge need le is freq uently util ized Use of i nsu l i n
syringes with a n integrated 30-ga uge syri nge and a
h u bless system may hel p to red uce toxin vol u m e loss
M U SCLE G RO U PS
A thorough knowledge of the facial m uscu latu re and
facial a natomy is req u i red for the proper use and place
ment of botu l i n u m toxin ( Fig 4 1 )
• Fore h ead-Fro n ta l i s M u sc l e
( F i gs 4 2 a n d 4 3 )
Insertion: Originates at fronta l bone ga lea a poneurotica
and i nserts i nto fibers of the procerus, corrugator, and
orbicu l a ris oc u l i
Function: O pposes depressor m uscles o f t h e glabellar
com plex a n d brows to elevate the brow and forehead
Lines noted: Horizonta l l i nes across the forehead
Injection technique: 2 to 3 u n its ( U ) added at 1 5-cm
i nterva ls across the m idforehea d , a m i n i m u m of 2 e m
a bove t h e u pper brow
Dose injected: Average 12 to 20 U
Avoid:
• Excess treatment of this m uscle; unopposed depressor
fu nction wi l l result in loss of u pper facial expression, a
"ti red " a ppea ra nce, a n d risk of brow ptosis
• Treatment of this m uscle if the fronta lis is supporting a
ptotic u pper eyelid or if the patient has low-set brows
and/or excess u pper eyelid skin
• I nject 1 e m a bove the eyebrows to red uce the risk of
brow ptosis Patient m ust be awa re that residual l i nes
wi l l be present after the treatment if low forehead wrin
kles a re present
A
B Figure 4.3 (A) Forehead lines prior to B TX-A treatment (B) Forehead lines 1 month following BTX-A treatment
Trang 37• I njection too close to the med ial orbita l ri m ; toxin d iffu
sion through the orbital septum to the levator pa l pebrae
su perioris and orbicula ris m uscles may lead to d i plopia
• G l a b e l l a r Co m p l ex-Th e Corrugator
S u perc i l i i , the Procer u s , M ed i a l
O rb i c u l a r i s O c u l i , a n d Fronta l i s
M u sc l es ( F i gs 4 4 a n d 4 5)
Insertion: Originates a t the nasa l process of the fronta l
bone and extends latera lly a n d u pward to i nsert i nto the
m id d le third of the eyebrow
Function: Opposes elevator m uscles of the fronta lis for
brow add uction and brow/skin downward and med ial
movement
Lines noted: Frown l i nes; "a ngry" or "worried " a p pea r
a nce
Injection technique: Fema les have a rc hed eye brows;
ma les have flatter or horizonta l eyebrows; tec h n i q ue ta i
lored to match the brow sha pe; 3 to 1 0 U i nto the pro
cerus; 4 to 6 U in the i nferior and su perior bel l i es of the
corrugators; 2 to 3 U i nto the medial orbic ularis ocu l i
Dose injected: 1 5 t o 4 0 U (dependent on m uscle mass)
Avoid:
• U ndertreatment of this region
• Too low of a n i njection resu lting i n toxin d iffusion i nto
the orbital septu m and orbit with resu lta nt l i d ptosis
Pal pation of the su perior bony orbita l ri m with i njection
1 e m or more a bove this land mark helps to m i n i m ize
Insertion: Enc i rcles the periorbita l region a n d i nserts i nto
the medial and latera l canthal tendons as wel l as i nto the
fibers of the fronta l , procerus, and corrugator su perc i l i i
m usc les
Function: Forcefu l closure of the eyes and depression of
the brows and eyelids
Lines noted: Latera l canthal l i nes; "crows feet"
Injection technique: 3 to 5 U a re i njected i nto th ree
poi nts in a vertica l line 1 em from the latera l canth us; if a
strong sna p test is noted , 2 to 4 U can be placed 3 e m
below the mid pupil lary l i ne
A
B Figure 4.5 (A) Glabellar complex before BTX-A injection and (B) 3 weeks following BTX-A injection
Trang 38Avoid:
• I njection of the i nfraorbita l region if a delayed snap test
is noted; ectropion of the i njected l i d may develop
• Overtreatment of this a rea ; i m proper eye closure, brow
ptosis, or l i d ptosis may ensue
• An i njection ai med too low at the lower periorbita l wrin
kles Wea ken ing of the levator labii su perioris m uscles
with an u pper l i p d roop and a bnorma l s m i l e may be
observed
• U p per N asa l R oot ( F i g 4 8)
Insertion: Encircles the periorbita l region a n d i nserts i nto
the medial a n d latera l ca ntha l tendons as wel l as i nto the
fibers of the fronta l , procerus, and corrugator su perc i l i i
m usc les
Function: Nasa l wri n k l i ng
Lines noted: U pper nose fa n n ing rhytides; " bunny l i nes"
I njection tec h n ique: 2 to 4 U is i njected i nto each latera l
nasa l wa l l i nto the belly of the u pper nasalis as it traverses
the dors u m of the nose
Dose injected: 4 to 8 U
Avoid: I njection i nto the u pper nasofacial groove may
resu lt i n lip ptosis
Use of botu l i n u m toxin i n the lower face is m i n i ma l ly
beneficial Other treatment modal ities a re l i kely to be
more beneficial with fewer potentia l side effects A strong
u ndersta n d i n g of the lower face and neck a natomy is crit
ical for i njection placement ( Fig 4.9)
• N aso l a b i a l Fo l d ( F i gs 4 1 0 a n d 4 1 1 )
It is key to weigh the l i m ited benefit of BTX-A in this
region com pa red with the i ncreased risk of compl ica
tions F i l l i ng agents may provide greater benefit with
fewer side effects
Insertion: Result of skin laxity, gravitational ptosis, a n d
su bcuta neous fat loss overlying t h e c uta neous attach
ment i n the zygomaticus major a n d m i nor, levator labii
su perioris, a n d levator labii su perioris a laeq ue nasi
m usc les
Function: Associated with mouth a n d l i p movement
Lines noted: Pro m i nent c rease, med i a l c heek; "gummy
show"
Injection technique: 1 to 2 U i njected i nto the u pper
aspect of the nasola bial fold 2 to 3 m m latera l to its inser
tion with the nose
Dose injected: 2 to 4 U
Avoid:
• Complete relaxation of this a rea ; u pper l i p ptosis c reat
ing a sad a ppea ra nce may occ u r
Trang 39• Uneven pa ra lysis; a n asymmetric smile or d ispropor
tionate l i p may be seen
• Per i ora l R eg i o n-O rb i c u l a r i s O r i s
w i t h Contri b u t i n g F i bers from
the B u cc i n ator, C a n i n u s , a n d
Tr i a ngu l a r i s M u sc l es ; Depressor
Angu l i O r i s ; M e n ta l i s M u sc l e
( F igs 4 1 2 a n d 4 1 3 )
Insertion: Orbicula ris oris origi nates from the maxi llary
a lveolar border ru n n i ng circu mferentia lly a round the
mouth to the overlyi ng cuta neous attach ments; d epres
sor a ngu l i oris ( DAOl a rises from the mand i bu la r oblique
line, i nserting i nto the a ngle of the mouth It is conti n uous
with the platysma m uscle; menta l is m uscle origi nates
from the mandibular incisive fossa and d escends to a
cuta neous i nsertion
Function: Opposition and protrusion of the l i ps; mouth
a ngle depression; lower lip protrusion and chin d i m p l i ng
Lines noted: Deep and superficial rhyt id es, u pper and
lower l i p ; promi nent angular folds, "sad a p pea rance";
c h i n wri n kling
Injection technique: 0 5 to 1 0 U i njected 2 to 3 m m
a bove t h e verm i l ion border i n fou r a reas each for the
u pper and lower lip; 1 to 2 U i njected at the i ntersection
of a line d rawn from the nasolabial fold and a n a rea 1 em
a bove the jawl ine a ngle; 5 to 10 U i nto the i nferior m id
c h i n
Dose injected: 4 t o 8 U for t h e u pper and lower l i ps; 2 to
4 U for the DAO; 5 to 10 U for the mentalis m usc le
Avoid:
• Overtreatment of this a rea ; speech d ifficu lties, an
asym metric s m i le, i n a b i l ity to close the mouth, d rooling
and a ltered facial expressions may ensue
• Deep i njections; i n c reased risk of side effects
• Too h igh of an i njection for the DAO; i n a b i l ity to raise
the corner of the mouth may develop
• N ec k- P l atys m a M u sc l e Co m p l ex
( F i g 4 1 4)
Insertion: Origi nates on the fascia of the u p per pectora lis
major a n d deltoid m uscles a n d proceeds u pwa rd a n d
med ia l ly a long t h e sides o f t h e neck Fi bers a re inserted
i nto the mandi ble, su bcuta neous tissue of the lower face,
periora l m uscle, and skin
Function: Facial a n i mation; lower jaw depressio n ; lower
A u r i c u l aris su perior m usc le
A u r i c u laris anterior m usc le
-"71 'T- =-' ' T +- 0 rbicu laris oris m usc le
:.dr!'J-f- Depressor angu l i oris m usc le
Depressor labii i nferioris m uscle
Figure 4.9 Anatomical illustration of the musculature of the lower face and neck
Trang 40Injection technique: 2 to 5 U i njected from the s u perior to
i nferior portion of each platysma! ba nd at 1 to 1 5 em
i nterva ls with the patient's teeth clenched to contract the
m usc le d u ring i njection
Dose injected: 20 to 1 00 U
Avoid: Too deep an i njection; neck wea kness, laryngea l
m usc le wea kness, or dysphagia may develop
POSTOPERATIVE CON S I DERAT I O N S
• I c e or cold compresses may b e a pplied to red uce pos
sible bruising and edema
• Active contraction of the treated m uscles for 20 to 30
seconds every 30 m i n utes for 4 hours afte r treatment
may exped ite toxin u pta ke
• Physical activity should be l i m ited for 4 hours after
treatment to avoid the theoretica l possibility of u nto
• Mask- l i ke expression less face
• Anti body resista nce
• Flu-l i ke sym ptoms
TREATMENT B E N EFITS
Recovery from BTX-A paralysis genera l ly begins at 3 to
4 months after i njection Patients who routinely receive
BTX-A may note the recovery time to exte nd to 4 to
6 months over ti me Side effects includ i ng eyelid a n d
eyebrow ptos is a n d bruising genera l ly resolve with i n 2 to
3 weeks of onset Treatment benefits may be lengthened
with concom ita nt conservative use of a fi ller for soft tissue
a ugme ntation
Figure 4 10 Approximate injection sites for nasolabial folds
Figure 4 1 1 Approximate injection sites for the perioral muscles
Figure 4 1 2 Approximate injection sites for the depressor anguli oris muscle