Ablative CO2 laser resurfacing using computerized scanners became widely used in 1995. Results were great, but so were challenges with healing and complications. Soon thereafter, ablative scanned Er:YAG lasers were also introduced as a less aggressive method, but even after significant technological improvements, skin tightening results with Er:YAG lasers, in the opinion of many users, were never of the level achieved by the CO2 lasers. For the past dozen years, ablative resurfacing, particularly with CO2 lasers, has remained the gold standard for treatment of age- and actinic-related rhytids of the facial skin. The combination of technological improvements with the lasers, experience in how to use these lasers, and know-how in managing the treated areas has dramatically reduced the problems that were initially encountered with these modalities. Nevertheless, prolonged healing time, need for intensive follow-up, significant complication risks, a high incidence of residual hypopigmentation, unimpressive results for acne scars, counterindication of use for darker skin types, and limitations of use for the face only have been major stimulants in the search for better alternatives. For a while, it was felt that nonablative resurfacing and skin tightening with lasers, broadband light, or radiofrequency devices would provide the searched for alternative. In spite of significant and ongoing improvements with nonablative technology, including such innovative ideas as the use of skin suction devices to better position the tissues for energy delivery, results of nonablative resurfacing have lagged far behind ablative techniques.

TOGETHER WITH the help of many of my friends and colleagues, I have attempted to provide the reader of this textbook with practical, up-to-date information on the broad range of cosmetic procedures that are generally performed in an office setting.

This textbook is focused on the common cosmetic applications of fillers; neurotoxins; laser, light, radiofrequency, and ultrasound devices; chemical peels; and microdermabrasion. Supporting chapters on anatomy, anesthesia, minimally invasive suture suspension lifts, and mesotherapy round out the text.

This is an international, multispecialty, multiauthored textbook. The fifty senior contributing authors include experts in various topics from the fields of dermatology, facial and general plastic surgery, and cosmetic surgery and medicine and hail from the United States, Canada, Europe, South America, and Asia. Because the United States lags far behind the rest of the world with respect to the variety of options available for fillers and neurotoxins, American readers can benefit greatly from such author diversity.

The sections on lasers and other energy devices for resurfacing, skin tightening, and treatment of fat and cellulite attempt to cover some of the most recent devices available, with some short sections devoted to specific individual brands. Brand names are frequently mentioned in this text, not to promote the products but to make it easy for readers to identify the products discussed.

Suture suspension methods using ordinary sutures weaved in and out of tissues and/or looped around tissue have been around for some time, but have never been proven very practical or effective. Problems with tissue puckering and the sutures eventually cutting through the tissue that was pulled up and suspended seem to doom this type of approach. One version of such lifts, the curl lift, is still being used by some cosmetic practitioners, and one of its strongest proponents, Dr. Pierre Fournier, still promotes it, but in the past couple of years, only its latest version, which can incorporate barbed sutures.

The introduction of cogged sutures, originally with small barbs, to distribute tension and induce tissue fibrosis seemed like a revolutionary concept that might lead to better results. The initial attempts to perform face lifts using sutures with multiple barbs, cogs, or anchors that distribute tension over a greater surface started in Russia with the use of bidirectional polypropylene barbed sutures. The concept was introduced in Russia a decade ago, by Dr. Marlen Sulamanidze, as APTOS threads. It was introduced in the United States in 2000. A U.S. patent for similarly barbed sutures by Duke University plastic surgeon Dr. Gregory Ruff apparently preceded the APTOS thread concept and was the basis for the development of ContourThreads. The original Sulamanidze 2.0 polypropylene self-anchoring APTOS threads had bidirectional small barbs and floated freely in the subdermis.

Laser skin resurfacing remains the most effective modality for skin rejuvenation. Indications for treatment include dyschromia, photoaging, rhytids, skin laxity, and acneiform scars. Although numerous nonablative laser and light devices have been developed over the years, none of them is able to deliver results equivalent to ablative devices. The effectiveness of ablative lasers results from their ability to accomplish two major effects: first, complete and total vaporization of the epidermis removes unwanted pigment and solar-damaged cells; second, there is deeper penetration and diffusion of thermal energy that heats dermal tissues, causes tissue contraction, and stimulates new collagen production. The net effect of these two processes is that a new, more uniform epidermis is regenerated, without unwanted pigmentation. Additionally, solar elastosis is removed from the superficial dermis, yielding a brighter, more lustrous skin tone, and immediate tissue contraction plus new collagen production lead to the reduction of wrinkles and tighter skin.

The use of ablative lasers for skin resurfacing goes back to the 1980s. Early devices consisted of continuous wave CO2 lasers. These lasers provided adequate ablation of tissue; however, longer dwell times resulted in prolonged and unpredictable thermal heating, charring of the tissue, and a high risk of scarring. The true breakthrough occurred in the early to mid-1990s, when CO2 pulsed lasers with pulse durations in the millisecond domain were introduced for resurfacing. The addition of efficient scanners made these systems even more practical.

Dermal fillers have steadily grown in use over the years, despite the limitations of available products. Longevity without permanence and the absence of animal proteins have been desired attributes in fillers. Hyaluronic acids (HA), and in particular, the Juvéderm family of dermal fillers (Allergan), have the desired characteristics previously lacking in other available fillers.

As we age, our faces begin to show the effects of gravity, sun exposure, and years of facial muscle movement such as smiling, chewing, and squinting. The underlying tissues that keep our skin looking youthful begin to break down, often leaving laugh lines, smile lines, crow's feet, and facial creases, in addition to a general loss of volume around the face. Soft tissue fillers can help fill in these lines and creases, temporarily replenish volume loss, and restore a more youthful looking appearance. Some characteristics of an ideal filler are being nonpermanent (but long lasting), having minimal side effects, not requiring allergy testing, being easy to use/inject, being painless on injection, being reversible, and being cost effective for both the physician and the patient.

HA fillers, primarily due to their ability to bind to large amounts of water and their favorable adverse event profiles, offer an attractive solution to addressing the aging face and lifting the skin. Despite these general features, HA dermal fillers are not all the same.

Lasers utilizing wavelengths of 1,064, 1,320, 1,450, and 1,540 nm were the first nonablative resurfacing modalities. Utilizing technology to cool the surface to protect the epidermis, these lasers effectively heat the dermis selectively, to a limited degree, to stimulate new collagen formation and tightening. The nonablative lasers will be discussed primarily for skin rejuvenation, as other uses, such as for acne scarring and hair removal, are addressed in detail in other chapters. The 1,064-nm wavelength laser reviewed in this section is a long-pulse system, in contrast to the Q-switched units popular for tattoo removal.

The near-infrared lasers induce thermal injury in the dermis, potentially heating and damaging collagen to the point of denaturation. The rate of denaturation is exponentially related to temperature. Because of this relationship, small temperature changes impact denaturation dramatically. The accumulation of denatured material rises exponentially with temperature but proportionally with time, and thus both the amount of energy delivered and exposure duration are important. At critical temperatures, depending on the tissue type, rapid denaturation occurs. In the dermis, the extracellular collagen protein is the dominant material in coagulation (denaturing) because elastin is extremely thermally stable, even at the temperature of boiling water. The melting point for collagen is between 60 and 70 degrees Celsius, and above these temperatures, dermal scars can result. Thus temperature levels within the collagen are critical to causing mild injury, resulting in production of new collagen versus complete denaturation with resultant scarring.

The use of fat as an autologous filling material dates back at least a century. In the 1970s and early 1980s, many plastic surgeons still used eyelid fat from blepharoplasty to fill in glabellar or even nasolabial fold lines through small slit incisions. The results were uniformly temporary, with full resorption after six to thirteen months. Injectable autologous fat grafting really has its roots closely tied to the introduction of modern liposuction. It is unclear who may have been the first to use fat harvested from liposuction, place it in a syringe, and reinject it back into the tissues. There were certainly many who started about the same time. In the early days of liposuction, contour deformities were quite common, and reinjecting fat was an obvious and, as it turns out, the most practical treatment option.

The idea of harvesting fat with a small cannula, in a relatively small syringe for reinjection, probably occurred to several physicians at about the same time. But it is Pierre Fournier who certainly deserves most of the credit for popularizing this procedure starting around 1984–1985. Fournier used a very simple technique of harvesting the fat with a 5- to 10-cc syringe fitted with a 14-gauge cannula, and after letting the fat settle and discarding the separated serum, he reinjected it as “small strands of spaghetti” through a 14- or 16-gauge needle. He used it primarily for nasolabial folds, glabellar frown lines, and marionette lines and was also beginning to place it in hands.

Although our choices of fillers in the United States are still far more limited than for most of the world, with the introduction of several new fillers during the past four years, we now have a variety of different products to meet our patients' needs.

The first step in choosing the correct filler is proper evaluation of the patient and understanding what the patient needs, wants, and also, can afford. The majority of patients who come for a consultation are interested in treatment of the nasolabial folds, treatment of the lateral oral commissural folds (marionette lines), adding volume to the lips, and treatment of the vertical upper and lower lip lines and glabellar frown lines. With increasing public awareness (or after pointing out the possibilities), patients may also be interested in treatment of tear-trough deformities, chin crease and lateral chin depressions, cheek and chin augmentation, and prejowl contours. Finally, some patients lack volume or have undergone age-related volume shifts that need to be addressed and corrected.

In my practice, the vast majority of patients have limited budgets and limited downtime. In general, those patients whose needs cannot be met by 1–2 cc of commercial filler (and/or BOTOX) choose to limit treatment to a limited cosmetic concern. Or, if they can afford it, they may opt for more definitive procedures with longer-lasting and relatively predictable results such as ablative resurfacing and lifts.

Adapting neurotoxin (NT) to individual patients is the key to natural results. Doing so requires careful evaluation of each patient's anatomy and the position of various key anatomic components, particularly the eyebrows, at rest and at various levels of muscle activity.

As discussed in their own separate chapters by Drs. Beddingfield, Sadick, and Rossi, there are many possible applications of NT on the face and neck.

In my practice, I find that NT is most practical for the upper face. I rarely, if ever, use BOTOX for the perioral area or the chin. I find that fillers are far more practical in these areas as they last much longer and have more predictable results. And for very fine and superficial perioral lines that do not do as well with fillers, resurfacing is a far better choice, especially with availability of the new fractional lasers, ranging from the near-infrared to erbium and CO2. I do occasionally use BOTOX on the neck. It is very helpful for stubborn platysmal bands postplatysmaplasty procedures and can delay recurrence of bands in patients with a strong platysma muscle combined with thin subcutaneous tissues, but the high cost makes it impractical for most patients. My results with primary treatment of the bands and jowls (Nefertiti neck method) have been variable and too often unimpressive for the cost and duration, and some patients complain of weakness in opening their mouth as a result of weakness of the platysma. Time will tell if prolonged use can improve results.

Restylane (Q-Med) was introduced in 1994 as the first nonanimal stabilized hyaluronic acid (NASHA) filler and quickly became widely used around the world. In spite of intense competition from other, newer hyaluronic acid (HA) products, Restylane remains the best-selling product today. It was the first HA product to receive Food and Drug Administration (FDA) approval, in December 2003, and is distributed in the United States by Medicis Aesthetics Inc.

Restylane is a partially (single) cross-linked HA manufactured from Streptococcus bacterial fermentation. It is a moderately viscous clear particulated gel (biphasic gel) that can be injected through a 30-gauge needle. Restylane, like other HA products, binds water very well. In fact, as, over time, it loses cross-linkage as it undergoes enzymatic degradation, its volume can actually increase as more water becomes bound to the exposed HA.

For this type of product, the manufacturing process can determine the gel particle size, which, at equal concentrations of HA, determines viscosity of the gel. Outside the United States, a variety of Restylane products are available, which are of variable particle size and thus of variable numbers of particles per milliliter. The number of particles per milliliter is inversely proportional to the particle size. The larger the particle size, the greater the viscosity.

Four Restylane products are available in Canada and Europe (Table 8.1). They are, in order of particle size, Restylane Fine Lines, Restylane, Perlane, and Restylane SubQ. In the United States, only Restylane and Perlane are FDA approved.

Tumescent anesthesia is used today for various surgical procedures on the skin. Although most commonly used for liposuction and for harvesting fat for use as an autologous filler, the technique has been applied to various other procedures, including laser resurfacing, laser tattoo removal, endovenous ablation of varicose veins, and various medical and cosmetic surgical procedures. Tumescent anesthesia is achieved by injecting relatively large volumes of dilute neutralized lidocaine solution with epinephrine into the subcutaneous tissue. Tumescent anesthesia allows procedures that previously required conscious sedation or general anesthesia to be performed more safely, while patients are awake or mildly sedated. Commonly, it decreases or eliminates the need for narcotic analgesics or IV sedation for many cosmetic procedures. Tumescent lidocaine solutions have also been attributed antibacterial effects, possibly accounting for the very low rate of infection seen with tumescent liposuction. The use of dilute epinephrine in the tumescent solution further increases the safety of procedures, including liposuction, by decreasing blood loss. When used for resurfacing procedures, distending the skin can better expose the base of wrinkles to the resurfacing procedure.

Tumescent anesthesia, which revolutionized liposuction, was developed in the mid-1980s by dermatologic surgeon Dr. Jeffery Klein, who was able to demonstrate that lidocaine serum levels remained within safe limits following the injection of what were then considered high doses of lidocaine in terms of milligrams per kilogram, while at the same time achieving excellent anesthetic effect, if the lidocaine was delivered as large volumes of very dilute (0.05%) solution into fatty tissue.